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Trauma > Circulation > Flashcards

Circulation Flashcards

1
Q

Name 5 indications CVP insertion

A
  • Infusion inotropes
  • total parenteral nutrition
  • haemodynamic monitoring
  • poor peripheral venous access
  • provide venous sheath access to place other devices eg cardiac monitors
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2
Q

Name 4 relative contraindications CVP

A

No absolute. All can be resolved by selecting alternative site.
• coagulopathy
• thrombocytopenia
• thrombosed target vein
• infected area at catheter site insention

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3
Q

Name 5 complications CVP

A 
Mechanical
• bleeding
• haematoma
•Pneumothorax
• arterial puncture
• haemothorax
Infections
Thrombotic
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4
Q

Which CVP insertion site has the least complications?

A

Subclavian

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5
Q

Name 3 sites CVP insertion

A

Subclavian (best)
Internal jugular
Femoral (most complications)

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6
Q

Which position should patient be for internal jugular CVP insention?

A

Trendelenburg

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7
Q

Which technique is best for CVP insertion?

A

Seldinger technique (over guide wire )

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8
Q

How many skin sutures to secure CVP ?

A

4

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9
Q

anatomical course of subclavian vein? (4)

A
  • Begin at lateral border first rib from axillary vein
  • run anterior and inferior to artery
  • Cross clavicle just medial to mid-clavicular point 2 cm lateral, 2 cm caudal to middle third clavicle.
  • join internal jugular vein medial to anterior scalene muscle to form brachiocephalic vein behind sternoclavicular joint
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10
Q

Surface marking for subclavian vein for CVP insertion?

A

Junction of middle and lateral thirds of clavicle

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11
Q

Anatomical course of internal jugular vein? (5)

A
  • Originate within posterior part of floor of tympanic cavity and is continuous with sigmoid sinus. Origin demarcated by superior bulb of internal jugular vein.
  • descends in carotid sheath with carotid artery, just lateral to artery. Cn x lie between artery and vein.
  • descend into thorax posterior to space between 2 heads of scm muscle in anterior triangle
  • this relationship not present in 20% - may lie deep, medial or superfical to carotid artery
  • unite with subclavian vein to form brachiocephalic vein.
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12
Q

Surface marking for insertion CVP in internal jugular?

A

Apex of triangle formed by scm heads and clavicle, lateral to carotid pulse. Aim for ipsilateral nipple.

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13
Q

Name 5 signs limb ischaemia (arterial injury)

A 
5 p
Pulselessness
Pain severe
Pallor
Poikilothermia (cold limb)
Paralysis
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14
Q

What causes pneumopericardium?

A

Penetrating pericardial injury

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15
Q

Name 3 xr signs mediastinal haemorrhage

A
  • Widened mediastinum
  • left apical pleural cap
  • deviated trachea or ngt to the right.
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16
Q

Define shock

A

Inadequate organ and tissue perfusion with oxygenated blood

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17
Q

Name 4 major types of shock and 3 examples of each

A

1 • Hypovolemic : haemorrhagic vs non-haemorrhagic. haemorrhage, severe burns, high output fistulas , dehydration, ascites…

  1. • cardiogenic: cardiomyopathic vs arrythmic vs mechanical. blunt myocardial injury, dysrhythmias, mi, congestive heart failure, cardiomyopathy…
  2. • distributive (vasodilation): septic, neurogenic/spinal, anaphylactic, sirs, drug and toxin induced, endocrine
  3. • obstructive: tension pneumothorax, cardiac tamponade, pulmonary embolisms, aortic stenosis. Constrictive pericarditis, abdominal compartment syndrome
  • neuropathic: drugs (type distributive)
  • endocrine: adrenal failure, addison’s, myxedema (type distributive)

SHOCKED: septic, spinal/neurogenic, hemornhagic/ hypovolemic, obstructive, cardiogenic, anaphylactik , endocrine, drugs (neuropathic distributive)

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18
Q

Name 5 early clinical signs of shock

A
  • tachycardia - first sign!
  • Tachypnea
  • narrow pulse pressure ( sbp decrease first)
  • cool extremities
  • reduced capillary refill
  • reduced CVP
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19
Q

Name 3 late clinical signs of shock

A
  • Hypotension
  • altered mental status
  • reduced urine output
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20
Q

In which types shock will there be warm skin?

A

Septic and neurogenic/spinal

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21
Q

What will blood gas values show in shock? (3)

A

Metabolic acidosis
• high lactate
• low ph
• high (negative ) base deficit

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22
Q

Most common type shock in trauma?

A

Haemorrhagic/ hypovolemic

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23
Q

Normal CVP? (Cm H2O and mmhg)

A

5-10 cm h2o or 2-6 mmhg

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24
Q

Name 5 causes raised CVP

A 
>10 cm
• fluid overload
• heart failure
• increased intra-thoracic pressure
• pulmonary embolism
• vasoconstriction
Decreased venous compliance, reclining, squatting, valsalva , resp pump, muscle pump
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25
Q

Name 3 causes decreased CVP

A

<5 cm
. Fluid loss (hemorrhage, vomiting, burns, ketoacidosis)
• excessive use diuretics
• vasodilation (medications, sepsis, neurogenic shock)

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26
Q

Beck’s triad for cardiac tamponade?

A
  • Hypotension
  • distended neck veins
  • muffled heart sounds
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27
Q

Borders of the “cardiac box”?

A

Significance: high risk that penetrating injury here could involve heart.
• from below clavicles to xyphoid
• from right mid clavicular line to posterior mid-line

28
Q

Name 2 early physiological response to shock

A

Tachycardia

Cutaneous vasoconstriction- cold skin

29
Q

Normal CPR ratio

30
Q

How often should breaths be given in CPR if patient has advanced airway

A

1 every 6 seconds

31
Q

Name the 4 cardiac arrest rhythms

A
  1. Asystole
  2. Ventricular fibrillation
  3. Ventricular tachycardia pulseless
  4. Pulseless electrical activity
32
Q

Name the 2 shockable cardiac arrest rhythms

A
  • Ventricular fibrillation

* pulse-less ventricular tachycardia

33
Q

Name 3 scenarios in which you would consider stopping CPR

A
  • no reversible cause: hypovolaemia, oxygenation, tension pneumo, tamponade (hott)
  • no shockable rhythm
  • compressor is too tired to continue
34
Q

Name 6 complications of massive transfusion protocol

A

1 hypothermia

  1. Dilution coagulopathy
  2. Hypocalcemia
  3. Volume overload
  4. TRALI- transfusion related acute lung injury
  5. Transfusion reactions
35
Q

Fluid of choice for initial management shock?

A

Crystalloid’s: ringers, plasmalyte

36
Q

How tell difference between cardiac tamponade and tension pneumothorax clinically?

A
  • Normal or reduced air entry vs none

* normal percussion vs hyper-resonant

37
Q

Name 5 symptoms and signs cardiac tamponade

A 
• Beck's triad in <35%:hypotension, distended neck veins, muffled heart sounds
• abnormal GCS common
• ipsilateral haemothorax common
• anal sphincter relaxation with soiling
. Shock hypovolemic
• low voltage ECG
38
Q

Initial management cardiac tamponade ? (4)

A

• Secure airway
. Ventilate and oxygenate
• minimal fluid resus. Sometimes blood necessary but often not.
• pericardiocentesis while await surgery or transport

39
Q

Definitive management cardiac tamponade ? (3)

A
  • Emergency sternotomy or thoracotomy
  • evacuate blood
  • suture cardiac injury
40
Q

Formula for awake shock index? (ASI) interpretation?

A

Bp/ hr
> 0,9 chance for massive haemorrhage
Normal 0,5 - 0,7

41
Q

Name the symptoms of class 1 haemorrhage and treatment.

A

None except anxiety. Compensated

<15% blood loss (less than 750ml)

42
Q

Name the symptoms of class 2 haemorrhage and treatment. (4)_

A 
Tachycardia >100
Ventilatory rate 20-30
urine output 20-30 ml /h
Still compensated
Treat with crystalloids
15-30% loss (750-1500 ml )
43
Q

Name the symptoms of class 3 haemorrhage and treatment. (5)_

A 
• Tachycardia >120
• ventilatory: rate 30-40
. SBP decreased
• urine output 5-15 ml . /h
No longer able to compensate. Need transfusion.
30-40% loss. 1500 - 2000 ml
44
Q

Name the symptoms of class 4 haemorrhage. (4)_

A 
• Tachycardia > 140
• ventilatory. rate >35
. SBP greatly decreased
• urine output minimal.
Minutes to live.
> . 40% loss. 2000 ml
45
Q

Compression rate of CPR?

A

100- 120 per min

46
Q

How often rotate compressors CPR?

47
Q

Which 3 things make a difference in patient survival after cardiac arrest and CPR?

A
  1. High quality CPR
  2. Early defib
  3. Find and treat cause
48
Q

Name 10 reversible causes of cardiac arrest

A 
5 Hs
Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypo/hyper Kalaemia
Hypothermia

5 Ts
Tension pneumo
Tamponade
Toxins 
Thrombosis (pulmonary)
Thrombosis (coronary)
49
Q

When should one consider stopping CPR? (3)

A
  • no reversible cause
  • no shockable rhythm
  • compressor too tired to continue
50
Q

How calculate mean arterial pressure?

A

[ SBP + (2x dbp)] /3

51
Q

Define massive transfusion (3)

A 
>10 units packed RBC within first 24h of admission (restore entire blood volume)
Or
>4 units in 1 hour
Or
Replace 50% blood volume in 4 hours
52
Q

How and when should tranexamic acid (cyclocapron) be administered for haemostatic resuscitation?

A
  • Must be administered within 3 hours injury otherwise increase risk bleed (antifibrinolytic)
  • 1g loading dose over 10 min followed by infusion of 1 g over 8 h iv
53
Q

Name 3 endpoints of resuscitation and how to achieve

A
  1. Haemodynamic - restore do2 by volume loading (improve preload and co) and optimize hb
  2. Metabolic - eliminate tissue acidosis. Measure serum lactate, base deficit and ph
  3. Regional perfusion - cap refill, core-peripheral temperature difference, loc, splanchnic oxygen delivery, ileus, inadequate hepatic oxygen delivery, lack renal blood flow
54
Q

During pericardiocentesis , towards where is needle pointed?

A

Tip of left scapula

55
Q

Most reliable sign of cardiac tamponade?

A

Pulsus paradoxus

56
Q

Ideal site for intraosseous puncture and infusion?

A

1 cm below and medial to tibial tubercle

57
Q

Acute effect of NSAIDs on hypovolaemic patients?

A

Acute glomerular necrosis

58
Q

How long after Acute limb ischaemia does nerve damage occur?

A

After 4-6 hours

Irreversible after 12 hours

59
Q

Gold standard of diagnosing vascular injury?

A

Arteriography

60
Q

Name 8 signs or injuries of possible vascular injury needing imaging of mediastinum

A

• Fracture first and second ribs, sternum and scapula
. Sterno - clavicular joint dislocation
• trans axillary gunshot
. Widened mediastinum xray
• obliteration aortic notch, left apical pleural cap, aorta-pulmonary window
. Left haemothorax
• oesophageal and tracheal deviation to right
• depression left main bronchus

61
Q

Name 6 signs of possible vascular injury needing imaging of limbs

A
  • Multiple fractures
  • multiple penetrating injuries
  • shotgun
  • knee or elbow dislocation
  • degloving injury
  • gunshot tract along axis of vessel
62
Q

Name 6 indications prophylactic fasciotomy

A
  • prolonged hypotension
  • extensive soft-tissue injury
  • arterial and venous injury
  • bone plus vascular injury
  • delayed vascular repair more than 6 hours
  • inability to assess patient eg head or spinal injury
63
Q

Name indications therapeutic fasciotomy

A

Concerned about development of compartment syndrome
Signs = increased tissue turgor and extensive deep haematoma in presence of ischaemia
Nb to do fasciotomy before vascular repair to avoid ischaemia reinfusion injury

64
Q

Where is venous cutdown on great saphenous vein usually performed?

A

1 cm ant to medial malleolus

65
Q

Defib energy/voltage setting for shock?

A

Most are biphasic: 120-150 J (increase joules with each shock given)

If monophasic, give 360 J

Trauma (21 decks)

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