CNS and Musculoskeletal Trauma Flashcards
1
Q
Age 15-24 yrs old are more apt to be involved in what types of trauma
A
MVC and violence often involving ETOH
2
Q
Age >75 yrs old are more apt to be involved in what types of trauma
A
Falls
3
Q
How many head injuries in the US per yr
A
1.6 million
4
Q
How many permanent neurologic injuries in the US per yr
A
70,000-90,000
5
Q
Types of primary traumatic brain injuries
A
Skull fx, vascular injuries, subdural and epidural hemorrhage, brain parenchyma injuries such as contusions and axonal injuries
6
Q
Types of secondary traumatic brain injuries
A
Occur after the initial event and potentially preventable
7
Q
Types of preventable secondary injuries are
A
Hypoxia, hypercapnia, hyperthermia
8
Q
Secondary injuries may involve
A
Reperfusion, superoxide production, exciotoxic amnion acid release, necrosis and apoptosis
9
Q
What types of skull fractures require early surgery to decrease the incidents of meningitis
A
Open skull fx, deep scalp lacs and fractures extending into sinuses
10
Q
Are all skull Fx assoc with intarcrainal lesions
A
NO, but it should alert the CRNA to a potential underlying brain injury
11
Q
What is the most common focal intracranial injury
A
Subdrual hematomato, yes tomato, LOL
12
Q
What percentage of TBI have hematomatos
A
24%
13
Q
What TBI has the highest mortality rate
A
Subdural Hematomatos (squishy tomato’s)
14
Q
How do you fix a subdural hematomato
A
surgical decompression
15
Q
What percentage of TBI have eipdural tomatoes
A
6%
16
Q
Classic presentation of an epidural hematomato
A
period of lucidity followed by neurologic decompensation and coma
17
Q
Do all epidural hemotomatos need surgical intervention
A
NO small ones can be observed
18
Q
Where is a cerebral contusion/hemotomato located
A
In the brain parenchyma
19
Q
Determinants of outcomes for cerebral contusion/hemotomato are
A
GCS, presence of hypoxia, hematomato volume
20
Q
Interventions may include
A
Surgical evacuation, with or without craniotomy if elevated Intercarranial hypertension is present
21
Q
Diffuse injuries are caused by
A
acceleration deceleration or rotational injuries
22
Q
The best diagnostic tool for diffuse injuries is
A
MRI
23
Q
Diffuse injuries are classified as
A
Mild- coma 6-24 hr, Moderate- >24 hrs without decerbrate posturing, Sever- > 24 hrs with decerbrate posturing or faccidity
24
Q
CRNA goals are to prevent further ________ injuries
A
secondary
25
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.
26
Contribution systemic factors to secondary TBIs
hypotension, hypoxia, anemia, hypoventilation, hyperglycemia, hyponatremia, hyperosmolar state, coagulapathy
27
Preferred method of intubation? nasal or oral
Oral
28
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
29
Goals for TBI ICP is a CPP of
60-70
30
Goals for MAP without ICP monitoring
MAP 70-80
31
While restoring intervascular volume with isotonic IVF can you use vasopressors
YES!!!!
32
Strong Indications for ICP monitoring
Sever head injury (GCS 40, motor posturing, SBP \< 90
33
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
34
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
35
volatile agents lead to an increase or decrease in ICP
Increase due to increase CBF
36
Goals of Musculoskeletal Trauma Treatment
resuscitation, pain relief, improved stability and alignment, enhanced mobility, restoration of function
37
MS resuscitation what type of shock is the most common
Hypovolemic Shock
38
What type of MS trauma causes Hypovolemic shock
Long bone and Pelvic FX
39
Pain induced sympathetic discharge causes
hyper-inflamatory response and increased morbidity and mortality, Splinting causes impaired ventilation
40
Within 24 hr the following Fx should be stabilized
pelvis, femur, acetabulum fx
41
Early fixation by intramedulary nails, plates and external fixation devices reduce the following
Morbidity, ARDS, sepsis
42
Why are fractures definitively treated on a delayed basis
allows for swelling to decrease and improves wound healing
43
The following can be life threatening MS injuries
Multiple Fx, pelvic Fx, Femur Fx, and when assoc with massive hemorrhage
44
Average blood loss for a femur Fx
1500 mls
45
Blood loss for a pelvic Fx can range for what to what
3 to 10 L
46
75% of vascualr trauma are from what type of trauma
Penetrating
47
Compartment Syndrome is
A rise in interstitial pressure in a closed osteofascial compartment, compromising capillaries and causeing tissue ischemia
48
Compartment Syndrome causes
Fractures, sever soft tissue injury, arterial hemorrhage
49
Compartment Syndrome occurs most commonly
lower legs and volar forearm
50
Only treatmentf or Compartment Syndrome is
fasciotomy
51
Urgent MS Problem requiring surgery in 6-8 hrs
Open fx, traumatic arthrotomy, dislocations, displaced femoral neck fx
52
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
53
ETOH causes what in trauma Pt
vasodilation and inability to shiver, suppression of ADH, decreased airway reflexes and a decrease in MAC
54
Cocaine in trauma Pt can cause
coronary spasms, Iso can cause arrhythmias, Precedex and versed are good choices for anesthesia
55
Amphetamines in trauma Pts
Decrease MAC due to dopaminergic and serotonergic depletion
56
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
57
Fat emboli are identified inthe lungs what % of Skeletal trauma
90
58
Fat embolism syndrome occurs in up to ____ of patients after long bone fracture
10
59
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
60
Risk factor of a fat emboli
Delayed stabilization of Fx, manipulation of FX, male, age 10-40, muptiple Fx, intramedullary reaming
61
Fat emboli Tx
supportive care measures, O2, maintain intravascular volume, inotropes PRN
62
Differential Diagnosis of a Fat emboli
Pneumo, pulmonary contusion, aspiration, massive transfusion volume over load
63
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
64
Majority of trauma in pregnancy are R/T
2/3 MVC, falls, domestic violence and penetrating injuries
65
Drugs and ETOH are indicated in what % of cases
20
66
Best strategy to save the fetus is
save the MOM, DUHHHH!!!!
67
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
68
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
69
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
70
hematologic changes
↓Hematocrit from Anemia, internal bleeding ↑White blood cells R/T Infection ↑ Coagulation factors Thromboembolic disease
71
Most common injury is what type of injury
Blunt
72
Most common cause of fetal death
placental abruption
73
Loss of placental surface of \_\_\_\_\_\_% or more has a likelihood of fetal demise
50
74
Pregnancy and Burns
Treat the same
75
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)
76
After how many weeks should the goal be to save both mom and fetus??
24 weeks
77
If initial resuscitation efforts are unsuccessful fetal delivery via C section should begin within how many min
5
78
Complications of CPR in Pregnancy
Liver Lac, uterine rupture, hemothorax, Fetal: cardiac arrythmia/asystole, hypoxia, acidosis, neuro damage
79
Pergo Airway managment, anatomical/physiologic changes
Mucosal edema, increased O2 requirment, Decreased FRC
80
Prego airway difficulty in about how often
1:2500
81
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)
82
Ways to improve placental perfusion
Left uterine displacement, raise maternal BP, Increase FiO2, Ensure surgical retraction is not a factor
83
Volital agents should be used at less then what to avoid uterine relaxation and increased bleeding
1 MAC
84
Avoid what inhaled anesthetic in pregos
N2O
85
Ketamine \> ___ /kg can increase uterine tone in 2nd trimester and decrease uterine perfusion / fetal oxygenation
2mg
86
What drug will potentiate NMB that pregos get for Pre eclampsia and will cause hypotension in volume depleated Pts
Magnesium
87
Terbutaline and ephedrine or atropine can cause
Ventricular ectopy
88
Leading cause of Mortality and morbidity in Peds is
Pedi Trauma
89
Anatomical differences with Peds
Large head, prominent occiput, Large epiglottis,
90
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
91
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.
92
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
93
In a Pedi the BP may not be effected until what % is lost
30-40
94
Persistant tachycardia w narrowing pulse pressure may indicate
impending cardiavascular collapse
95
Fluid resuscitation in a Pedi is
20ml/ kg of LR once or twice
96
PRBC resuscitation in a Pedi is
10-20 ml/kg in increments
97
Signs of adequate volume resuscitation
Normal BP Pulse pressure \> 20 mm/hg Pulse rate and col
98
Succinylcholine in Peds
Large volume of distribution incareses dose to 2-3 mg/kg May cause bradycardia, junctional, or sinus arrest.
99
Dose for atropine if a parasympathetic response occurs in infants 6 mths of less
10 mcg/kg
100
Pediatric VItal Normal Values
101
NDNMB Roc dose for peds is
0.9 to 1.2 mg/kg for Rapid conditions
102
Avoid N20 in Pedi Traumas due to
Unknown pneumothorax, air embolism or pneumocephalus
103
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
104
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!
105
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
106
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
107
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.
108
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)
109
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).
110
Ketamine
Use with caution: hallucinations, seizures, mental disturbance, release of catecholamines; avoid in combination with levodopa (tachycardia, arterial hypertension)
111
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
112
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%.
113
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
114
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
