CCP 219 Single and Multi System Trauma 🩸

Question 1

American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhagic shock classification

Answer 1

links the amount of blood loss to expected physiologic responses in a healthy 70 kg patient

Question 2

Class 1 hemorrhagic shock

Answer 2

1. Volume loss up to 15% of total blood volume, approximately 750 mL
2. Heart rate is minimally elevated or normal.
3. Typically, there is no change in blood pressure, pulse pressure, or respiratory rate.

Question 3

Class 2 hemorrhagic shock

Answer 3

1. Volume loss from 15% to 30% of total blood volume, from 750 mL to 1500 mL.
2. Heart rate and respiratory rate become elevated (100 BPM to 120 BPM, 20 RR to 24 RR).
3. Pulse pressure begins to narrow, but systolic blood pressure may be unchanged to slightly decreased.

Question 4

Class 3 hemorrhagic shock

Answer 4

1. Volume loss from 30% to 40% of total blood volume, from 1500 mL to 2000 mL.
2. A significant drop in blood pressure and changes in mental status occur.
3. Heart rate and respiratory rate are significantly elevated (more than 120 BPM).
4. Urine output declines. Capillary refill is delayed.

Question 5

Class 4 hemorrhagic shock

Answer 5

1. Volume loss over 40% of total blood volume
2. Hypotension with narrow pulse pressure (less than 25 mmHg).
3. Tachycardia becomes more pronounced (more than 120 BPM), and mental status becomes increasingly altered.
4. Urine output is minimal or absent. Capillary refill is delayed.

Question 6

Hemoglobin and hematocrit in acute hypovolemic shock

Answer 6

1. Normal
2. Hemoglobin and hematocrit values remain unchanged from baseline immediately after acute blood loss
3. During the course of resuscitation, the hematocrit may fall secondary to crystalloid infusion and re-equilibration of extracellular fluid into the intravascular space.
4. “If you throw out half a pitcher of Kool-aid, it still tastes just as sweet.”

Question 7

What trauma interventions target the “coagulopathy” portion of the trauma triad

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Answer 7

1. Avoid dilutional fluid resuscitation with crystalloids
2. Early/preferential blood product resuscitation with either fresh whole blood or a 1:1:1 ratio (PRBC:plasma:platelet)
3. Allow permissive hypotension
4. Prevent hypothermia
5. TXA

Question 8

What factors of shock physiology contribute to worsening coagulopathy?

Answer 8

1. Consumption of clotting factors
2. Hypothermia
3. systemic Acidosis
4. Third spacing dilution
5. Shock liver (decreased production of clotting factors)
6. Fibrinolysis

Question 9

Discuss “permissive hypotension” in trauma cases with TBI as a competing interest

Answer 9

1. Target the brain first. Maintain MAP >80 to ensure cerebral perfusion to prevent secondary brain injury, regardless of bleeding status

Question 10

Considerations for electrolytes when transfusing large volumes of PRBCs?

Answer 10

1. Replenish calcium (due to citrate in RBCs) targeting serum ionized Ca++ >1
2. watch out for hyperkalemia d/t possible blood product cell lysis during storage

Question 11

Emergency reversal of anticoagulation from warfarin for life-threatening hemorrhage in adults

Answer 11

In descending order of preference

1. 4-factor PCC + Vitamin K
2. 3-factor PCC + Factor VIIA + Vitamin K
3. 3-factor PCC + FFP + Vitamin K
4. FFP + Vitamin K

Question 12

Assessment of Blood Consumption (ABC) score for MTP

Answer 12

1. Penetrating mechanism of injury
2. Positive FAST (Focused Assessment with Sonography in Trauma) examination (ie, evidence of hemorrhage)
3. SBP of 90 mmHg or less
4. Heart rate of 120 beats per minute (bpm) or greater

• Each positive parameter receives a score of one.
• A score of 2 or more predicts the need for massive transfusion with a sensitivity of 75 percent and a specificity of 86 percent.

Question 13

Which coagulation factors are dependent upon vitamin K for synthesis?

Answer 13

X-IX-VII-II (prothrombin group)

10-9-7-2

Question 14

Coagulation cascade intrinsic pathway

Answer 14

1. initiated by exposure of collagen in the vascular wall following trauma
2. This exposure of collagen appears to directly activate Factor XII (Hageman Factor)
3. Factor XII sets off the subsequent cascade
4. Factor XII -> Factor XI -> Factor IX -> Factor VIII -> Factor X

Question 15

Coagulation cascade extrinsic pathway

Answer 15

1. triggered by the presence of Tissue Factor that is released from injured vasculature
2. Tissue Factor in combination with Factor VII activates Factor X
3. Factor X converts prothrombin to activated thrombin.

Question 16

Coagulation cascade final common pathway

Answer 16

1. Intrinsic and Extrinsic arms converge upon activation of Factor X
2. Once activated, Factor X converts Prothrombin to Thrombin
3. Activated thrombin converts fibrinogen to fibrin

Question 17

the three stages of hemostasis

Answer 17

1. vascular phase
2. platelet phase
3. coagulation phase

Question 18

Primary haemostasis

Answer 18

the formation of a platelet plug

Question 19

secondary hemostasis

Answer 19

the activation of the clotting cascade which results in deposition of fibrin to strengthen the platelet plug

Question 20

Coagulation cascade intrinsic pathway

Answer 20

1. Begins in blood stream
2. activated when blood is exposed to collagen (damaged vessel)
3. Factor XII activated to XIIa by exposed collagen
4. XIIa activates XI to XIa
5. XIa combines with calcium, activates IX to IXa
6. simultaneously, VIII activated to VIIIa
7. IXa will join with VIIIa and form factor X activating factor
8. Factor X activated

Question 21

Coagulation cascade extrinsic pathway

Answer 21

1. Begins in vessel wall
2. Damaged endothelial cells release factor III (tissue factor)
3. factor III (tissue factor) combines with calcium, activates factor VII (hageman factor) and turns it into factor VIIa
4. VIIa activates Factor X

Question 22

targets for correcting anticoagulation in traumatic brain injury

Answer 22

1. Platelets >100
2. INR <1.5 (If supratherapeutic INR consider octaplex)
3. Target PTT <40 (If PTT too high, consider FFP)
4. If patient is heparinized consider protamine sulphate
5. Fibrinogen >1 (if fibrinogen <1 consider cryoprecipitate)
6. Target Hgb >90 (transfuse PRBC if necessary)
7. Consider TXA in low pressure bleed (such as SDH)

Question 23

antithrombin III

Answer 23

1. Antithrombin is a protein
2. functions as a naturally occurring mild blood thinner
3. blocks clotting by inactivating thrombin
4. heparin combines with antithrombin-III increasing the effectiveness of antithrombin-III by over 1000x

Question 24

Coagulation cascade final common pathway

Answer 24

1. factor Xa is activated
2. Factor Xa cleaves prothrombin to its active form, thrombin
3. Thrombin cleaves fibrinogen into its active form fibrin
4. Fibrin strands will begin to join together, and with the help of XIIIa this will cause the cross-linking of fibrin strands

Question 25

LMWH (dalteparin, enoxaparin) moa

Answer 25

1. binds to anti-thrombin III
2. LMWH is less effective at inhibiting factor IIa (acting mostly via inhibition of Xa).
3. Enhances AT effects more selectively on Factor Xa than on thrombin.

Question 26

UFH moa

Answer 26

1. binds to anti-thrombin III (AT-III)
2. this enhances antithrombin’s inhibition of several coagulation factors – especially factor Xa and factor IIa (thrombin).
3. Enhances AT effects on Factor Xa and thrombin.

Question 27

Fondaparinux moa

Answer 27

1. Binds and enhances the anti-Xa activity
   of ATIII by 300-fold
2. Enhances anti-Xa activity of ATIII
3. Specificity for AT → no binding to other plasma proteins

Question 28

UFH vs. LMWH

Answer 28

1. LMWH is easier to give logistically (doesn’t require IV infusion or monitoring).
2. LMWH has a decreased risk of heparin induced thrombocytopenia with thrombosis (HIT).
3. Studies comparing UFH and LMWH generally show that LMWH is more effective and causes less bleeding.
4. LMWH cannot be used in Renal failure (GFR < 30 ml/min).
5. LMWH cannot be used in situations where the Need to rapidly stop anticoagulation (e.g., in a patient at risk for bleeding, or pending a procedure)

Question 29

fibrinolysis pathway definition

Answer 29

1. Process of degrading the fibrin clot when it is no longer needed
2. prevents extension of clot beyond site of injury

Question 30

fibrinolysis pathway

Answer 30

1. Fibrinolysis initiated by endogenous tPA or uPA (urokinase-like plasminogen activator)
2. tPA or uPA convert plasminogen to plasmin in the presence of fibrin
3. Plasmin degrades the fibrin clot
4. Plasmin also inactivates factors Va and VIIIa

Question 31

Normal range for platelets

Answer 31

150–400 × 10⁹/L

Question 32

Normal range for INR (non anti-coagulated blood)

Answer 32

0.9–1.2

Question 33

Normal range for Prothrombin time (PT)

Answer 33

10–14 seconds

Question 34

Normal range for aPTT (non anti-coagulated blood)

Answer 34

22-30 seconds

Question 35

Normal range for fibrinogen

Answer 35

2.0 to 4.0 g/L

Question 36

Normal range for hemoglobin

Answer 36

Male 125–170 g/L

Female 115–155 g/L

Question 37

warfarin reversal

Answer 37

1. The goal of warfarin reversal is to increase the available amount of Vitamin–K dependent clotting factors, which will lead to a decrease in INR
2. Warfarin is a vitamin-K dependent clotting factor inhibitor, specifically Factors 10-9-7-2
3. treatment options include withholding warfarin, administering oral or intravenous vitamin K, fresh frozen plasma (FFP), and prothrombin complex concentrate (PCC)
4. Rapid reversal is 4F-PCC + Vitamin K. If no 4F-PCC use FFP + Vitamin K

Question 38

explain the role of prothrombin complex concentrate’s (PCC) in reversal of anticoagulation

Answer 38

1. PCCs are “pooled plasma products”
2. PCC’s contain factors 10-9-2 with variable amounts of factor 7 in a concentrated form
3. they are virally inactivated and can be given in a small volume without the need to thaw the product first
4. All PCCs contain factors 10-9-2 but some products contain no or very little factor 7
5. PCCs with normal amounts of F7 are known as 4-factor PCCs whilst the products without F7 are 3-factor PCCs
6. Octaplex is a pooled plasma coagulation factor concentrate. Each vial contains coagulation factors 10-9-7-2. It also contains protein C, protein S, albumin, heparin and sodium citrate.
7. PCC (Octaplex) provides a more rapid and effective reversal of Warfarin than FFP, and uses less volume too (less chance of volume overloading your patient)

Question 39

explain the role of FFP in reversal of anticoagulation

Answer 39

1. FFP comes in approx ~250cc bags and contains all the clotting factors
2. It is type specific (must be ABO compatible)
3. FFP contains all coagulation factors present in whole blood
4. One unit of FFP corrects clotting factors by 2.5-5% in a 70 kg person
5. Going by current dosing, to achieve the equivalent amount of factor in 8 vials of 4F-PCC, it would take 4 liters, thatʼs 16 bags, of FFP.

Question 40

reversal of heparin/LMWH

Answer 40

1. Protamine sulfate
2. Protamine sulfate binds to either heparin or LMWH to form a stable ion pair, which does not have anticoagulant activity
3. Provides rapid reversal of anticoagulation d/t heparin or LMWH

Question 41

ATLS trauma assessment

Answer 41

1. Airway
2. Breathing
3. Circulation (carotid, femoral, pelvis, FAST)
4. Disability (pupils, GCS, collar)
5. Exposure, environment

Question 42

Hemostatic goals in MTP

Answer 42

1. Hgb > 70
2. Platelets > 100
3. INR < 1.8
4. Temp > 36
5. Fibrinogen > 1.5

Question 43

cornerstone principles of damage control resuscitation

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Answer 43

1. Permissive hypotension
2. Balanced haemostatic resuscitation
3. Early Damage control surgery

Question 44

cornerstone principles of balanced hemostatic resuscitation

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Answer 44

1. Minimal administration of crystalloid
2. Prevention of acidemia
3. Reduce coagulopathy of trauma
4. prevent hypothermia
5. Early transfusion of blood

Question 45

benefits of permissive hypotension in trauma

Answer 45

Decreased:

1. Decreased blood loss
2. Decreased Intra-abdominal hypertension
3. Decreased Academia
4. Decreased Haemodilution
5. Decreased Thrombocytopenia
6. Decreased Coagulopathy
7. Decreased Apoptotic cell death
8. Decreased Tissue injury
9. Decreased Sepsis
10. Decreased Mortality
11. Decreased volumes of crystalloid administration needed
12. Decreased blood product utilisation
13. Decreased postoperative recovery time

Improved:

1. Improved organ perfusion and survival
2. Improved recovery times post injury

Question 46

What are the principles of hemostatic resuscitation in trauma?

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Answer 46

1. Minimize crystalloid use
2. Prevent acidemia
3. Reduce coagulopathy
4. Keep warm
5. Give early blood

Question 47

main causes of secondary neuronal injury in TBI

Answer 47

1. Hypoxia

2. Hypotension

Question 48

describe diffuse axonal injury

Answer 48

1. occurs as the result of shearing forces from rotational acceleration or deceleration
2. shearing has a predilection for axons and the gray−white junction due to different specific gravities of gray and white matter
3. Cells are damaged → edema

Question 49

describe Intraparenchymal hemorrhage

Answer 49

1. the accumulation of blood in the parenchyma of the brain

2. caused by disruption of small intraparenchymal vessels

Question 50

describe Traumatic SAH

Answer 50

the accumulation of blood between the pia mater and the arachnoid membrane.

potential causes include:

1. direct extravasation of blood from an adjacent cerebral contusion
2. arterial dissection
3. direct damage to smaller veins or arteries
4. sudden increase in intravascular pressure leading to rupture

Question 51

describe subdural haemorrhage

Answer 51

1. the accumulation of blood immediately outside the arachnoid membrane of the brain underneath the dura mater membrane
2. caused by tearing of small bridging veins

Question 52

describe epidural hematoma

Answer 52

1. the accumulation of blood outside the brain, between the inner surface of the skull and the dura mater
2. caused by laceration of an artery (most commonly the MMA)

Question 53

hallmark signs of concussion (mTBI)

Answer 53

1. confusion

2. amnesia (involves loss of memory of the traumatic event)

Question 54

bleeding reversal for direct thrombin inhibitors (dabigatran)

Answer 54

1. Idarucizumab
2. TXA
3. 4F-PCC

Question 55

bleeding reversal for factor Xa inhibitors (Rivaroxaban, apixaban)

Answer 55

1. 4F-PCC

2. TXA

Question 56

bleeding reversal for warfarin

Answer 56

1. Vitamin K
2. 4F-PCC
3. FFP

Question 57

bleeding reversal for UFH

Answer 57

1. Protamine sulfate

Question 58

bleeding reversal for fibrinolytic agents

Answer 58

1. Cryoprecipitate
2. TXA
3. FFP

Question 59

bleeding reversal for anti platelet agents

Answer 59

1. DDAVP

2. platelets

Question 60

bleeding reversal for LMWH

Answer 60

1. Protamine sulfate

Question 61

L 🔥 T fluid airway intubation algorithm

Answer 61

1. 45° upright positioning
2. Suction-Assisted Laryngoscopy Airway Decontamination (SALAD)
3. seldinger intubation with a large-bore suction device (bougie through the DuCanto)
4. esophageal diversion using an endotracheal tube with meconium aspirator attached
5. scalpel-finger-bougie cricothyrotomy rescue

Question 62

initial ventilator settings for post drowning

Answer 62

initial settings per ARDS protocol

1. Tidal volume 6-8 mL/kg
2. Plateau pressure <30 mmHg
3. PaO2 80-100 mmHg
4. escalating PEEP
5. gastric tube to decompress stomach and increase lung ventilation

Question 63

define “drowning” (2002 Ustein-Style World Congress on Drowning)

Answer 63

1. An air/liquid interface present at the entrance to a victim’s airway, preventing the victim from breathing air.

Question 64

describe the pathophysiology of the drowning process

Answer 64

1. drowning person has reflex inspiratory effort occurs after breath holding, gasping, or unconsciousness
2. aspiration results in laryngospasm and the ingestion of liquid
3. Hypoxia leads to unconsciousness
4. tachycardia → bradycardia → PEA → asystole → death.

Question 65

pulmonary manifestations of drowning

Answer 65

1. Saltwater vs freshwater drowning doesn’t matter (in retrospective reviews of drowning victims they found that the actual amount/volume of fluid introduced into the lungs is typically quite negligible)
2. aspirated water reaches the capillary space → surfactant destruction → disruption of the alveolar-capillary membrane → subsequent fluid shift into the alveolar space
3. results in pulmonary edema and poor gas exchange → decreased lung compliance → increased right-to-left shunting, atelectasis, alveolitis, and ARDS

Question 66

most important predictor of drowning outcome

Answer 66

time interval or duration that the victim was underwater

Question 67

CaO2 equation

Answer 67

CaO2 = (1.34 X Hgb X SaO2) + (0.003 X PaO2)

Question 68

Do2 equation

Answer 68

DO2 = CaO2 x CO

Question 69

CO equation

Answer 69

CO = HR × SV

Question 70

define oxygen consumption (VO2)

Answer 70

total amount of oxygen removed from the blood due to tissue aerobic metabolism per minute

Question 71

normal VO2 in a 75 kg adult undertaking routine activities

Answer 71

approximately 250 ml/min

Question 72

define global oxygen delivery (DO2)

Answer 72

the total amount of oxygen delivered to the tissues per minute

Question 73

define the Oxygen extraction ratio (O2ER)

Answer 73

the ratio of oxygen consumption (VO2) to oxygen delivery (DO2)

Question 74

O2ER equation

Answer 74

O2ER = VO2/DO2

Question 75

causes of increased oxygen consumption (VO2)

Answer 75

1. fever and inflammatory states (e.g. sepsis, burns, trauma, surgery)
2. ↑ metabolic rate (e.g. hyperthyroidism, adrenergic drugs, hyperthermia)
3. ↑ muscular activity (e.g exercise, shivering, seizures, agitation/anxiety/pain, ↑ respiratory effort)

Question 76

what is the purpose of a “trauma score” within the context of a trauma system

Answer 76

1. trauma scores provide an accurate, reliable and reproducible description of injuries and prediction of morbidity and mortality outcomes
2. outcome predictions are based on anatomical injury + physiological injury + patient’s reserve

Question 77

describe the “Revised Trauma Score”

Answer 77

1. Quantifies severity of trauma injuries based on GCS, blood pressure, and respiratory rate
2. Higher score associated with higher survival. Consider trauma center for Trauma Score <4

Question 78

Describe the “Abbreviated Injury Scale”

Answer 78

1. an anatomically based severity scoring system that classifies an individual injury by body region according to its relative severity on a 6 point scale
2. AIS is the system used to determine the Injury Severity Score (ISS) of the multiple injury patient

Question 79

describe the “Injury Severity Score (ISS)”

Answer 79

1. Standardizes severity of traumatic injury based on worst injury of 6 body systems
2. The ISS is a score that attempts to standardize the severity of injuries sustained during a trauma
3. Rate only the most severe injury from each body system

Question 80

define “Massive transfusion”

Answer 80

1. the replacement of ≥10 units PRBC (1x total adult blood volume) in 24hr or;
2. ≥4 units PRBCs (½ total adult blood volume) in 4-6hrs
3. ≥4 units PRBC in one hour

Question 81

what are the primary goals of treatment in transfusion of the trauma patient?

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Answer 81

1. maintaining cardiac output
2. maintaining oxygen carrying capacity
3. maintaining hemostatic potential

Question 82

define Trauma-induced coagulopathy (TIC)

Answer 82

1. an impairment of hemostasis and activation of fibrinolysis that occurs in response to severe injury
2. independent of significant acidosis, hypothermia, or hemodilution
3. mediated primarily by activation of the thrombomodulin-protein C system
4. In trauma patients without preexisting coagulation defects, a prolonged PT and/or aPTT greater than 1.5 times normal on admission defines the presence of TIC

Question 83

how much does one unit of PRBC raises the hemoglobin level by?

Answer 83

approx 10 g/L

Question 84

how much does one unit of aphaeresis platelets (6-pack) raises the platelet count by?

Answer 84

approx 50k

Question 85

what clotting factors are replaced with cryoprecipitate?

Answer 85

1. fibrinogen
2. factor VIII
3. von Willebrand factor

Question 86

thresholds for anemia in different patient population groups (per WHO guidelines)

Answer 86

1. Pregnant females: <110 g/L
2. Non-pregnant females: <120 g/L
3. Males: <130 g/L

Question 87

define anemia

Answer 87

1. Anemia is a reduced concentration of RBCs, resulting in an inadequate oxygen supply to the tissues

Question 88

normal circulating blood volume in an adult

Answer 88

1. 75-80 mL/kg body weight

2. 5-5.5 L in a 70-kg adult

Question 89

what is the effect on body temperature of transfusion of un-warmed blood

Answer 89

Each unit of blood reduces the core temperature by 0.25°C

Question 90

why is it important to monitor calcium levels during transfusion?

Answer 90

1. Plasma contains citrate, which chelates calcium.

2. Frequently check ionized calcium levels and replenish calcium as necessary.

Question 91

VGH ICU fluid resuscitation formula for burn patients in the first 24 hours

AKA “Modified Parkland”

Answer 91

1. 3mL/kg LR or Plasmalyte-A x BSA % burned

2. Run the first half of the volume in over 8 hours and the rest over the remaining 16 hours.

Question 92

VGH/BC Burn Network burn resuscitation guidelines 2020

Answer 92

1. fluid resuscitation for major burns should start at 3cc/kg/%TBSA.
2. Perform hourly calculation of “ins” and “outs”. Titrate fluid resuscitation hour-by-hour, especially in the early phase of major burns trauma. Clinical endpoints include responses in blood pressure, heart rate, and lactate clearance.
3. Titrate urine output to 30-50cc/hr for major burns (50-100cc/hr in electrical burns to facilitate clearance of myoglobin and decrease the risk of acute kidney injury).
4. Use warmed, balanced crystalloids (Ringer’s Lactate or Plasmalyte-A) in major burns
5. Keep the patient warm

Question 93

indications to suspect cyanide toxicity in a burn patient

Answer 93

1. enclosed-space fire and presence of inhalation injury with altered level of consciousness (GCS < 13)
2. profound shock (SBP < 90mmHg)
3. high serum lactic acid (lactate > 10mmol/L)
4. narrow arterio-venous gradient (PaO2 on an arterial blood gas is similar to the PaO2 on a venous blood gas).

Question 94

VGH/BC Burn Network burn referral guidelines 2020 (AKA when to transport to a burn center)

Answer 94

1. Partial thickness burns >20% TBSA in 10 – 50yo
2. Partial thickness burns >10% TBSA in <10 or >50yo
3. Full-thickness burns >5% TBSA any age
4. partial or full-thickness burns of the hands, feet, face, eyes, ears, perineum, and/or major joints any age
5. high-voltage electrical injuries, including lightning injuries any age
6. significant burns from caustic chemicals any age
7. burns complicated by major trauma in which the burn injury poses the greatest risk of morbidity or mortality. if the trauma is main problem, transport to trauma centre with later referral
8. burns who suffer inhalation injury (critical airway/unsecured to nearest ER)
9. comorbidities that could complicate management, prolong recovery, or affect mortality
10. Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a burn center with these capabilities (aka VGH versus BCCH)
11. Burn Injury in patients who will require special social/emotional and /or long-term rehabilitative support, including cases involving suspected child abuse, substance abuse, etc

Question 95

define “massive hemothorax”

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Answer 95

1. Immediate return of blood of ≥1500mL when the chest tube is thrown in
2. Other indicator is ≥200mL/hr for 2-4 hours
3. Rapid accumulation of ≥1500mL blood in chest or ≥1/3 of patients blood volume in chest
4. Indicates need for urgent thoracotomy

Question 96

six leading causes of death associated to chest trauma

Answer 96

1. Tension PTX
2. Massive HTX
3. Open PTX
4. Cardiac tamponade
5. Airway obstruction
6. Flail chest

Question 97

Populations that hide shock well

Answer 97

1. Obstetrics (changes to HR, circulating volume)
2. Pediatrics (compensate compensate crash)
3. Rate controlled (mask the tachycardia)
4. Geriatric (baseline HTN, relative hypovolemia)

Question 98

What are the three highest yield data points for shock state differentiation?

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Answer 98

1) Skin (Distributive vs ALL)
2) JVP (Hypovolemic/distributive vs cardiogenic/obstructive)
3) U/S (Cardiogenic vs obstructive)

Question 99

Key questions to ask when presented with a patient in shock

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Answer 99

1. Is the patient in shock?
2. What type of shock is it?
3. How do I reverse this kind of shock?

Question 100

describe TEG for hemostatic evaluation

Answer 100

1. TEG is a whole-blood measure of the clotting cascade. 2. TEG measures clot stiffness from the point of primary hemostasis through stabilization and subsequent fibrinolysis
2. because TEG uses whole blood, the device analyzes all components of the hemostatic system
3. TEG is the best clinically available test of the coagulation profile in cirrhotic patients
4. The R-time reflects both pro- and anticoagulant factors, allowing the technique to measure the “balanced hemostasis.”

Question 101

optimal transfusion ratio in trauma

Answer 101

1. Haemostatic resuscitation involves resuscitation with blood components resembling whole blood
2. aims to avoid or ameliorate acute coagulopathy of trauma and the complications of aggressive crystalloid fluid resuscitation while maintaining circulating volume
3. Involves blood component ratios of 1 unit PRBCs : 1 FFP : 1 unit platelets

Question 102

goals of hemostatic resuscitation approach

Answer 102

1. maintain circulating volume
2. limit ongoing bleeding
3. prevent the lethal trial of hypothermia, acidosis and acute coagulopathy of trauma

Question 103

effects of hypothermia on trauma patients

Answer 103

1. Decreases platelet responsiveness
2. Increases platelet sequestration in liver and spleen
3. Reduces clotting Factor function (Factors XI and XII)
4. Leads to fibrinolysis

Question 104

effects of acidosis on trauma patients

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Answer 104

1. pH strongly decreases activity of clotting Factors V, VIIa and X
2. Acidosis inhibits thrombin generation
3. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias

Question 105

what are the problems associated with Large volume crystalloid resuscitation in trauma

Answer 105

1. Large volume crystalloids can → dilutional coagulopathy and exacerbate bleeding
2. Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock
3. large volume crystalloid resuscitations → tissue and organ edema → organ failure (eg pulmonary oedema, abdominal compartment syndrome)

Question 106

how does ARDS relate to trauma (how does trauma lead to ARDS)

Answer 106

1. Severe trauma predisposes to ALI and ARDS
2. development of ARDS may be related to mechanism of injury (eg, lung contusion, long bone fracture leading to fat embolism) or resuscitation (eg, transfusion)
3. In a study that included 1762 patients with major traumatic injury, ARDS occurred in 24%
4. Predictors of ARDS after trauma included increasing subject age; increasing APACHE II score; increasing injury severity score; and the presence of blunt injury, pulmonary contusion, massive transfusion, or flail chest.

Question 107

what are the 5 sites of clinically significant bleeding?

Answer 107

1. external (eg slashed wrists)
2. intrathoracic
3. intraperitoneal
4. retroperitoneal
5. pelvic or long bone fractures

Question 108

Steps to diagnosing air leak in chest tube

Answer 108

1. Persistent bubbling at the water seal indicates an air leak within the lung, tubing, or connections.
2. If the leak is within lung and the patient is mechanically ventilated, look at the set Vt, compared with the exalted Vt, to determine how much mL of air you are losing.
3. Clamp the chest tube near the chest wall. If this stops the leak, it is either a BPF or leakage from incision site. Seal up the incision site real good. Still leaking with clamp? BPF
4. If leak does not stop with proximal clamping, your drainage system is fucked. Do sequential clamping down the hose away from the patient to find the spot. Check all connections

Question 109

minimum suction pressure needed to operate the chest drain system at -20 cmH20 (water seal system or dry system)

Answer 109

1. To operate the chest drain at -20 cm H20, wall suction must have at least -80 mm Hg of vacuum.

Question 110

If a chest drainage unit is not connected to suction, how is it draining fluid from the chest cavity?

Answer 110

gravity draining

Question 111

explain chest tube tidaling

Answer 111

1. With a chest tube in the pleural space, the water level should fluctuate in the water seal chamber (tidaling) corresponding with respiration
2. When there is no air leak, the water level in the water seal chamber should rise and fall with the patient’s respiration
3. During spontaneous respiration (negative pressure breathing), the water level will rise during inhalation and fall during exhalation
4. during positive pressure ventilation (positive pressure breathing), the oscillation will be opposite. the water level will fall during inhalation and rise during exhalation
5. If tidaling doesn’t occur, the tubing could be kinked or clamped, or CT/tubing section may have become clogged

Question 112

The management of Traumatic Brain Injury (TBI) is focused on the prevention of _______ injury

Answer 112

secondary