CNS and Musculoskeletal Trauma Flashcards
Age 15-24 yrs old are more apt to be involved in what types of trauma
MVC and violence often involving ETOH
Age >75 yrs old are more apt to be involved in what types of trauma
Falls
How many head injuries in the US per yr
1.6 million
How many permanent neurologic injuries in the US per yr
70,000-90,000
Types of primary traumatic brain injuries
Skull fx, vascular injuries, subdural and epidural hemorrhage, brain parenchyma injuries such as contusions and axonal injuries
Types of secondary traumatic brain injuries
Occur after the initial event and potentially preventable
Types of preventable secondary injuries are
Hypoxia, hypercapnia, hyperthermia
Secondary injuries may involve
Reperfusion, superoxide production, exciotoxic amnion acid release, necrosis and apoptosis
What types of skull fractures require early surgery to decrease the incidents of meningitis
Open skull fx, deep scalp lacs and fractures extending into sinuses
Are all skull Fx assoc with intarcrainal lesions
NO, but it should alert the CRNA to a potential underlying brain injury
What is the most common focal intracranial injury
Subdrual hematomato, yes tomato, LOL
What percentage of TBI have hematomatos
24%
What TBI has the highest mortality rate
Subdural Hematomatos (squishy tomato’s)
How do you fix a subdural hematomato
surgical decompression
What percentage of TBI have eipdural tomatoes
6%
Classic presentation of an epidural hematomato
period of lucidity followed by neurologic decompensation and coma
Do all epidural hemotomatos need surgical intervention
NO small ones can be observed
Where is a cerebral contusion/hemotomato located
In the brain parenchyma
Determinants of outcomes for cerebral contusion/hemotomato are
GCS, presence of hypoxia, hematomato volume
Interventions may include
Surgical evacuation, with or without craniotomy if elevated Intercarranial hypertension is present
Diffuse injuries are caused by
acceleration deceleration or rotational injuries
The best diagnostic tool for diffuse injuries is
MRI
Diffuse injuries are classified as
Mild- coma 6-24 hr, Moderate- >24 hrs without decerbrate posturing, Sever- > 24 hrs with decerbrate posturing or faccidity
CRNA goals are to prevent further ________ injuries
secondary
Contribution cerebral factors to secondary TBIs
Increased ICP, expanding mass leasions, hypercapnia, hypoxia, venous obstruction with positioning and C collar, hypotension causing compensatory cerebral vasodilation, hyperventilation, SZ, and vasospasm.
Contribution systemic factors to secondary TBIs
hypotension, hypoxia, anemia, hypoventilation, hyperglycemia, hyponatremia, hyperosmolar state, coagulapathy
Preferred method of intubation? nasal or oral
Oral
Drugs to facilitate Intubation
Propofol, Etomidate, Lidocaine 1.5 mg/kg, Sucs vs Roc (Roc you buy till you get a twitch) Keep FIO2 at 100%, PaCO2 low normal range
Goals for TBI ICP is a CPP of
60-70
Goals for MAP without ICP monitoring
MAP 70-80
While restoring intervascular volume with isotonic IVF can you use vasopressors
YES!!!!
Strong Indications for ICP monitoring
Sever head injury (GCS 40, motor posturing, SBP < 90
Possible indications of ICP monitoring
Head injury and unable to follow neuro exam due to ETT placement with deep sedation or immediate non-neurosurgical procedure
Ways to decrease ICP are
Decompression, elevate the HOB, Hyperventilation to reduce PaCO2, osmotic diuretic w a loop diuretic, use propofol and a minimum volatile agents
volatile agents lead to an increase or decrease in ICP
Increase due to increase CBF
Goals of Musculoskeletal Trauma Treatment
resuscitation, pain relief, improved stability and alignment, enhanced mobility, restoration of function
MS resuscitation what type of shock is the most common
Hypovolemic Shock
What type of MS trauma causes Hypovolemic shock
Long bone and Pelvic FX
Pain induced sympathetic discharge causes
hyper-inflamatory response and increased morbidity and mortality, Splinting causes impaired ventilation
Within 24 hr the following Fx should be stabilized
pelvis, femur, acetabulum fx
Early fixation by intramedulary nails, plates and external fixation devices reduce the following
Morbidity, ARDS, sepsis
Why are fractures definitively treated on a delayed basis
allows for swelling to decrease and improves wound healing
The following can be life threatening MS injuries
Multiple Fx, pelvic Fx, Femur Fx, and when assoc with massive hemorrhage
Average blood loss for a femur Fx
1500 mls
Blood loss for a pelvic Fx can range for what to what
3 to 10 L
75% of vascualr trauma are from what type of trauma
Penetrating
Compartment Syndrome is
A rise in interstitial pressure in a closed osteofascial compartment, compromising capillaries and causeing tissue ischemia
Compartment Syndrome causes
Fractures, sever soft tissue injury, arterial hemorrhage
Compartment Syndrome occurs most commonly
lower legs and volar forearm
Only treatmentf or Compartment Syndrome is
fasciotomy
Urgent MS Problem requiring surgery in 6-8 hrs
Open fx, traumatic arthrotomy, dislocations, displaced femoral neck fx
Preop considerations for Ortho trauma
Degree of urgency,Full stomach,Uncleared spines Positioning injuries, Hypothermia, Major blood loss, Tourniquet problems with injury to underlying nerves, muscle, blood vessels Fat embolism after long-bone fractures with delayed emergence, ARDS, cardiovascular collapse Deep venous thrombosis Compartmental syndrome Severe postoperative pain
ETOH causes what in trauma Pt
vasodilation and inability to shiver, suppression of ADH, decreased airway reflexes and a decrease in MAC
Cocaine in trauma Pt can cause
coronary spasms, Iso can cause arrhythmias, Precedex and versed are good choices for anesthesia
Amphetamines in trauma Pts
Decrease MAC due to dopaminergic and serotonergic depletion
Weed in trauma Pts
tachycardia and vasodilation may manifest as orthostatic hypotension, Antisialogogic properties may actual facilitate intubation Chronic use has no effect on MAC, Decreased MAC in users under the influence May lead to delayed awakening
Fat emboli are identified inthe lungs what % of Skeletal trauma
90
Fat embolism syndrome occurs in up to ____ of patients after long bone fracture
10
S&S of a fat emboli
Respiratory insufficiency / Hypoxia / hypercapnia Petechial rash on conjunctiva, upper thorax, and axilla. Altered mental status Tachypnea / Tachycardia Pulmonary hypertension and right heart failure can occur. Cerebral edema Pulmonary edema Fat globules may appear in urine. May pass to systemic circulation through a patent foramen ovale
Risk factor of a fat emboli
Delayed stabilization of Fx, manipulation of FX, male, age 10-40, muptiple Fx, intramedullary reaming
Fat emboli Tx
supportive care measures, O2, maintain intravascular volume, inotropes PRN
Differential Diagnosis of a Fat emboli
Pneumo, pulmonary contusion, aspiration, massive transfusion volume over load
Transfusion related Lung Injury S&S
Occur 1-2 hours after transfusion Peak within 6 hours Hypoxia Fever Dyspnea Fluid in ETT possible Most recover in 96 hrs w supportive care
Majority of trauma in pregnancy are R/T
2/3 MVC, falls, domestic violence and penetrating injuries
Drugs and ETOH are indicated in what % of cases
20
Best strategy to save the fetus is
save the MOM, DUHHHH!!!!
cardiovascular changes in pregnance
↑Blood volume may ↑Cardiac output may ↓Blood pressure EKG changes Mimic myocardial ischemia or cardiac contusion ↓ Cardiac filling pressures Aortocaval compression
Pulmonary Changes in pregnancy
↑Functional residual capacity may cause Rapid onset of hypoxemia Increased uptake of inhaled agents ↑Oxygen consumption Alveolar hyperventilation and respiratory alkalosis causes ↓ Buffering capacity
GI changes in pregnancy
↓Gastric emptying causes ↑ Incidence of reflux and aspiration ↓Gastroesophageal sphincter tone Displacement of small intestine into the abdomen ↑ Risk of upper abdominal penetrating injuries
hematologic changes
↓Hematocrit from Anemia, internal bleeding ↑White blood cells R/T Infection ↑ Coagulation factors Thromboembolic disease
Most common injury is what type of injury
Blunt
Most common cause of fetal death
placental abruption
Loss of placental surface of ______% or more has a likelihood of fetal demise
50
Pregnancy and Burns
Treat the same
Cardiac Arrest in Pregos mainly from
PE, Eclampsia, Hemorrhage, trauma (head, Penetrating/blunt), Sepsis, MI, CHF, Amniotic Fluid embolism, and Iatrogenic (hyper magnesemia, failed airway, high spinal, local toxicity)
After how many weeks should the goal be to save both mom and fetus??
24 weeks
If initial resuscitation efforts are unsuccessful fetal delivery via C section should begin within how many min
5
Complications of CPR in Pregnancy
Liver Lac, uterine rupture, hemothorax, Fetal: cardiac arrythmia/asystole, hypoxia, acidosis, neuro damage
Pergo Airway managment, anatomical/physiologic changes
Mucosal edema, increased O2 requirment, Decreased FRC
Prego airway difficulty in about how often
1:2500
Anesthetic Managment goals in Prego trauma
Optimization of gas exchange Restoration of blood volume and tissue perfusion Protection of brain and spinal cord Maintenance of uteroplacental circulation and fetal oxygenation Prevention of maternal awareness Detection of unrecognized injuries Correction of coagulopathy Maintenance of normothermia Avoidance of teratogenic drugs (during the first trimester)
Ways to improve placental perfusion
Left uterine displacement, raise maternal BP, Increase FiO2, Ensure surgical retraction is not a factor
Volital agents should be used at less then what to avoid uterine relaxation and increased bleeding
1 MAC
Avoid what inhaled anesthetic in pregos
N2O
Ketamine > ___ /kg can increase uterine tone in 2nd trimester and decrease uterine perfusion / fetal oxygenation
2mg
What drug will potentiate NMB that pregos get for Pre eclampsia and will cause hypotension in volume depleated Pts
Magnesium
Terbutaline and ephedrine or atropine can cause
Ventricular ectopy
Leading cause of Mortality and morbidity in Peds is
Pedi Trauma
Anatomical differences with Peds
Large head, prominent occiput, Large epiglottis,
Gen ETT sizes
Newborn 3-3.5 < 1 yr old 3.5-4 1 yr old 4-4.5 2 yrs old and older is 4 +age/4
Reasons to intubate a Pedi
Loss of consciousness or altered level of consciousness with inability to protect the airway Inability to maintain patency of airway or clear secretions Provide positive pressure ventilation and adequate oxygenation Significant burn with airway injury.
Abnormal breathing / ventilation may consist of
Irregular RR and pattern Stridor Grunting Nasal flaring Retractions Head bobbing Use of accessory muscles Paradoxical pattern (“rocking boat”) suggests airway obstruction
In a Pedi the BP may not be effected until what % is lost
30-40
Persistant tachycardia w narrowing pulse pressure may indicate
impending cardiavascular collapse
Fluid resuscitation in a Pedi is
20ml/ kg of LR once or twice
PRBC resuscitation in a Pedi is
10-20 ml/kg in increments
Signs of adequate volume resuscitation
Normal BP Pulse pressure > 20 mm/hg Pulse rate and col
Succinylcholine in Peds
Large volume of distribution incareses dose to 2-3 mg/kg May cause bradycardia, junctional, or sinus arrest.
Dose for atropine if a parasympathetic response occurs in infants 6 mths of less
10 mcg/kg
Pediatric VItal Normal Values
NDNMB Roc dose for peds is
0.9 to 1.2 mg/kg for Rapid conditions
Avoid N20 in Pedi Traumas due to
Unknown pneumothorax, air embolism or pneumocephalus
Pedi Hct levels
Normal Acceptable
Premature 40–45 35–40
Newborn 45–65 35–40
3 months 30–42 25
1 year 34–42 20–25
6 years 35–43 20–25
Effects of Hypothermia in Peds
Increased oxygen consumption
Left shift of oxyhemoglobin dissociation curve
Coagulopathy with prolonged bleeding
Metabolic and lactic acidosis, hypoglycemia
Apnea
Depressed myocardial contractility, arrhythmias
Impaired drug metabolism, delayed emergence from anesthesia
Increased mortality!
Elderly Cardiovascular Changes
Decreased connective tissue compliance and distensibilty
Arteries, especially aorta, becomes stiff and non-compliant
Chromic increase in afterload
Concentric LVH and decline in diastolic compliance
Maximum aerobic capacity decreases with age
Elderly Pulmonary Changes
Predisposition to perioperative pulmonary problems
Primary cause of morbidity and mortality
Decreased strength of respiratory muscles
Progressive loss of alveolar surface area
Impaired nervous control of ventilation
Reduction in elastic recoil of chest wall
Dangerous predisposition to hypoxemia in the elderly trauma patient
Arterial oxygenation is impaired
Age related V/Q mismatch
80% can have marked atelectasis after induction
Tendency for upper airway collapse
Hypercapnic and hypoxic respiratory drives are impaired
Decrease in airway protective reflexes
Denitrogenation takes longer
Tracheal intubation unchanged
Propofol
Induction dose reduced by 20% (slower induction requires lower doses) (20-year-old: 2.0–3.0 mg/kg IV; ↓ Central volume of distribution; ↓ intercompartmental clearance
80-year-old: 1.7 mg/kg IV or less). Maintenance dose: same requirements 120 min after starting a continuous infusion.
Midazolam
↑ Sensitivity of the brain ↓ Clearance
Sedation/induction dose reduced by 50% (20-year-old: 0.07–0.15 mg/kg IV; 80-year-old: 0.02–0.03 mg/kg IV). Maintenance dose reduced by 25%. Recovery: delayed (hours)
Etomidate
Central clearance; ↓ volume of distribution oInduction dose reduced by 20% (20-year-old: 0.3 mg/kg IV; 80-year-old: 0.2 mg/kg IV).
Ketamine
Use with caution: hallucinations, seizures, mental disturbance, release of catecholamines; avoid in combination with levodopa (tachycardia, arterial hypertension)
Opoids
Fentanyl, alfentanil, sufentanil •↑ Sensitivity of the brain •Induction dose reduced by 50%. Maintenance doses reduced by 30–50%. Emergence: may be delayed
Remifentanil •↑ Sensitivity of the brain; ↓ Central volume of distribution; ↓ intercompartmental clearance •Induction dose reduced by 50%. Maintenance dose reduced by 70%. Emergence: may be delayed
Muscle Relaxants
Succinylcholine •↓ Plasma cholinesterase; ↓ muscle blood flow; ↓ cardiac output; ↓ intercompartmental clearance •↓ Onset time. ↓ Maintenance dose requirements. Duration of action clinically indistinguishable from mivacurium. Differences: no changes in initial dose. •prolonged block with metoclopramide
Pancuronium,vecuronium,rocuronium •↓ Muscle blood flow; ↓ cardiac output; ↓ intercompartmental clearance; ↓ clearance; (volume of distribution) •↓ Onset time. ↓ Maintenance dose requirements. ↑Duration of action. Recommended dose reduced by 20%.
Neostigmine
↓ Clearance; ↑ Duration of action; because muscle relaxants have a markedly prolonged duration of action, larger doses of reversal agents are needed in elderly patients
Local Anesthetics
↑ Sensitivity of the nervous tissue (?)
↓ Hepatic microsomal metabolism of amide local anesthetics (lidocaine, bupivacaine);
↓ plasma protein binding;
↑ cephalad spread
↓ Epidural (and spinal) dose requirements. Duration of spinal and epidural anesthesia seems clinically independent of age
