Casefiles 3: blunt trauma, hemorrhagic shock, penetrating abd. trauma, burns Flashcards
FAST
Focused Abdominal Sonography for Trauma
a quick US designed to detect pericardial effusion and intra-abdominal free fluid
especially helpful for evaluation of the hemodyamically unstable, multiple trauma patient.
four areas evaluated in the FAST
pericardial space, right upper quadrant subhepatic space, left upper quadrant perisplenic space, and pelvis.
diagnostic peritoneal lavage (DPL) helps to identify ?
intraperitoneal bleeding as the cause of the hypotension. Positive results can be based on aspiration of greater than 10 mL of blood or enteric contents from the peritoneal cavity
-get cell count analysis if no blood, positive lavage is WBC count more than 500 cells/mm3 or RBC count of more than 100,000 cells/mm3
what is abdominal CT scan good for in the blunt trauma patient?
solid organ injuries, retroperitoneal injuries, and peritoneal fluid
- don’t use for unstable trauma pt
- lacks sensitivity or specificity for hollow viscous injury identification
the Pan-scan includes ?
CT imaging of the brain, c-spine, chest, abdomen, and pelvis
? is rarely the cause of hemodynamic instability in a trauma patient; therefore, the evaluation should be directed toward identification of a ?
rarely TBI
bleeding source or mechanical source (such as tension pneumothorax).
what clinical feature in a TBI patient contributes to secondary brain injury and worse neurologic outcomes?
Persistent hypotension
prioritization of his injuries example
treatment of the pneumothorax (airway)
to supportive care and monitoring of his TBI
to reduction of the fractured left lower extremity to improve the circulatory status to the left lower extremity
to repair of his superficial scalp lacerations
Laboratory tests are an adjunct to the s/s of shock and include the use of ?
base deficit calculated from arterial or venous blood gas or lactate
Rotational thromboelastometry (ROTEM) and thromboelastography (TEGS) assesses ?
the quality of the clot formation in the injured patient.
allows the physician to decide if the patient needs PRBCs, FFP, platelets, or cryoprecipitate.
hemostatic resuscitation
packed red blood cell:FFP:platelets in a ratio of 1:1:1
several conditions mandate operative interventions after penetrating trauma include ?
peritonitis, evisceration, and hemorrhagic shock
The use of ? can reverse the coagulopathy associated with the use of Coumadin
factor IX prothrombin concentrates
-essential for patients who are bleeding and have no margin for expansion of the process like in a closed head injury.
If the patient is in shock with distended neck veins and midline trachea, what is the diagnosis?
pericardial tamponade
The early administration of this anti-fibrinolytic agent soon after major injuries (within 3 hours of injury) has been shown to produce lower transfusion requirement and improved survival in a randomized controlled clinical trial (CRASH-II Trial)
tranexamic acid (TXA)
massive transfusion generally defined as ?
greater than or equal to 10 units of PRBC transfusion over a 24-hour period
patients that may require massive transfusion
systolic BP less than 110 mm Hg, HR greater than 105, hematocrit less than 32%, and pH less than 7.25 in a trauma patient with high injury mechanism (high-speed motor vehicle crash, penetrating truncal injury, fall from height, and auto vs pedestrian crash).
“lethal triad”
often associated with severe injuries and large volume blood losses
hypothermia, acidosis, and coagulopathy
initial negative FAST examinations do not reliably rule-out ?
intra-abdominal injuries in stable patients with abdominal penetrating trauma.
single SW to the epigastric region and signs of shock that include diaphoresis, tachycardia, and marginally low blood pressure + diffuse abdominal tenderness that is suggestive of peritonitis
best next step?
exploratory laparotomy
SW to RLQ with +DPL (7000 RBC/mm3 and 750 WBC/mm3)
what is next best step?
laparotomy
NOT diagnostic laparoscopy
immediate and late complications of major burn trauma
early: Airway compromise and tissue hypoperfusion
late: wound sepsis, functional loss, and psychological trauma
what are the most critical interventions during initial management of severe burn victims
intubation and the initiation of mechanical ventilation
two 2nd degree burn types and treatments
Superficial partial-thickness: topical wound care such as silver sulfadiazine
Deep partial-thickness: often treated by excision and skin-grafting
3rd degree burns
Full-thickness burn of the skin involving the entire epidermis and dermis layers
painless, appear white or black with a leather-like appearance
Parkland Formula
(Affected TBSA%) × (4 mL of Lactated Ringer) × (weight of patient in kg).
1/2 of the calculated volume is given over the first 8 hours and the remainder given over the subsequent 16 hours.
The rate and volume of administration are adjusted to keep urine output between 0.5 and 1.0 mL/kg/h.
Modified Brooke Formula
lactated Ringer 2 to 4 mL/kg×% TBSA during the first 24 hours, with 1/2 of the volume given in the first 8 hours and the remaining fluid in the subsequent 16 hours.
During the second 24 hours, colloid fluid (5% albumin in lactated ringer) is given at 0.3 to 0.5 ml/kg×% TBSA titrated to maintain urine output of more than 0.5 mL/kg/h.
escharotomy
incision made in the “leathery” and nonexpansive full-thickness burn sites to help improve tissue perfusion if there is a circumferential burn wound in the extremities
-can be made in truncal region
A topical agent most useful for full-thickness, infected burns which can penetrate eschars
Sulfamylon (Mafenide)
drawbacks: pain with application and metabolic acidosis relating to its carbonic anhydrase inhibition activities
Silver Sulfadiazine (SS)
most commonly applied topical agent for superficial burn wounds
soothing, but can’t penetrate eschars or help infected burns
Silver Nitrate
topical burn wound agent. It has limited eschar penetrance and turns tissues a black color; also leaches Na+ and Cl- from tissue
Major burn wounds are generally defined as injuries with ? TBSA involvement
more than 20%
if this large will produce systemic inflammatory responses and interstitial edema in tissues and organs away from the injured areas
All victims rescued from the scene of closed-space fires should have their ? levels measured. level of greater than 30% can produce permanent central nervous system (CNS) dysfunction, and a COHgb level greater than 60% can produce coma and death.
carboxyhemoglobin (COHgb)
level of greater than 30% can produce permanent (CNS) dysfunction, and a COHgb level greater than 60% can produce coma and death.
The half-life of CO in the blood in a patient receiving room air is ?; whereas, the half-life of CO in a patient receives 100% oxygen delivered through an endotracheal tube by a ventilator, is ?
250 minutes
reduced to 40 to 60 minutes
Inflammatory mediators such as prostaglandins, thromboxane A2, and reactive oxygen radicals are released from injured burned tissues, which produce ?
local edema, increased capillary permeability, decreased tissue perfusion, and end-organ dysfunction
rule of 9’s adult
whole head: 9 front chest: 9 back chest: 9 front abdomen: 9 back abdomen: 9 whole arm: 9 front leg: 9 back leg: 9 genitalia: 1
rule of 9’s infant
front head: 9 back head: 9 front chest: 9 back chest: 9 front abdomen: 9 back abdomen: 9 whole arm: 9 front leg: 7 back leg: 7
desired UOP
adults: UOP of 0.5 mL/kg/h is sufficient
children: UOP of 0.5 to 1.0 mL/kg/h is desirable
infants: UOP of 1 to 2 mL/kg/h is strived for
what are indications of abdominal compartment syndrome and are potential indications for abdominal decompression?
Bladder pressures greater than 20 mm Hg plus at least one additional organ dysfunction
signs of extremity hypoperfusion and suggest the need for decompressive procedures such as escharotomies and/or fasciotomies
Impaired capillary refill, increasing pain, and paresthesias
major types of biologic dressings applied for temporary wound coverage
Porcine or bovine xenografts, cadaver skin, and acellular dermal matrix
after the resuscitation phase, the optimal goal in the management of burn wounds is to ?
excise the burn wounds and provide early coverage with autologous split-thickness skin graft to facilitate early wound coverage and to minimize the risk of wound sepsis
systemic burn complications
- hypermetabolic state
- activation of the complement and coagulation pathways leading to microvascular thromboses, capillary leak, and interstitial edema
- subsequent counter-regulatory anti-inflammatory response that produces immune-suppression and susceptibility to nosocomial infections and sepsis
other burn complications
AMS, pneumonia/resp. failure, myocardial depression, VTEs, GI ulcers, acalculous cholecystitis, pancreatitis, and hepatic dysfunction, infection, corneal abrasions/ulcerations, burn scars, psychosocial trauma
patients recommended for transfer to burn center
- younger than 10 y or older than 50 y with full-thickness burn more than 10% TBSA
- Any age with TBSA burn more than 20%
- Partial- or full-thickness burn involving face, eyes, ears, hands, genitalia, perineum, and over joints
- Burn injury complicated by chemical, electrical, or other forms of significant trauma
- Any patient requiring special social, emotional, and long-term rehabilitative support
Candidates for outpatient burn treatments
some adults with partial-thickness burns measuring less than 10% TBSA, children and elderly patients with less than 5% TBSA burns, and adults with full-thickness burns measuring less than 2% TBSA.
burn degrees
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