Complex Trauma Flashcards
What is the “mainstay” of decision making
Risk mitigation–to the patient, public, and other crews
What is the goal of CRM?
evaluate potential risks, communicate findings, work collaboratively with others, and limit potential adverse events
What is the Risk assessment equation?
R=f (pXc)
Risk=function of (probability X consequence)
What is a common Trauma assessment tool?
MARCH
M-massive bleed
A-Airway
R-Respirations
C-Circulation
H-Head/Hypothermia
Describe Muliorgan Dysfunction Syndrome?
Organ dysfunction in the acutely ill patient resulting in the need for immediate intervention to achieve/Maintain homeostasis.
What is the shock index?,
Shock index is gathered by dividing HR by SBP, a shock state is a value greater than 1.
What are some easy steps to optimize delivery of oxygen (DO2) to the shock patient?
- HF O2
- MAP of 65, TBI MAP 80
- Control what you can
- Avoid fluctuations in hemodynamics
- Minimize MVO2 with sedation
Name 4 complications of a myocardial contusion
- Septal wall rupture
- Myocardial infarction
- Arrhythmia
- Poor contractility (Tamponade)
what are the key points to neuroprotective trauma care pre-hospitally?
Avoid acidosis hypothermia and coagulopathy.
Goals:
- MAP 80 (SBP 110)
- Avoid Hypoxia (Spo2 94%)
- Normothermia
- ETCO2 35
- Head of bed 30 Deg
- Ventilate appropriately
How does the RV differ from the LV in terms of:
- Afterload
- Wall Thickness
- Volume
- Dependence on septal contraction
- Afterload: approximately 1/4 that of the LV
- Thickness: approximately 1/3 that of the LV
- Intraventricular volume: 10-15% greater than LV (lower ejection fraction)
- Dependence on septum: More dependant! 40% of RV output due to Septal contraction
Describe coronary blood supply to the RV and inferior LV
- RV is supplied by the RCA
- iLV is supplied by RCA in ~80% of people (right dominant), the remaining 20% are more or less equally split between LCX (left dominant) or combined LCX + RCA (co-dominant) supply
- Figures are highly variable between sources
The RV is highly sensitive to changes in __________(preload/afterload/both)
BOTH!
While RV is highly preload dependant, it is also very intolerant of increased afterload
What are ECG features of inferior infarct which suggest RV involvement?
- ST elevation in V1
- ST depression in V2 along with V1 STE makes the findings highly specific for RV infarct
- ST depression in V2 with isoelectric ST in V1
- STE in III > STE in II
- Atrial dysrhythmia further suggest RV involvement
Describe the purpose and placement of the V4R lead when acquiring an ECG
- used to strengthen the case for RV infarction, typically in context of inferior infarct
- V4 is moved from the 5th ICS, at the mid-clavicular line on the left side of the chest to the same position on the right
Describe sensitivity, specificity, and diangostic value of STE in V4R in detection of RV infarct
- 88% sensitive
- 78% specific
- 83% diagnostic accuracy
Describe features of this ECG which suggest RV infarct
- Presence of inferior STEMI (80-85% of population has right-dominant circulation)
- STE in III>II
- STE in V1
Describe the role of PEEP in alveolar recruitment
- PEEP does NOT recruit alveoli!
- It mainatains alveolar recruitment
- recruitment is only possible through sustained increase in Pip or Pplat
- Once alveoli are recruited, PEEP holds them open
Describe the management of APE or ARDS in presence of suspected RV infarct
- limit tidal volumes to <8mL/Kg (RV is HIGHLY afterload dependant, don’t want to increase workload)
- Decrease MVO2
- Increase DO2
- HFO2
- Fluid resuscitation as required
- Pt positioning
- PEEP
According to traditional CRM models, risk is a function of _________
probability and consequence
Describe the START method for MCI triage
- All ambulatory patients = GREEN
- Non-ambulatory and WITHOUT signs of instability = YELLOW
- Non-ambulatory and WITH signs of instability = RED
- Airway maneuvres required for spontaneous breathing
- Resp Rate > 30
- Absent radial pulse or cap refill >2s
- Unable to follow commands
- Non-ambulatory, with apnea following airway maneuvers = BLACK
What are the criteria for “black-tagging” someone under START triage procedures
- Patient must be apneic following attempts to manually open the airway
- Other obvious signs of death/futility
Under START protocols, whgich patients are the highest priority for immediate Tx/transport?
RED-tagged
- airway maneuvers required
- RR>30
- Absent radial pulse or cap refill >2s
- Unable to follow commands
What are the JumpSTART criteria and how do they differ from START criteria?
- Trauma triage guidelines for pediatric patients in MCI
- Very similar to START, except:
- A carotid pulse check is included with apnea after opening the airway
- If pulses are present, give 5 rescue breaths and check if apnea remains (if apneic, black tag, otherwise RED)
- Signs of respiratory instability are RR<15 or >45 (instead of >30 for adults)
- Instead of following commands, children must be A,V, or appropriate P (i.e. withdrawing instead of posturing) to be considered “YELLOW” (delayed)
What is a HOTTT drill, and what are it’s components?
HOTTT is used to identify and adress reversible causes of cardiac arrest in trauma
- Hemorrhage: Stop all bleeding
- Oxygenate: ETI as required
- Tension: needle thoracentesis
- Tourniquet: specifically refers to AAJT, but good reminder to re-check Tqs
- Transfuse: get in the blood!
Describe treatment for release of a crush injury
- Calcium chloride and sodium bicarbonate
- IV N/S loading prior to release of crush
- Tourniquets on and ready
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