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Advanced Principles III > Barash Chapter 53- trauma > Flashcards

Barash Chapter 53- trauma Flashcards

1
Q

The general approach to evaluation Acute trauma victim has three components:

A

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

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2
Q

Why do a tertiary survey within 24 hours after trauma?

A

To potentially diagnose missed injuries during the initial survey

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3
Q

What are the difficult trauma related reasons for tracheal intubation?

A

Maxillofacial,
Neck
chest injury
cervicofacial burns.

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4
Q

Signs of upper and lower airway obstruction

A 
Dyspnea 
cyanosis 
hoarseness 
strider 
dysphonia 
Subcutaneous emphysema 
hemoptysis
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5
Q

What physical findings may be present before symptom indicating airway obstruction and requiring specialized technique to secure airway?

A

Cervical venous distention ,
crepitation
Tracheal tug and/or deviation
Jugular venous distention maybe present before symptoms appear

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6
Q

What are the initial steps in airway management

A

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

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7
Q

In what type of brain injury is blind passage of a nasal pharyngeal airway or NG or nasotracheal tube avoided

A

Basilar skull fracture because the air we may enter the anterior cranial fossa

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8
Q

True or false airway assessment must include a rapid examination of the interior neck for feasibility of access to the cricothyroid Membrane

A

True

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9
Q

Why is tracheostomy not desirable in the initial phase compared to cricothyrotomy

A

Because it takes longer to perform

It requires Neck extension which may cause or exacerbate cord trauma in patients with cervical spine injuries

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10
Q

If a cricothyroitomy is in place for more than 2 to 3 days what should you do?

A

Conversion to a tracheostomy to prevent Laryngeal damage

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11
Q

What are the contraindications to cricothyrotomy

A

Younger than 12 years ( permanent laryngeal damage)

and suspected Laryngeal and Trauma( uncorrected airway obstruction)

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12
Q

Why does rapid sequence induction with cricoid Pressure in Trauma patients necessary?

A

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

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13
Q

What is the anesthesia approach for head, open eye, and contained major vessel injuries ?(3)

A
  1. Ensure adequate oxygenation in ventilation
  2. Deep Anesthesia
  3. Profound muscle relaxation before airway manipulation= they don’t buck cough or go hypertensive&raquo_space; less Intracranial, intraocular, intravascular pressure elevation.
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14
Q

In head,open eye, or contained major vessel injuries, what can happen if you allow the patient to cough , buck or go hypertensive

A
  1. Herniation of the brain
  2. extrusion of eye contents
  3. dislodgment of a hemostatic clot from an injured vessel
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15
Q

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

A

1.Preoxygenation and opioid loading
2.Large doses of IV anesthetic and muscle relaxant
Watch for :
Low BP&raquo_space; ICP, Low CPP,

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16
Q

Is ketamine still contraindicated in patients with head or open eye injury?

A

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

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17
Q

Do use ketamine in patients with contained major vessel injury ?

A

No ! because by increasing systemic blood pressure it can cause dislodgment of a hemostatic plug initiating bleeding in vascular injuries

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18
Q

Can sux be used in head , open eye or contained major vessel injury ?

A

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

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19
Q

When comparing video laryngoscopy to direct laryngoscopy what is a disadvantage

A

Video shows longer intubation time resulting in decline of oxygen saturation to 80% or less in a lot of patients!

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20
Q

Most common cause of cervical spine injuries

A
  1. High speed MVA
  2. Falls
  3. Diving
  4. Gunshot
  5. Head injuries especially if low GSC = c spine injury
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21
Q

What are the complications associated with the C collar:

A
  1. Pressure ulcer
  2. Elevated ICP
  3. Compromise central venous access
  4. Airway management challenges if reintubation is needed
    * once you establish airway r/o c- spine injury to clear the neck as soon as possible
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22
Q

What happens to blunt trauma induced C spine injury after admission

A

Worsening neurological deficits either because of delay in diagnosis or improper C-spine protection and/or manipulation

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23
Q

What indicates a low probability of C - spine injury

A
  1. No posterior midline neck tenderness and no focal neurologic deficit
  2. Normal level of alertness
  3. No evidence of intoxication
  4. No painful distracting injury
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24
Q

What is the Canadian C-spine rule for radiography after Trauma (which identifies Low risk patients)

A
  1. 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 .

  1. Can the patient rotate the neck laterally left and right for 45° in each direction without pain
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25
Q

How do you rule out C - spine injury in pre-elementary school children ( age 4 and under )

A

Absence of clinical findings .

you don’t need diagnostic studies or radiation exposure

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26
Q

Children with persistent midline neck pain with no other clinical findings AND negative intitial findings will you get imaging to rule out C-spine injury?

A

No ! because that indicates a little possibility of unstable C spine injury

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27
Q

Gold standard for ruling C spine injury in or out?

A

MRI is gold standard : but it is too sensitive and show too much .
Instead MDCT with less than 3mm cuts is used . Only thing is , possibility of missing 1 unstable C spine in about 5000 patients

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28
Q

How to do Airway management in C- spine injury

A

To DL : best do Manual inline stabilization ( MILS) w/ 2 operators + the physician doing the airway.

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29
Q

Is a hard cervical collar sufficient to provide absolute protection . True or False

A

A hard collar alone does not provide absolute protection especially not against rotational movements of the neck .

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30
Q

How is MILS performed?

A

1) First operator : Stabilize and align the head in a neutral position without applying cephalad traction
2) Second operator: Stabilize both shoulders by holding them against the table or stretcher
3) The anterior portion of the hard collar which limits mouth opening may be removed after immobilization

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31
Q

How does MILS affect your intubation ?

A

Suboptimal glottic view

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32
Q

If patient has a hematoma from a vertebral fracture which leads to enlargement of the prevertebral space, how can anesthesia make that patient worse during DL ?

A

That causes greater interior pressure that needs to be applied to the tongue by the laryngoscope blade in order to visualize the larynx. The increase in ant. pressure goes to the spine = increase the movement of the unstable vertebral segment

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33
Q

During direct laryngoscopy Is there a higher pressure with MILS or without MILS?

A

With Manual Inline Stabilzation

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34
Q

Besides DL what other measures can be used to secure the airway in acute phase of cervical spine immobilization

A

VL, gum elastic bougie, Translaryngeal retrograde intubation, cricothyroidotomy

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35
Q

Flexible fiber optic laryngoscopy and translaryngeal guided intubation cause almost no Neck movement but why don’t we use them in the initial airway management phase

A

Blood
Secretion
Long preparation time
Difficulty of their use in comatose, uncooperative or anesthetized pt

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36
Q

Disadvantage of nasotracheal intubation

A
  1. Risk of epistaxis
  2. Failure of intubation
  3. Possibility of entry into cranial vault or the orbit if there is damage to the cranial base or the maxillofacial complex
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37
Q

What are the usual signs of basilar skull facture

A
  1. Battle sign : (takes 1 day to appear , bruise over the mastoid process from blood along the periauricular artery )
  2. Raccoon eyes
  3. Bleeding from the ear or the nose
  • just bc those signs are not there ‘yet” does not mean the don’t have cranial base fracture
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38
Q

Can supraglottic device with or without the aid of FOB be used?

A

Yes, but has same neck movement as DL

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39
Q

In regards to C spine injury : when is the use of FOB preferred

A

In the SUBACUTE phase of the spine injury when time constraints , full stomach and patient cooperation issues do not exist!!!!!

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40
Q

Why is high impact maxillofacial injury challenging for airway management

A

Not only soft tissue Edema of the pharynx and parapharyngeal hematoma, blood or debris in the oropharynx maybe responsible for partial or complete airway obstruction in the acute stage of these injuries

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41
Q

How can liberal administration of fluids in maxillofacial Trauma worsen the patient

A

Serious airway compromise may develop within a few hours in up to 50% of patients with major penetrating facial injuries, multiple trauma, caused by progressive inflammation or Edema resulting from liberal administration of fluids

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42
Q

Maxillofacial Hemorrhage most frequently from what artery?

A

Internal maxillary artery or its branches

Less frequently : facial external carotid, sphenopalatine arteries and other small branches

Life treathening= do packing, intermaxillary fixation if that doesn’t work do angioembolization

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43
Q

If there is fracture induced encroachment of the airway or the mandibular movement is limited patient : pain , trismus ( lockjaw ) = pt cannot open the mouth what do you do

A

Fentanyl titrated 2 to 4 µg /kg over a period of 10 to 20 minutes will improve the patient’s ability to open the mouth if mechanical limitation is not present

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44
Q

In direct airway injury if there is bleeding into the oropharynx , will flexible fiber-optic be useful ?if not what do you do ?

A

Waste of time !
Retrograde technique using a wire or epidural catheter passed through a 14 gauge catheter introduced on the trachea through the crycothyroid membrane : IF THE PT CAN OPEN MOUTH

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45
Q

When is the surgical airway indicated in direct airway injuries

A
  1. Airway compromise
  2. Direct laryngoscopy has failed or is considered impossible
  3. When the jaw will be wired
  4. When a tracheostomy will be performed anyway after repair of the fracture.
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46
Q

Direct airway injury , WHen is Tracheostomy indicated ?

A
  1. ER
  2. As a delayed procedure in OR for airway control within 12 hours of arrival
  3. An elective sx during definitive surgery within or more than 12 hours following admission of the hospital
  4. Comminuted mandibular, mid-facial, bilateral LeFort III and panfacial fractures are likely to be managed by tracheostomy for definite of surgery
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47
Q

Can be done to avoid the complication of tracheostomy

A

Submental or submandibular intubation

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48
Q

What does submental or submandibular intubation involve

A

Pass the proximal end of the FLEXIBLE ARMORED OROTRACHEAL tube through a small submental incision

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49
Q

Mid face fx with frontal sinus or orbitozygomatic and orbitoethmoid complexes what other type of fracture is most likely involved ?

A

Cranial fracture

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50
Q

When do cervical airway injury happen usually

A

Blunt or penetrating Trauma

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51
Q

Air escape, hemoptysis, and coughing are present in almost all …

A

Penetrating injuries

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52
Q

Hoarseness, muffled voice , dyspnea , strider , dysphasia, odynophagia , cervical pain and tenderness , ecchymosis, subcutaneous emphysema , flattening of the thyroid cartilage protuberance , what diagnosis ? *

A

Major blunt laryngotracheal damage .

Which may actually be missed either because the patient is asymptomatic or unresponsive, or the S/S are missed *

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53
Q

No Resp distress or hemodynamic compromise, do you CT first or airway first ?

A

CT first .
Don’t go blind in the compromise airway , it will make it worse.
But if you have to , use FOB if possible or a surgical airway

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54
Q

There 5 grades of laryngeal injuries

A

1 . no Fx, minor laceration , minimal edema = minimal airway s/s

  1. Undisplaced fx , mucosal damage but no exposure of cartilage = mild airway compromise
  2. Displaced fx, vocal fold immobility = significant compromise
  3. Multiple fx with instability = significant compromise
  4. Laryngeal separation = catastrophic airway obstruction.
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55
Q

If there is a stab in airway already , can you use that stab to pass your tube and intubate ?

A

Yes

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56
Q

***If it’s grade 5 laryngotracheal damage ( cartilaginous fx) or mucosa abnormalities. What is your choice of intubation technique?

A

Awake intubation With FOB
or
Awake tracheostomy

Can’t do a cricothyroidotomy ** laryngeal damage precludes cricothyroidotomy **

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57
Q

Up to ____% of blunt laryngeal injury may have ______injury ; perform a _______with caution

A

70% blunt laryngeal
Have Cervical spine injury
Tracheostomy = be careful

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58
Q

If pt with cervical airway trauma is confused or cant cooperate , do you do an awake intubation ?

A

No, go to OR , use ketamine or inhalation gas, intubate without muscle relaxant .

If pt has episodes of apnea while under gas anesthesia, put patient upright and do the usual maneuvers

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59
Q

Complete transection of trachea is

A

Life threatening

Distal trachea will retract in to the chest - OBSTRUCTION!!!

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60
Q

Penetrating thoracic airway injury can occur anywhere , but where does blunt trauma usually affect?

A

Posterior membranous portion of the trachea and the main stem bronchi , usually 3cm of the carina .

Believe it or not , tracheal intubation can cause this injury

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61
Q

What are the S/S of blunt thoracic airway injury ?

A 
Pneumo
Pneumomediastinum 
Pneumopericardium 
SubQ emphysema 
Continuous air leak from chest tube 
* but these are not specific to thoracic airway damage .
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62
Q

What will happen to your ETT cuff if there is perforated airway ?

A

Can’t get a seal around the ETT ,

Or

on CXray shows large radiolucent area in the trachea corresponding to the cuff = perforated airway

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63
Q

What are the CXray signs of perforated airway?

A

Seeing the cuff on X-ray
A radiolucent line along the prevertebral fascia bc of the air tracking up from mediastinum
Peribronchial air
Dropped lung sign : complete intrapleural bronchial transection causes the apex of lung to descend all the way to the hilum

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64
Q

For airway techniques in thoracic airway injury , danm if you anesthetize and relax , danm if you do it awake. Why? What happens with each technique ?

A

Anesthesia and muscle relaxant = irreversible obstruction bc you relax the peritracheal and peribronchial structures that airway patency
Awake intubation = airway loss bc of further distortion of the airway by the ETT , pt agitation or rebleeding

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65
Q

Is condensation a way to verify tube placement in these patients ?

A

No
Auscultation and ETCO2
But you may not hear
Or ETCO2 may be low or not present if shock or circulatory collapse

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66
Q

What can prevent you to hear when you auscultate for tube placement in these thoracic airway trauma patients ?

A

Pulmonary contusion
Atelectasis
Diaphragmatic rupture w/ abdominal content migration
Pneumothorax

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67
Q

Tracheal injury what is preferred method of intubation then ?

A

ETT using a bronchoscopic guidance DISTAL to the tracheal injury . That’s the new trend vs surgical management

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68
Q

What type patients will not be part of the new trend and will have to have surgical management?

A 
If the lesion is > 4 cm 
Is cartilaginous vs membranous 
Esophageal trauma also present 
Progressive subQ emphysema 
Severe dyspnea needing intubation 
Pneumothorax w/ air leak through chest 
Difficult to mechanical ventilate 
Mediastinitis
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69
Q

What are the IMMEDIATE threats to patient life after trauma that may alter respirations

A

Tension Pneumothorax
Flail Chest
Open pneumothorax

Other that may not be immediate :
Hemothorax 
Closed pneumothorax 
Pulmonary contusion 
Diaphragmatic rupture with abdo content herniation 
Actelectasis with mucus plug 
Aspiration 
Chest wall splinting
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70
Q

What are the classic signs of tension pneumothorax?

A
  1. Cyanosis
  2. Tachypnea
  3. Hypotension
  4. Neck vein distention ( if Hypovolemic may be see this)
  5. Tracheal deviation ( may be difficult to see)
  6. Diminished breath sound
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71
Q

What sign is usually diagnostic of tension pneumothorax in the supine position ? Describe

A

Deep sulcus sign : pleural air track in the lateral and caudal region of the lung instead of the apex

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72
Q

What is definitive dx of Tension pneumo ?

A

CT

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73
Q

How to relieve the Tension pneumo?

A

Insert a 14 gauge catheter 4th or 5th intercostal space midaxillary line

Or

2nd ICS midclavicular line

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74
Q

Flail chest , there is costochondral separation or sternal fracture . What makes them into Resp failure ?

A

Underlying pulmonary contusion

Increased elastic recoil&raquo_space; increased WOB&raquo_space; Resp insufficiency/failure&raquo_space; hypoxemia!

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75
Q

Over how long does Resp insufficient/ failure develop with flail chest ?

A

Develops over 3 to 6 hr period&raquo_space; worse CXray and worse ABG ( hemopneumo, paradoxical chest wall movement , pain induced splinting make gas exchange worse )

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76
Q

Fraction of lung contused is indicative of

A

ARDS

Especially if contuse volume is > 20%

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77
Q

Rib score system . 1 point is assigned to each of these type of fractures

A

6 or more rib fx=1
Bilateral fx= 1
Flail chest =1
3 or more severely (bicortically) displaced fx =1
1st rib fx = 1
At least 1 rib fx each ant, lateral, Posterior regions of ribs= 1

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78
Q

Rib score and Vital capacity have linear correlation with

A

Development of
Pneumonia
Resp Failure
Tracheostomy

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79
Q

Vital capacity 50 % means what in flail chest patient ?

A

Little risk of pulm complications

But less than 30% = probability increase 2.5 times

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80
Q

Flail chest , Vital capacity below ____% means _____times likely to develop pulmonary complications

A

Below 30%

2.5 times increased probability

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81
Q

True or false . Once there is chest wall instability , must have respiratory support ?

A

False, only if there is gas exchange abnormalities

Liberal tracheal intubation make things worse patient mortality and complication increase

Just do effective pain relief = improve Resp function and no need for a vent . Use thoracic epidural with LA and opioids or thoracic paravertebral block

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82
Q

Besides pain continuous pain control what else to do for flail chest patient who do not have gas exchange issues ?

A

O2 , CPAP 10 -15 cmH2O using face mask , airway humidifier, IS, Bronchodilators , airway suction with FOB , nutrition. Overzealous fluid and blood make oxygenation worse bc it worsens pulmonary injury

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83
Q

If head injury patient does not have a known threat to cerebral herniation , avoid hyperventilation …why ?

A

Increased cerebral vasoconstriction = decreased perfusion + cerebral lactic acid build up

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84
Q

If hypovolemic , how is hyperventilation bad ?

A

It interferes with venous return and cardiac output , leading to hypotension , further decrease in organ perfusion and even cardiac arrest

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85
Q

What ventilation technique is Best to prevent hemodynamic deterioration and decrease likelihood of ARDS ?

A

Low TV: 6- 8 mL/kg
Moderate PEEP
Producing low inspiratory or plateau pressures

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86
Q

What ventilation goal to use in intubated but spontaneously breathing patient s?

A

Airway pressure release ventilation where breathing is superimposed on the vent by intermittent brief decreased of CPAP = improved V/Q , BP , less sedation needed , better O2 delivery, less VAP( happens in 30% of pulmonary contusion )

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87
Q

Bil severe pulmonary contusion use what ventilation mode ?

A

High frequency Jet ventilation

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88
Q

Severe unilateral pulmonary contusion unresponsive to other vent measures , use a…

A

Double lumen tube

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89
Q

How do you diagnose systemic air embolism which can happen after penetrating lung trauma, blast injury or blunt thoracic trauma where both distal passages and pulmonary veins are affected ?**

A 
You will see:***
Hemoptysis 
Circulatory instability 
CNS dysfunction 
IMMEDIATELY AFTER ARTIFICIAL VENTILATION 
\+
Air in blood from the radial Artery .
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90
Q

If there is air bubble in the coronary arteries during thoracotomy , what is the diagnosis ?

A

Systemic air embolism

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91
Q

You know there is systemic air embolism bc of lung contusion , what Resp maneuvers do you do to prevent air entry in the systemic circulation ?

A

Isolating and collapsing the lacerated lung with a double lumen tube

Or

Lowest possible TV using a single lumen tube
TEE of the left side of heart to see if there is any air bubble

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92
Q

Most common cause of dramatic Hypotension and shock is***

A

Hemorrhage***

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93
Q

The second most common cause of mortality after trauma ***

A

Hemorrhage ***

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94
Q

First most common cause of mortality after trauma is

A

Head injury

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95
Q

What is the primary goal in bleeding

A

urgent surgical control of the source

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96
Q

Why is it important to remove the tourniquet as soon as urgent surgical control is achieved

A

To avoid Pressure-Induced nerve damage, skin necrosis, limb ischemia.

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97
Q

What is the optimal systolic blood pressure in the trauma patient?

A

100 to 110 mmHg mercury for elderly

And 90 for younger patient

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98
Q

Elderly vs young , who is more at risk for significant tissue hypoperfusion in the presence of normal blood pressure

A

Elderly (> 65 )

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99
Q

Carbon monoxide takes how long to remove it on room air, 100% O2 , and at 3 atm in hyperbaric chamber

A

4 hours on room air
60 to 90 minutes with 100% O2
20 to 30 minutes at 3 atm in the hyperbaric chamber

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100
Q

Normal IOP is

A

10 to 21 mmHg

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101
Q

What is considered a predictor of increased mortality in shock patients independent of injury , SBP, or presence of head injury?

A

Inability for the patient to elevate heart rate in the face of hypo perfusion!!!

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102
Q

What are the Early clinical indicators of the severity of hemorrhagic shock

A 
Heart rate
BP 
Pulse pressure 
Respiratory rate 
Urinary  output
Mental status
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103
Q

Why does hematocrit drop in hemorrhage

A

Because of immediate activation of transcapillary refill. Low Hct = suspect extensive bleeding

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104
Q

Shock index formula:

A

Hr / SBP

In elderly (HR/SBP )x age or

SI x age

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105
Q

Normal SI

A

.6

Closer to 1 = Increased mortality

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106
Q

Assessment of Bloof consumption score ask 4 questions ( used to determine the amount of transfusion)

A

Heart rate 120
systolic blood pressure 90
penetrating injury
Positive FAST

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107
Q

White blood like that level indicates major bleeding

A

> 2 mmol/L

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108
Q

Damage control resuscitation

A

Brief permissive hypotension
rapid control of any bleeding source minimal crystalloid infusion
early administration of plasma in other blood products in a balanced ratio 1:1:1 of packed red blood cells plasma and platelets by activation of the MTP
and TXA

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109
Q

What is the purpose of damage control resuscitation?

A 
To prevent :
1.pulmonary edema 
2.ARDS 
3.and  Multiple Organ - MOF 
And 
abdominal compartment syndrome.
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110
Q

If you give > 1.5 L to 1 unit blood ratio in the first 24 hrs , what will happen to the patient ?(2)

A

ARDS

Abdo compartment syndrome

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111
Q

Permissive hypotension is contraindicated in: (3)

A
  1. Brain injury
  2. spinal cord injury
  3. elderly with chronic systemic Hypertension because adequate perfusion is crucial
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112
Q

Most useful and practical tools of organ perfusion during all phases of shock ?(2)

A

1) Base deficit
and
2) Blood Lactate level

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113
Q

Base deficit reflects: (3)

A

1) Severity of shock
2) Oxygen debt
3) Changes in O2 delivery

Base deficit is better than Arterial pH

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114
Q

Base deficit -2 to -5 means

A

Mild shock

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115
Q

Base deficit -6 to -9 mmol/L indicates

A

Moderate

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116
Q

Base > 10 mmol/L

A

Severe shock

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117
Q

Why is blood lactate less specific than base deficit as a marker of tissue hypoxia

A

Because of increased epinephrine Induced skeletal muscle glycolysis accelerated pyruvate oxidation decreased hip had a clearance of lactate in early mitochondrial dysfunction

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118
Q

What is the half-life of lactate

A

15 to 30 minutes in a healthy individual failure to clear lactate within 24 hours after reversal of circulator shock is a predictor of increased mortality

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119
Q

What is normal plasma lactic concentration

A

0.5 to 1.5 mm/L

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120
Q

Lactate levels over 5 mm/L indicates

A

Lactic acidosis :significant

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121
Q

Recommended hemoglobin concentration in all phases of management is

A

729 grand per deciliter

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122
Q

To increase brain oxygenation in 75% of head injured patient how old should PRBC be

A

Less than 19 days storage to increase HgB 9 to 10g/dL

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123
Q

MTP means

A

10 unit in 24 hr
> or = 4 PRBC in first hour with need to to continue assumed

It does not take plasma into account

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124
Q

Can use Liquid plasma up to how many days after collection

A

28 days

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125
Q

How long does it take to Saul FFP or PF 24

A

30 to 45 minutes

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126
Q

PF 24 vs FFP

A

PF frozen within 24 hour collected ( only contains 60% of factors in FFP except fibrinogen bc it has a t1/2 of 12 hours )

FFP is frozen within 8 hours

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127
Q

A kid has massive hemorrhage if had to be given how much blood ?

A

> 40ml/kg

Or

Given 50% of blood volume over 24 hrs

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128
Q

Circulating blood volume in an infant is :

A

80 ml kg

90 for Barrash

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129
Q

Children over 3 months , circulating blood volume is

A

70 ml/ kg

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130
Q

What is the most constant vital sign indicating early volume loss?

A

Narrowing pulse pressure

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131
Q

Children have a greater hemodynamic reserve and VS only deteriorate after they have lost ____to ____% blood volume

A

35 to 40 %

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132
Q

Neonates don’t have Vitamin K and functional fibrinogen until

A

6 months

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133
Q

In pediatric actual trigger for activating the MTP

A

High injury severity score

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134
Q

Kid with base deficit > 6 or INR 1.8 predicts what ?

A

High chance to die .

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135
Q

What are the two components of coagulopathy of the trauma patient

A

A cute traumatic coagulopathy and resuscitation associated coagulopathy

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136
Q

Signs of life

A 
Pupillary response 
Spontaneous ventilation 
Carotid pulse 
Palpation blood pressure 
Extremity movement 
Cardiac electrical activity
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137
Q

Of all the possible secondary insults in the injured brain, what has the most or greatest detrimental impact

A

Decreased oxygen delivery due to Hypotension and Hypoxia

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138
Q

40% of death from trauma are cause by …

A

Head injury

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139
Q

Most common early complication of head trauma are :

A 
ICH 
Herniation 
Seizures 
Neurogenic pulmonary edema 
Cardiac dysrhythmias 
Bradycardia 
Systemic HTN
Coagulopathy
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140
Q

Does phenylephrine constrict cerebral vessels ?

A

No

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141
Q

What is the most important cause of death in the head injury patient ?

A

Low BP

Especially < 90

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142
Q

AVPU alert , verbal stimuli , Response to pain , unresponsive to assess consciousness

A

True true

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143
Q

Uncal Herniation under the Flax cerebri how does the pupil look?

A

Dilated and unresponsive “ blown “

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144
Q

Pupil that is dilated and sluggish

A

Uncus ( temporal lobe ) is compressing. Oculomotor nerve

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145
Q

CT , concave border in brain , Dx?

A

Subdural hematoma

146
Q

CT scan has convex outline aka lenticular configuration?

A

Epidural hematoma

147
Q

In patients with brain trauma how to prevent or alleviate the secondary injury ?

A

Prevent Hypotension and Hypoxemia anemia raised ICP acidosis and hypoglycemia greater than 200

148
Q

Are the most important therapeutic maneuvers in the patients with brain trauma

A

Maintaining ICP,CPP, and oxygen delivery

149
Q

Head injury , where do you want MAP , PaO2, ICP and CPP

A

MAP > 80
PaO2 over 95
ICP below 20 to 25 mmHg
CPP at 50 to 70 mmHg

150
Q

Why CPP > 70 no longer practiced ?

A

Bc it causes ARDS

151
Q

LR solution Na 130 , Osmolality 255 mOsm/L not given in brain injury bc ?

A

Slightly hypotonic , may promote swelling in uninjured of brain if given in large quantities

152
Q

How is Mannitol IV administered ? What you rate .

A

0.25 to 0.5g/kg
Repeat every 4 to 6 hrs to control ICP
Some say up to 2mg/kg

153
Q

How does mannitol Improve cerebral blood flow

A

By decreasing the Hct

154
Q

Signs and symptoms of Manitou toxicity are

A

Hyponatremia
high serum osmolality
Gap between calculated in measured serum osmolality over 10 mOsm/L
When given to patients with renal failure or at doses of 2 to 3 g/ kg

155
Q

Can mannitol make edema of the injured brain tissue worse ?

A

Yes !

156
Q

What other fluid is as efficacious as mannitol to manage ICP and at what rate is it infused?

A

Hypertonic Saline 15% at 0.42mL/kg

157
Q

What does long period of hypertonic saline cause ?

A

Hypernatremia
Hyperosmolality
Hyperchloremic acidosis BC of renal HCO3 loss secondary to increased level Cl-

158
Q

When do you D/C hypertonic saline ? When plasma sodium reaches

A

160 mEq/L

159
Q

When CPP is maintained above the recommended 50 mmHg to 70 mmHg, hyperventilation is good practice ?

A

No , bc hyperventilation will cause brain ischemia . And even if CPP. 50 to 70 , the first 6 hrs will always have brain ischemia in the brain injured patient

160
Q

When and how should hyperventilation be used ?

A

Short term ,
For patients with severe head injury and elevated ICP not responding to normal ventilation and diuretics
BUT
Not in the first 24 hours after injury

161
Q

Hyperventilation can cause ALI ?

A

Yes

162
Q

Everything you do can’t fix the ICP , what med can you give ?

A

Pentobarbital

163
Q

Hypoglycemia can cause ( in the brain injured ) <40

A

Metabolic crisis

164
Q

Hyperglycemia > 200

A

Detrimental effects through excitotoxicity ,
oxidative stress
and inflammation cytokines release

165
Q

Patient from ICU getting surgery keep VS, PaO2 , and PaCO2 should be maintained at

A

The same level

166
Q

Flacid areflexia , loss of patient rectal sphincter tone , paradoxic respiration, bradycardia in a hypovolemic patient suggest what diagnosis ?

A

Spinal cord injury

167
Q

In cervical spine trauma , what S/S indicate cord injury ?

A

Ability to flex but not extend the elbow

Response to painful stimuli above but NOT below the clavicle

168
Q

How do you rule out cervical spine injury without radiology according to the guidelines ?

A

Absence of neck pain
Absence of paresthesia
A negative physical examination :lack of tenderness with palpation
No tenderness during voluntary flexion and extension of the neck
In a neurologically intact , conscious patient

169
Q

Complete spinal cord injury vs incomplete

A

Incomplete: intact sensory perception over the sacral distribution and voluntary contraction of the anus are present

Complete : those above not present and no possibility of recovery

170
Q

Spinal Shock

A

Absolute flaccidity
Loss of reflexes

So spinal shock does not allow you to figure out if it;s complete vs incomplete spinal cord injury Initially , so don’t stop therapy . Spinal shock subsides in 3 to 5 days .

171
Q

Do not leave a patient on a hard board for more than

A

1 hr

172
Q

If patient has cervical spine fx how do you move pt ?

If it’s thoracic or lumbar , how do you move ?

A

C Spine : immobilization or MILS ( Manual Inline Stabilization)

Thoracic lumbar : Log rolling

173
Q

Canadian C-Spine rule . High risk factors :

A

Age >/= 65
Dangerous mechanism
Parathesia in extremities

174
Q

Canadian C-SPine low risk factors allowing beck range of Motion

A 
Simple rear-end MVW
Ability to sit or ambulate in ED
No immediate- onset neck pain 
No midline C spine tenderness 
if no , do CT
175
Q

Canadian C-spine , third question is

A

Able to rotate neck 45 degrees left and right ? If unable do Radiography.

176
Q

Spinal shock is also called Neurogenic Shock which is

A

Hypotension ,

bradycardia (bc of loss of vasomotor tone and sympathetic innervation of the heart)

177
Q

Spinal shock is usually present in what injury

A

Cervical or thoracic spine

But gets better in 3 to 5 days

178
Q

Intubation of Neck injuries , Tracheal intubation may cause bradycardia bc of unopposed vagal stimulation , so what do you do prior to intubation

A

Pre oxygenate and give .4 to .6 mg of atropine

If Brady happens during intubation : give atropine , glyccopyrrolate , isoproterenol or cardiac pacing

179
Q

Injuries at C5 or lower vs Injuries at C4 or above .

A

C5 and below = Normal Tidal Volume

C4 or above = permanent ventilatory assistance

180
Q

Huge catecholamine release after acute trauma May be short but has lasting effects …

A

Pulmonary edema from pulmonary capillary damage and shifting of a large portion of blood volume into the pulmonary circulation + LV dysfunction .

181
Q

3 to 5 days after injury , what will be developing in the patient if pt was given overzealous fluid ?

A

Acute pulmonary edema

182
Q

Paradoxic respiration

A

Partial chest wall collapse during inspiration . = TV , increased risk Hypoventilation.

Worse in upright position. Bc the diaphragm cant keep its dome-shaped since the weight of the thoracic contents is not opposed by normal tone

183
Q

Supine or upright is best for quadriplegic patient ?

A

Supine

But the comorbities like sleep apnea may not allow much of that

184
Q

What to do to manage the hemodynamic of a Quadriplegic patient ?

A

Central Line
PAC ( swan )
LV dysfunction in 25% = hypotension , keep MAP >85
Increase the preload to a PCWP of 18 mmHg= avoid pulmonary edema

185
Q

Hypotension desire adequate fluid, acidosis , or low mixed venous Po2 , give …

A

Inotropes such as dopamine

186
Q

How soon after injury to we initiate DVT prophylaxis ?

A 
Within 72 hours :
LMWH or low dose UFH 
Rotating bed
SCD 
Electrical stimulation
187
Q

Neck Injury

A

.

188
Q

If you don’t treat neck injury promptly what can ensue ?

A 
Hemorrhage 
Asphyxia 
Mediastinitis 
Paralysis 
Stroke 
Death
189
Q

FAST

A

Focused assessment sonography in Trauma

190
Q

Signs of cervical artery injury ?

A

Absent or decreased upper extremity/distal carotid pulses

+ carotid bruit or thrill

191
Q

Penetrating neck injury zones :

A

Zone 1 = narrow area above clavicles from cricoid to the sternal notch

Zone 2 = between the cricoid and the angle of the mandible ** most common

Zone 3 =between the angle of the mandible and the cranial base.

192
Q

Hard vs Soft signs of neck injury . Compare and contrast .

A

Hard signs : urgent/emergent sx
Soft signs : just a CT will do
Hard signs : hypotensive/shock , active bleeding, expending hematoma , neurologic deficit , airway compromise , air bubbling through the wound, massive Sub Q emphysema and hemetemesis

193
Q

What indicated esophageal injury ?

A 
Dysphasia 
Odynophagia 
Hematemesis 
SubQ crepitus 
Prevertebral air on lateral cervical radiograph
194
Q

Partial Spinal Cord injury produces what syndrome . Describe the syndrome

A

Brown Sequard : ipsilateral motor and contralateral sensory deficits

195
Q

Amaurosis fugax

A

Can’t see out of 1 or both eyes due to low blood flow

196
Q

Cervical blunt trauma , usually cause hematoma that may compress the cervical veins , displace the airway , laryngeal congestion . If artery is involved___,___,___ or ___can occur . And if carotid or vertebral artery : ____may occur.

A

Intimal tear, pseudo aneurysm, fistula, or thrombosis.

Cerebral Ischemia

197
Q

Patients with cervical vascular injury may have :

A 
Cervical bruit 
AMS
Lateral icing neurologic deficits 
Hemiparesis 
TIA 
Amaurosis Fugax 
Horner syndrome
198
Q

Chest Injury

A

.

199
Q

Single rib fracture do not usually need ———can be treated instead with ———

A

No need for mechanical ventilation

Can treat with analgesics

200
Q

What kind of chest wall fractures have severe underlying thoracic abdo cranial ,skeletal injury and interfere with breathing ?

A

Rib, Scapula, sternal fractures,

201
Q

What must come to mind when a chest injury patient has SubQ emphysema, pulmonary contusion , and rib fractures .

A

Suspect pneumothorax

202
Q

What are the s/s of tension pneumothorax?

A 
It’s present in >50% pneumothorax 
Dyspnea 
Tachycardia 
Cyanosis 
Agitation 
Diaphoresis 
Neck vein distention 
Tracheal deviation 
Displacement of maximal cardiac impulse to the opposite side
203
Q

Upright X-ray is best to detect pneumothorax, you can’t do upright or pt will die ( being dramatic ) what do you look for in the X-ray done supine to detect pneumothorax? Why ?

A

Deep sulcus sign .

Bc air accumulates in the anteromedial sulcus first , then lateral and caudal regions

204
Q

Can you use an Ultrasound to diagnose a pneumothorax?

A

Yes , put probe longitudinally over the intercostal space . Use that in case of an emergency

205
Q

Definitive diagnosis of pneumothorax is

A

CT chest

206
Q

Once a pneumothorax is diagnosed in a trauma patient , small pneumo vs large pneumo , how do you treat ?

A

Doesn’t matter the size , they need a chest tube and that should be before intubation and before positive pressure ventilation.

207
Q

Pneumothorax chest tube catheter size

A

26 to 32 French

208
Q

Hemothorax catheter size

A

30 to 40 French catheter

209
Q

If pt drains 1000ml or 200ml/hr for several hours , what intervention is indicated ?

A

Thoracotomy

Also : white lung on X-ray and continuous air leak from chest tube mean thoracotomy is needed

210
Q

Classic findings of pericardial tamponade

A

Tachycardia, hypotension, distant heart sounds, distended neck veins , pulses paradoxus, pulsus alternans

But pt with hypovolemia may not show that …😒

211
Q

TEE showing pericardial sac and presence of ventricular diastolic collapse has —-% reduction of cardiac output

A

20

212
Q

How do you perform anesthesia for the patients with pericardial tamponade ?

A

Ketamine or etomidate since they produced relatively little myocardial depression.

213
Q

Commotio Cordis is …

A

Agitated heart ,
Sudden V tach, cardiac arrest and oftentimes death in young people who receive a big to the chest during the 10 to 20 milliseconds of T wave upstroke .
It’s different from myocardial contusion because there is no structural heart damage

214
Q

VSD can be detected on chest X-ray by seeing …

A

Increased pulmonary vascularity with a normal Heart size

215
Q

In thoracic aorta injury , where along the thoracic aorta does blunt trauma usually occur ?

A

The isthmus : where where the free and fixed portions of the descending aorta ( just distal to the left subclavian .

2nd place is the roots of the thoracic aorta

216
Q

Because the TEE can cause aortic rupture in the already injury thoracic aorta , what is the preferred imaging to diagnose the injuries there ?

A

CT :
Multi detectector CT ( accurate )

Use a TEE only when you had to go to surgery immediately without prior CT

217
Q

3 grades of traumatic aortic injury :

A

Grade 1 : intramural clot , intimal flap and or mural clot

Grade 2 : subadventitia ( under the adventia) rupture , media is injured , the geometry of the aorta is changed and/or hemomediastinum

Grade 3 : TRANSECTION w/ huge blood extravasation , obstruction inside the lumen causing pseudo coarctation and ischemia

Vancouver classic action has a 4th grade : contrast extravasation

218
Q

Clamp and sew technique during left thoracotomy to fix blunt aortic injury , what are the potential complications ?

A

Mortality, Morbidity especially paraplegia or renal dysfunction are also frequent with this technique

219
Q

Why is lung isolation with a double-lumen Endobrinchial tube is necessary ?

A

To prevent contamination of the contralateral lung from blood entering the airway during dissection of the aorta in proximity to the lung .

220
Q

What labs or parameters should be monitored during aortic clamp release ? What are the treatments ?

A

Systemic BP and Potassium

If potassium is high a rise in K+ should be treated with insulin and glucose

221
Q

Endobascular aortic repair vs thoracotomy ?

A

Minimally invasive and less complication than thoracotomy. But an endoleak between graft and vascular wall is an early complication .

222
Q

Why place radial artery on the right ?

A

Because subclavian artery is covered by stent

223
Q

During aortography and stent placement what may have to be done

A

Stop ventilation and lower the mean BP at 60mmHg

224
Q

Diaphragmatic injury

A

.

225
Q

What happens when the diaphragm is injured ?

A

The contents of the abdomen migrate in the chest = lung compression , abnormal gas exchange, or heat compression&raquo_space; dysrhythmias and/or hypotension.

226
Q

What organ protects the right side of diaphragm ?

A

The liver , so more often damaged are on the left . That also means …right side damage are missed all the time

227
Q

Looking at CXray , how do you know that the stomach is deplaced into the chest ?

A

NG tube is found ABOVE the diaphragm

228
Q

Anesthesia induction for diaphragmatic injury , what precautions?

A

Avoid aspiration of gastric contents

229
Q

Abdominal and pelvis injury

A

.

230
Q

If there is no abdominal distention, does it mean you can rule out intra-abdominal bleeding ? Why ?

A

No because 1 L of blood and accumulate before a very small change in abdominal circumference is seen
+
The diaphragm can moved upward (cephalad) to make more room to allow more blood without having abdo distention

231
Q

Can CT abdomen some mesenteric or bowel injury

A

No . Unless its a 64 slice CT

232
Q

Fast is most needed for _______patient who may not be safely transported to _____

A

Hemodynamically unstable

CT

233
Q

advantage and disadvantages of FAST ( focused assessment with sonography )

A

Inferior to CT , operator dependent, only moderate sensitivity , can’t diagnose injuries that do not have intraperitoneal fluid
Cannot determine severity of injuries

What it can do well…

Has good specificity 
Dx injury also with intraperitoneal fluids 
Less expensive 
Requires 1/3 of the time 
And no hazard radiation
234
Q

What 4 distinct regions do we screes during FAST

A 
Subxiphpid = detect pericardial bleed
RUQ = detect hepatorenal punch 
LUQ = detect perisplenic blood 
Just above the pubic symphysis = detect blood 
In rectovesical pouch
235
Q

Which patient groups cannot be managed non-operatively?

A 
Patients with blunt trauma who have 
advanced age 
low admissions systolic pressure 
high injury severity score 
metabolic acidosis 
lower GCS 
requirement for multiple Transfusion
236
Q

Why does Hypotension happen on opening the peritoneal cavity filled with blood

A

One. Because of hemorrhage

two. Because of sudden release of compression on the splanchnic vessels causing capacitance vasodilation

237
Q

Patients with pelvic fracture should get what exam before installation of a urinary catheter? Why?

A

Urethrogram should be performed because pelvic fractures may also enjoy your bladder in the urethra

238
Q

What are the key diagnostic measure for pelvic fracture on a CT scan

A

Pelvic ring disruption Arterial extravasation elevated blood pressure secondary to compression by hematoma volume is greater than 500 ML

also

hemodynamic instability after adequate fracture Stabilization is suggestive of pelvic Hemorrhage

239
Q

Extremity injuries

A

.

240
Q

What complications can occur, if fracture repair is delayed

A

Increased risk of DVT
pneumonia
sepsis
Pulmonary and cerebral complications of fat embolism

241
Q

Open factors have additional risk of——-

One left and repaired for more than —— hours are likely to become——

A

Infection

> 6 hours&raquo_space; septic

242
Q

What are the signs and symptoms of the classic syndrome for vascular injuries( 5 Ps)

A 
Pain 
pulselessness 
pallor 
paresthesias 
paresis
243
Q

The definition of diagnosis for vascular trauma is

A

Arteriography

Some patients may receive duplex ultrasound study as a screening test

244
Q

If patient is unconscious what are the signs of compartment syndrome

A

Swelling and tenseness of the extremity

245
Q

What is a definite of diagnosis for compartment syndrome and when is surgery indicated

A

Measure compartment pressures using a transducer attached to a fluid field extension tube and a needle inserted into the various compartments of the extremity.
A pressure greater than 30 cm of H2O means immediate surgery

246
Q

Burns

A

.

247
Q

What are the three wrist factors determining the death rate in burn injury patients

A

Inhalation injury
Burn size greater than 40% of TBSA
Age greater than 60

248
Q

How many TBSA % is involved in full thickness burns

A

> 10% TBSA

249
Q

How many %nof TBSA is involved in partial thickness burns

A

> 25% in adults but > 20% in extremes of age

250
Q

What are major burns

A

Burns in face and feet or perineum Inhalation, chemical and electrical burns
burns in patients with severe pre-existing medical disorders

251
Q

What are the two phases of burn injury

A

Burn shock phase
and
hyper metabolic and hyperdynamic phase

252
Q

Describe the burn shock phase

A

Continued plasma lost from intravascular space into burned and often intact tissues for about the 1st or 2nd day after injury

253
Q

How long does the subsequent hyper metabolic and hyperdynamic phase of burn last

A

Months

254
Q

What happens to patients with burns over 40% of TBSA

A

They consistently develop catabolism ,weight loss which may last up to 1 year

255
Q

Hey severe burn is a systemic disease what gets stimulated and released ?

A

Release of inflammatory mediators such as interleukins and tissue necrosis factor locally (wound edema ) and into the circulation resulting in immune suppression hypermetabolism, protein catabolism,insulin resistance ,sepsis and MOF

256
Q

What interventions may decrease the extent of catabolism

A

Prevention of sepsis

maintain normal body temperature and management of pain

257
Q

What is the color of a partial thickness burn

A

Red,
blanches to touch
sensitive to painful stimuli and heat

258
Q

Describe a superficial partial thickness burn

A

A.k.a. first-degree burn

Involves the epidermis and upper dermis and heal spontaneously

259
Q

Describe a deep partial thickness burn

A

A.k.a. second-degree burn

Involves the deep dermis and require excision and grafting to ensure rapid return of function

260
Q

Describe a full thickness burns

A

A.k.a. thirddegree burn
it does not Blanch even with deep pressure and
has no sensation

There is complete destruction of the dermis it requires would excision and grafting to prevent wound infection that may lead to local sepsis and systemic inflammation

261
Q

What Structure does a fourth-degree burn involve

A

Muscle fascia and bone

It necessitates complete excision and leaves the patient with limited function

262
Q

What tool imaging is used to judge the death of the burn

A

Laser Doppler imaging

263
Q

The child Palmar surface excluding the digits represent what percent of TBSA?

A

0.5%

264
Q

What is the more accurate is specific estimation of the TBSA

A

The lund-Browder table

265
Q

Singed hair , facial burns, soot in the mouth or nose , swallowing difficulties , dysphonia or hoarseness with or without respiratory distress may indicate

A

Upper or lower airway injury

266
Q

What physiological complications occur if there is lower airway burns

A

Decreased surfactant and mucociliary function ,
mucosal necrosis and ulceration , edema , tissue sloughing ,
and
secretions produce bronchial obstruction , air trapping and bronchopneumonia.

267
Q

How long after does parenchymal lung injury take place ?

A

1 to 5 days and looks like ARDS

268
Q

When does pneumonia or PE occur ?

A

They are late complications and occurs 5 days or more after burns

269
Q

By how much does presence of lung injury in burns increase fluid requirements ?

A

By 30 to 50 %

Also increases mortality and rate from thermal injuries

270
Q

If patient is moderately burned and has a patient airway , what is the top priority ?

A

Highest possible O2 concentration via face mask

271
Q

In what occasions is immediate tracheal intubation indicated ?

A 
Massive burns 
Stridor 
Respiratory distress 
Hypoxemia ‘hypercarbia 
Loss of consciousness 
AMS
272
Q

Can kids sustain an awake fiber optic ?

A

No .

Use inhaled O2 and Sevo then use FOB or regular DL which ever is more appropriate

273
Q

Since we consider those traumatic burn patients a full stomach what medication can be given to facilitate emptying of the stomach without causing agitation ? Don’t say reglan please …

A

Methylnaltrexone
Bc it antagonizes the peripheral but not the central effects of morphine = antagonizes gastric effect of morphine without causing agitation

274
Q

What Significant risk does surgical airway carry

A

Pulmonary sepsis in late upper airway sequelae
Only ones who should get those are those at risk to develop complications such as dysphasia dysphonia after prolonged tracheal intubation

275
Q

Why do we use low levels of peep immediately after securing the airway

A

To prevent pulmonary eDema that may happen secondary to loss of laryngeal auto peep in patients with significant area obstruction before intubation

276
Q

Tracheal intubation should be based on clear criteria. What are those criteria

A

Large full thickness burns
inability to protect the airway
or
signs of airway obstruction

277
Q

What does the treatment for smoke inhalation in Burns involve

A

Ventilatory management intensive care treatment of carbon monoxide and cyanide Toxicity

278
Q

Why is there hypoxemia in the first 36 hours after airway injury despite Tracheal intubation ,Ventilation ,peep , bronchodilators, etc..

A

Because of acute pulmonary edema

279
Q

Why does hypoxemia Occur from these 2 to 5 in airway injury patient displayed trickle into Bashan Ventilation peep Bronchodilators

A 
Atelectasis 
bronchopneumonia 
airway edema resulting from Mucosal necrosis and sloughing 
viscous secretions
 distal airway obstruction
280
Q

How does CO produce tissue hypoxia

A

By imparing O2 unloading

281
Q

CO impairs unloading of O2 , what else it causes ?

A

1 mitochondrial function interference
Interferes with Uncoupling oxidative phosphorylation
Reduces ATP
Causes metabolic acidosis

282
Q

Co is a myocardial toxin bc of its effects on the mitochondrial function . True or false

A

True . So true that even after hyperbaric O2 and resuscitation, patient won’t come back

283
Q

Normal oxygen saturation reading on pulse ox does not exclude the possibility of CO Toxicity but a _——measured by coax immature should raise a suspicion

A

A low arterial O2 saturation

284
Q

Crab on oxide toxicity alone without line injury but with a decreased PaO2 , Will you see tachypnea or will it be absent

A

Tachypnea will be absent

285
Q

Classic cherry red color of the blood is absent in most patient but it occurs only at carboxyhemoglobin concentration above

A

40%

286
Q

What are the carotid bodies are sensitive to?

A

Sensitive to arterial P02 and not to the O2 content

287
Q

What are the advantages of 100% FiO2 in carbon monoxide poisoning

A

Improves oxygenation by promoting elimination of carbon monoxide by decreasing the blood half-life of carboxyhemoglobin from 4 hours at room air to about 60 to 90 minutes when on 100% O2
and
the half-life is reduced to 20 to 30 minutes at 3 atm in a hyperbaric chamber

288
Q

If you have unexplained metabolic acidosis in the absence of cyanosis what diagnosis do you suspect

A

Cyanide toxicity

289
Q

The reason why plasma Lactate levels can be elevated in severe burns

A

Hypovolemia
carbon monoxide Toxicity
or cyanide Toxicity

290
Q

Patient has no major burn half after smoke inhalation but has lactic acidosis what are you suspecting

A

No toxicity

291
Q

The definition of diagnoses that can be made for cyanide Toxicity

A

That cyanide level which is toxic above 0.2 mg/L and lethal at levels be on 1 mg/L

292
Q

Is the half-life of cyanide

A

One hour

293
Q

> 155 TBSA burn, what intervention is essential?

A

Fluid resuscitation in the early care

294
Q

For small burns how do you manage Fluid replacement

A

Oral or IV at 150% of calculated maintenance rate

1 1/2 times the maintenance rate pretty much

295
Q

What can occur if resuscitation volume exceeds 300 ML per kilogram for 24 hours

A

Abdominal compartment syndrome with impedance of Venous return

296
Q

What is fluid creep

A

Administration of fluid in excess of the amount recommended by the park and formula in modern burn management

297
Q

Is the addition of glucose necessary when using resuscitation formula as it is

A

Only in children especially weighing less than 20 kg

298
Q

Silver sulfadiazine without free water , what can happen

A

Hypernatremia along with CNS effects including intracranial bleed

299
Q

What does aqueous 5% nitrate solution cause

A

Hyponatremia , cerebral edema

300
Q

What is the rule of 10

A

The total body surface area is multiplied by 10 to determine the estimated hourly fluid rate then for every 10 kg above Eddie kilo of body weight 100 ML per hour is added to the calculated rate

301
Q

What stroke pressure variation and what delta down suggest Hypovolemia in responsiveness to fluid

A

SPV over 5 mmHg
And Delta down over 2 mmHg
Suggest hypovolemia and responsiveness to fluid

302
Q

What 2 levels are considered acceptable markers of organ hypoperfusion ?

A

Base deficit and Blood lactate level

Another one is the

Arterial to end tidal CO2 difference

303
Q

What arterial to ETCO2 difference to measure organ hypoperfusion predict mortality

A

> 10 mmHg after resuscitation

304
Q

What variables are included in the O2 delivery index ?( DO2I )

A

Hgb concentration
Arterial oxygen saturation
Cardiac output

Normal is 500ml/ min/m2

305
Q

What O2 consumption index value indicated a flow dependent phase of O2 utilization ?

A

Less than 170/mL/min/m2

306
Q

What O2 extraction ration value suggest absence of dysoxia ?

A

When lO2 extraction ratio is less than 0.25 to 0.3 ( 25 to 30% )

307
Q

CVP > 10, MAP > 65 and Hgb > 10 g/dL mean…

A

Adequate organ perfusion

308
Q

What 5 major clinical conditions should anesthetic be tailored to ?

A 
1Airway compromise 
2Hypovolemia 
3Head and eye injuries 
4Cardiac Injury 
5 Burns
309
Q

If patient have hypoxia and hypercarbia and you give them succs, you might as well Hand your license over because the patient is going to ….

A

Brady , dysrhythmias then die !!! To the morgue

310
Q

For a patient in shock , how do you dose Propofol?

A

Reduce the dose by 10 to 20%

311
Q

How do you adjust the etomidate dose in shock ?

A

No evidence of required adjustment of dose of Etomidate is shock . But … the author reduces the dose by 25 to 50 % when hypovolemia is present

312
Q

How do you calculate dose for fentanyl or remifentanil when given on hypovolemia

A

Give 1/2 dose that of healthy ppl

313
Q

What happens when you give opioids to hypovolemic trauma patients ?

A

Hypotension by inhibition of central sympathetic activity , not bu cardiovascular nor bardo receptor depressant effects .

And these trauma depends on that sympathetic activity to compensate and maintain there low BP .

314
Q

How can you prevent recall in traumatic patient in whom you cannot use anesthetics ?

A

0.6 mg scopolamine and midazolam ( if patient can tolerate that ) before airway management may decrease likelihood of recall

315
Q

What BIS level may prevent recall in Trauma patients ?

A

BIS lower than 60

316
Q

By how much does hemorrhagic shock decrease MAC

A

By 25%

Bc the trauma/shock make them release natural endorphins

317
Q

ISO can impair CO, organ blood flow and eventually cardiovascular depression despite causing little impairment of tachycardia . So can DES , so can SEVO. But at least they have _____solubility in blood and can come off quickly . What MAC should be used in these gases then ?

A

Low solubility

< 1 MAC

318
Q

If patient has severe head injury where Autoregulation and CO2 responsiveness are impaired can ISO with hyperventilating at MAC less than 1 help decreased ICO and CBF ?

A

Not even if less than 1 MAC or with hyperventilation it will not , Instead it will cause increase ICP and CBF . So wait until the skull is opened before using the ISO . Start with opioid, midazolam or etomidate

319
Q

The anesthetic agents selected for management of brain injury should produce 3 important effects :

A

1) least increased in ICP
2) Least decrease in MAP
3) greatest reduction in CMRO2

320
Q

What is most important factor causing cerebral ischemia in head injury patients ?

A

Increased ICP from intracranial hematoma

321
Q

Since anesthetics cause hypotension which goal should you maintain to prevent cerebral ischemia that results from hypotension ?

A

Avoid hypotension : MAP<60 to 70 mmHg or SBP <90 to 100 mmHg .

322
Q

CRMO2 is reduced by all IV anesthetics. TRue or false

A

Yes , even ketamine

323
Q

All IV anesthetics cause cardiologist depression which in turn reduces CPP . True or false ?

A

False , Ketamine is the only one that does not depress the heart and therefore does not reduce CPP

You can always give opioids : fentanyl 2 to 3 mcg/kg for example which decreased the amount of these IV anesthetics needed

324
Q

Why would etomidate or propofol cause increase in ICP ? ( not a trick question )

A

Etomidate > propofol cause myoclonus which can raise ICP or IOP which can be prevented by carefully timin muscle relaxant.

325
Q

All inhalation agents can decrease CBF and CBV and thus ICP . True or False

A

FALSE !

They all increase CBF&raquo_space;CBV» ICP

326
Q

All inhalation agents decrease CRMO2 while increasing CBF . True or False ?
While …
IV anesthetics decrease both CBF and CMRO2 .true or false ?

A
  1. True IA = decreased CRMO2 but increase CBF

2. True IV Anesthetics = decreased CMRO2+ CBF

327
Q

Which gas has the least uncoupling ( low CRMO2 and high CBF ) , or least vasodilatory effect and thus most widely used ?

A

Isoflurane , but DES and SEVO have comparable effect on cerebral circulation .

But ISO < 1 Mac + hyperventilation in patient with cerebral tumors or mild edema = no raise in ICP.

328
Q

When does ISO have the potential to increase CBF and ICO even when given at less than 1 MAC with hyperventilation?

A

When there is severe head injury which means cerebral auto-regulation and CO2 responsiveness are impaired .
It’s prudent not to use ISO in these patients , at least not until the skull is open . Best to use : Propofol, Midazolam or etomidate instead .

329
Q

N2O = increase CBF , CBV , ICP . You can fix that issue by by giving

A

Adequate Doses of barbiturates or hyperventilation .

330
Q

How can you give N2O so that it is not deleterious in patient with MINIMAL ICP elevation ?

A

When you give it AFTER a bolus or DURING infusion of IV anesthetics.

331
Q

Cardiac Injury

A

.

332
Q

If pt has cardiac tamponade, what 2 things MUSt be maintained .

A

Preload
And
Myocardial contractility

If you don’t the RV inflow obstruction will be worse !

333
Q

When do you administer anesthetics when caring for patient with cardiac tamponade and why ?

A

After evacuation of the pericardial blood under local. Because all anesthetics can depress myocardial contractility and cause vasodilation .

If general anesthesia is required , you only induce after patient is prepped and draped

334
Q

What vent mode goal do you have for general anesthesia with patient with cardiac tamponade ?

A

Bc both anesthesia and controlled ventilation with PEEP = decreased CO , avoid deep anesthesia and high airway pressures before evacuation of the hemopercardium .
If its chronic or chronic : use ketamine since it increases CI better than other anesthetics .

Ketamine is the agent of choice : give small doses after IV fluid blouses/infusions

Smallest possible doses of anesthetics ***

335
Q

What is your anesthetic goal if patient suffered blunt myocardial injury ?

A

Maintain contractility

Lower pulmonary vascular
resistance that result from concomitant
pulmonary contusion , etc..

only give anesthesia after restoring intravascular volume

Use inotropes preferably amrinone or milrinone
Since the have advantage of pulmonary vasodilation

Best technique to consider for maintenance
Is IV anesthetics +opioids to avoid myocardial depression produced by inhalation agents

336
Q

Anesthesia for Burns .

A

.

337
Q

what are the characteristics of hyper metabolic state :

A

Tachycardia , Tachypnea , catecholamine surge , Increased O2 consumption, augmented catabolism

338
Q

Why is early extensive and repeated escharotomy important in burn patients ?

A

It attenuates :
Hyper metabolic response
Insulin resistance

Decreases fluid loss and improve survival

339
Q

What regional block would you do for analgesia of donor site .

A

Tumescent infiltration in the form of continuous infusion of LA

340
Q

Harvesting of skin is usually taken from the lateral thigh , what block would you do ?

A

Lateral cutaneous nerve , or a TAP block

341
Q

If its anterior thigh harvest . What block ?

A

Fascia iliaca

342
Q

Burnet Torso , what block

A

Paravertebral block

343
Q

For How long after burn injury succinylcholine should be avoided

A

At least 1 year because of risk of lethal increase in potassium level when the burn size is greater than 10% TBSA

344
Q

Non depolarization and depolarising muscle relaxant response doe not change in the the 1st _____hours after burn injury

A

24 hours

345
Q

How does succ in burn cause hyperkalemia ?

A

Upregulation of of acetylcholine receptor which covers the entire muscle membrane
Extra expression of 2 new type of acetylcholine receptors + new nicotinic neural alpha-7 acetylcholine receptors

And the new nicotinic a-7 receptor can be depolarized by both succinylcholine and choline = hyperkalemia galore !

346
Q

All nondepolarizing muscle relaxants including cisatricurium in patient with burn > ___% of TBSA . That starts at _____week and peaks at ____ weeks after injury

A

> 30 % TBSA

Starts at week 1
Peaks at week 5 to 6 weeks after injury

347
Q

What is the onset delay of rocuronium used as rapid sequence induction or as treatment of laryngospasm when succ is contraindicated ?

A

Delay onset time by 50 seconds when 0.9mg/kg dose is used .

The 50 seconds is a 30% delay compare to patients without burn …
So increasing the dose to 1.2mg/kg decrease the delay by 30 seconds , but onset is still 25 to 30 seconds longer than in patient without burn .

348
Q

What are the deleterious effects of crystalloid in Trauma/Massive hemorrhage patients ?That is the physiological mechanism of it ?

A

Crystalloids have effect on the glycocalyx and the syndicate-1 ( A network of soluble plasma components on the endothelium stabilizing membrane integrity)
Massive hemorrhage alters the integrity of the endothelial glycocalyx; damage to the cell plasma is thought to be the primary mechanism of shock in these patients .

Although plasma is able to reconstitute syndican-1 , the main component of glycocalyx , crystalloids cause further destruction , worsening of the endothelial dysfunction .

349
Q

How can overinfusing fluids before the control of the hemorrhage may lead to further bleeding ?

A 
By increasing arterial and venous pressures ,
Displacing a hemostatic plug 
Diluting clotting factors and platelets 
Reducing body temperature 
Decreasing blood viscosity
350
Q

What is the dose of TXA ?

A

Given in first 3 hrs of injury
Then 1 g in 10 minute bolus followed by 1 g over 8 hours .

Or

Usual of TXA : is 10 to 15 mg/kg followed but 1 to 5 mg/kg/hr .

351
Q

If given over 3 hrs , TXA can cause what ?

A

Increase risk bleeding related of mortality

352
Q

Other benefits of TXA :

A

It helps protect the mucosa lining of the instestine and helps protect against over inflammation

353
Q

What is TXA ?

A

Competitive inhibitor of Plasmin and Plasminogen

354
Q

What is the dose for Aminoproceic acid ?

A

100 to 150 mg/kg followed by 15mg/kg/hr

355
Q

Is the leading cause of mortality after blood transfusion

A

TRALI

356
Q

Pulmonary eDema with subsequent hypoxia happening six hours after blood transfusion

A

TRALI

357
Q

Coagulopathy after trauma . 2 main categories :

A

ATc and RAc

358
Q

Each 1C drop in temp causes

A

Platelet dysfunction decrease by 10% plus enhancing fibrinolytic

359
Q

Burn hyper metabolic phase

A 
Tachycardia 
Tachypnea 
Catecholamine 
Increase o2 consumption 
Augmented catabolism
360
Q

Why early extensive eschorotomy 2nd day to 2nd week help stop hyper metabolic

A

Decrease insulin resistance
Decrease fluid requirement
Improval survival

361
Q

N2O effects on CBF CBV

A

Up the CBF CBV ICP when used with inhaled anesthetics if PaCO2 is normal or increased

Advanced Principles III (11 decks)

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