Chapter 22, part 2 Flashcards
Secondary chest survey
A portable AP chest radiograph should be obtained fi not already performed.
Blunt chest trauma
If subjected to high-speed deceleration injury and are found to have any findings suspicious of an injury to a great vessel, should be evaluated for aortic transection
What is the study most often used to evaluate for traumatic aortic injury?
Contrast chest CT
What remains the criterion standard for detection of thoracic aortic injury and should be performed in the case of an equivocal CT or TEE?
Contrast aortography
Unstable pt with a penetrating abdominal wound
Emergent exploratory laparotomy is indicated
Stable pt with a stab wound to anterior abdominal wall
Local wound exploration in performed
If the anterior fascia is violated, exploration in the OR is mandated
Stable pts who have a stab wound to the back or flank
Contrast-enhanced CT scan is used to identify retroperitoneal and intraperitoneal injuries
Pt with localized tenderness over the thoracic or lumbar spines
CT of the thoracic and/or lumbar spine with image reformatting is the best imaging modality, esp if a spiral CT eval of the chest, abdomen, and pelvis has already been performed
How is the stability of the pelvic ring and pelvis evaluated?
Medial and AP compression or, if questionable, by AP pelvic radiograph
Unstable pelvic fxs
Need to be immediately stabilized by some form of circumferential compression to close down pelvic volume and help tamponade venous bleeding
This can be accomplished by commercial device or bedsheet
Rectal tone exam
Assessed to evaluate for gross bleeding, SCI, and the position of the prostate in males
In females with a pelvic fx, the vagina should be inspected to r/o vaginal wall disruption and bleeding
Extremity exam
All should be examined for deformity, bruising, lacerations, penetrating injury, soft tissue injury, peripheral pulses, and neurologic function
What are hard signs of vascular injury?
Pulsatile bleeding Expanding hematoma Palpable thrill Audible bruit Regional ischemia Diminished or absent pulses
What are soft signs of vascular injury?
Hx of active bleeding
Stable nonpulsatile hematoma
Neurologic deficit d/t primary nerve injury
Proximity of wound to major vascular structures
Causes of extremity compartment syndrome
Severe soft tissue injury Hematomas Fxs Arterial injuries Massive fluid resuscitation
What can be associated with femur fxs?
Significant internal bleeding as the thigh configuration becomes more spherical and less cylindrical
Tx of femur fxs
Traction splint for immobilization and reestablishment of nl thigh architecture
Consequences of compartment syndrome
Muscle necrosis Myoglobinuria Renal failure Vascular compromise Limb loss
S/sx of increased interstitial tissue pressure and decreased tissue perfusion
Pain (esp with passive motion) Paresthesias Swollen tense extremity Paresis or paralysis Loss of peripheral pulses (late finding)
How does CPAP work?
Delivers oxygenated air with positive pressure to the airways continuously throughout the respiratory cycle
Decreases the overall work of breathing (WOB) by recruiting previously unventilated, atelectatic alveoli; increasing functional residual capacity, and enhancing overall lung compliance
When is CPAP beneficial?
Pts suffering from restrictive and neuromuscular lung diseases, and it has been shown to reduce the need for intubation when compared with conventional therapy in pts with acute COPD exacerbations
Used in the tx of OSA
How does BiPAP work?
Delivers a set volume at positive pressure with inhalation while maintaining a separate amount of PEEP during exhalation
When is BiPAP most beneficial?
Hypoventilating pts with hyperinflated lungs, as in emphysema
OSA when pts cannot tolerate CPAP.
Volume control ventilation
Delivers a preset volume of oxygenated air to the pt with each breath
What are the two most commonly used modes of volume control ventilation?
Assist control
Intermittent mandatory ventilation
Assist control (AC) mode
The ventilator is triggered to deliver a preset volume of gas with each pt breath.
A RR is also preset, ensuring that a sufficient minute volume is delivered to the pt
Intermittent mandatory ventilation (IMV) mode
The pt can breath spontaneously without full assistance from the ventilator
spontaneous breaths may be supported with some pressure, but a fixed volume is not delivered
Synchronized intermittent mandatory ventilation mode
A variation of IMV, which synchronizes the ventilator with the pt so that delivered breaths are initiated only after the pt exhales completely
Pressure control (PC) ventilation
The peak inspiratory pressure (PIP) rather than volume is preset, and tidal volumes vary depending on lung compliance
RR is also preset, and gas flow in this mode is either time cycled or flow cycled
Pressure support ventilation (PSV)
A variation of the PC mode that requires a spontaneously breathing pt.
Every pt breath triggers the ventilator to deliver a preset amount of positive pressure
Popular weaning mode
Mixed mode ventilation strategy
PSV is often combined with IMV or CPAP when attempting to wean pts from ventilatory support
Permissive hypercapnia
A strategy utilized to minimize barotrauma and volume trauma to the lung
Inverse ratio ventilation increases the inspiratory time to >50% of the respiratory cycle, increasing mean airway pressure and recruiting alveoli by auto-PEEP
Airway pressure release ventilation (APRV)
A relatively new mod of ventilation that has gained significant popularity int he tx of ARDS
It is a time-triggered, pressure-limited, time-cycled mode of mechanical ventilation that can be conceptualized as high CPAP with regular, brief, intermittent releases of airway pressure, which allow for ventilation
