CRIT CARE/TRAUMA Flashcards
1
Q
Splenectomy - OR
A
Divide splenophrenic, splenorenal, splenocolic attachments
Divide short gastrics using energy device
Divide hilum with endo GIA vascular stapler
2
Q
Duodenal hematoma in child - mgmt (blunt trauma)
A
Leave alone
NGT for decomp
TPN
Consider feeding access
3
Q
Size ETT in kid
A
Size of pinky
Check breslow tape***
Age/4 + 4
4
Q
Tx of fat embolism
A
Supportive care
5
Q
Ideal filling volume/CVP
A
10
6
Q
Ideal CO
A
3-5
7
Q
Ideal PA pressures
A
25/10
8
Q
Ideal PAWP
A
16-18
9
Q
Ideal SVR
A
1000
10
Q
Forearm fasciotomy
A
Incision in the biceps groove and cross antecubital fossa in s-shaped fashion
Travel down forearm along border of brachioradialios
Veer medial towards middle of wrist, stop halfway in the middle of the palm of the hand
11
Q
Plateau pressure goals in ARDS
A
<30
12
Q
Optimize oxygenation/ventilation in ARDS
A
Paralysis
Recruitment maneuvers
Reverse I:E ratio
APRV
13
Q
SVT mgmt
A
Awake, nonintubated: valsalva
Adenosine 6 mg –> short asystolic pause
Esmolol
14
Q
Afib with RVR - unstable
A
Activate code team Amio bolus 150 mg Synchronized CVN @ 200J - requires sedation Phenyl gtt 2 g Mg sulfate Crystalloid boluses \+/- intubation
15
Q
Afib with RVR - stable
A
Replete lytes PRN esp K, Mg, Ca
5 mg IV metop x 3 every 5 min
Cardizem gtt (ensure HD stable)
Amiodarone gtt @ 1mg/min after bolus 150 mg over 10 min
16
Q
Any time you intubate remember ..
A
order confirmation CXR
17
Q
How to monitor argatroban gtt
A
PTT
goal 60-90 just like heparin
18
Q
Assess fluid status
A
Bedside US (IVC monitoring)
Passive leg raise esp if aline
UOP
Lactate
19
Q
Hypovolemia –> SVR?
A
High
20
Q
Low SVR, Low CVP, High CO
A
Septic shock
21
Q
High CVP, Low CO, High SVR
A
Cardiogenic shock
22
Q
Low CVP, Low CO, Low SVR
A
Neurogenic shock
23
Q
Once afib with RVR has stablilized on amio gtt
A
Extubate ASAP
Cont infusion over 24 hours then transition to PO
Repeat EKG, echo, trops
F/u with cards
24
Q
Pt is coding as you arrive
A
Organize team, initiate ACLS
Attach AED
Intubate and connect to end tidal CO2 monitor
Ensure adequate IV access and send off stat labs incl ABG
25
Chest compressions in adult - goals
ET CO2 > 10
100-120 compressions/min
2 cm depth
Allow for complete chest recoil
26
Rhythm shows PEA
```
Redose 1 mg epi q3-5 min
Check pulses q2 min
Start checking for reversible causes incl bleeding
Consider cardiac and pulmonary US
Addn adjunts: Ca, Mg, Amio, Lidocaine
```
27
Hs & Ts - reversible causes of arrest
```
Hypothermia
Hypovolemia
Hypoxia
Hypo/hyperkalemia
H+ (acidosis)
```
Toxins
Tension PTX
Tamponade
Thrombosis (pulm and cardiac)
28
V fib on monitor
Unsynchronized defibrillation at 150 J
29
V tach on monitor
Synchronized defib at 125-200J
30
Post-MI care
Stat EKG, CXR, echo
Consult cards
Initiate levo gtt PRN
Cath lab
31
Basics of VA ECMO
Provides cardiac and pulmonary support
Blood is removed from venous drainage cannula, oxygenated, pumped back into arterial cannula placed into descending aorta which perfuses brain and UE via retrograde flow
32
VA ECMO Cannulation
Access contralateral femoral a and vein
via US guidance
Admin heparin
Insert approp size venous drainage and arterial cannulas over a wire using fluoro guidance
Insert venous drainage cannula to just below RA and arterial cannula to just below descending aorta
With circuit primed, initiate flow and adjust to support cardiac function
Once stabilized, insert distal perfusion cannula just below arterial cannula insertion site to ensure distal perfusion to extremities
33
Post-ECMO monitoring
Transfer back to ICU
Start continuous heparin gtt
Frequent Xa monitoring
Hourly neurovascular checks of LE
First wean pressor support then slowly wean blood flow
Daily echos, once heart improves can decannulate in OR with primary repair
34
Hx of alcoholic cirrhosis found down - h&p?
recent alcohol/drug use
previous cirrhosis complications - UGIB, heart and kidney problems, encephalopathy, ascites
medications?
35
Hx of alcoholic cirrhosis - labs/imaging?
CBC, CMP, coags, type and screen, blood cx, UA, alcohol level, drug screen, acetaminophen level, ammonia
CXR (volume status, pleural effusions)
Ensure 2 large bore IVs
36
Best determinant of intrinsic liver function (lab)
INR
37
How are SBP and UGIB related?
Infection --> coagulopathy
| Large volume ascites --> incr portal pressure --> coagulopathy
38
UGIB + cirrhosis - abx?
Ceftriaxone
39
Major complications of TIPS
new or worsening encephalopathy
| in-stent stenosis (correct w/dilation)
40
Abdom pain + large volume ascites
R/o SBP
CT scan
Paracentesis with culture, neutrophil count, protein count, LDH and glucose
41
Diagnostic of SBP (fluid analysis)
Neutrophils >250
| Exclude 2ndary BP which is dx when 2+ of following: total protein >1, gluc<50, LDH > upper limit of normal for serum
42
Mgmt of large volume ascites/UGIB in cirrhotic
```
Paracentesis
IV high dose PPI BID
Ceftriaxone
Octreotide
Consider hepatologist consult
```
43
Prep for trauma pt
Prepare team - ID roles, get equipment in the room
Detailed primary and secondary surveys, obtain 2 large bore IVs, send comprehensive labs, obtain vitals, perform FAST exam, order CXR and pelvic XR
44
Basics of neurogenic shock mgmt
Replace volume
Avoid overresuscitation
Pressors to support distributive shock
MAP goals 85-90
45
Bradycardia in neurogenic shock - tx?
Atropine
| Consider external or internal pacing if no response
46
Delirium tx
```
Awake and interactive during day, min stimulation at night
Engage his family and friends
Review meds including narcotics, benzos
R/o infection
Check thyroid, blood glucose and LFTs
```
47
Delirium/agitation tx (meds)
Melatonin
Quetiapine
IV haldol
Monitor daily EKGs for QT prolongation
48
Dx AKI - next steps?
Check FENA/urine lytes
ID any nephrotoxic medications
Renal US to r/o hydronephrosis
D/w surgeon re: ureter
49
Urine Na >40
Intrinsic AKI
50
Urine Na <20
Prerenal AKI
51
Muddy casts
ATN
52
RBC cast
glomerulonephritis
53
WBC cast
AIN, pyelonephritis
54
+Hgb but no RBC in UA
Rhabdo
55
K+ of 8 - next steps?
```
EKG
3g of IV calcium
10U Insulin
1 amp D50
Monitor glucose hourly
Start albuterol nebulizer tx
```
56
Norepi MOA
Lots of alpha 1, some beta 1 agonism
57
Vaso MOA
V1 and V2 agonism
58
Epi MOA
Some alpha 1, lots of beta 1 agonism
59
Phenyl MOA
Lots of alpha 1 agonism
60
ARDS - additional workup
BAL
Echo
CT PE?
61
Berlin Criteria (ARDS)
Sx within 1 week of known insult
Bilateral opacities c/w pulm edema NOT fully explained by cardiac failure or fluid overload
Moderate to severe impairment of oxygenation
62
ARDS management
```
Lung protective ventilation
Treating ventilator dyssynchrony
Proning
Paralyzing
Consider use of steroids, APRV, NO
Consider ECMO
```
63
Decreased mortality and time on vent in ARDS (vent changes)
Lower tidal volumes and plateau pressures
64
How to check plateau pressure
Inspiratory hold
65
Ways to improve ventilator synchrony
Additional sedation
Change mode
Incr inspiratory pause
Incr tidal volume
66
Dose of steroids in ARDS
50 mg IV hydrocortisone q6h
67
Neck exploration (vascular injury)-OR
Anterior border of SCM from angle of mandible down to sternal notch
Divide platysma, retract SCM and IJ laterally
Proximal control of common carotid
Follow proximally into hematoma
Control with finger over injury and continue dissection to obtain distal control around CCA and ECA
Prior to clamp, anesthesia admin heparin and place argyle shunt in common carotid into ICA
68
<50% defect common carotid artery
Patch angioplasty with bovine pericardium
| Low threshold to do reverse interposition bypass with saphenous vein
69
Following carotid artery repair in trauma
Continue exploring neck for airway or esophageal injury
| Ensure flow with doppler
70
ICA transection
Reverse saphenous vein interposition graft
| OR 6 mm PTFE
71
Distal ICA stump - no backbleeding
Gently pass 2 Fogarty and inflate it and pull back until adequate backbleeding
Should be done at time of shunt placement if no good backbleeding evident
72
Pseudoaneurysm with extrav at base of CCA - options?
If vascular available for endovascular and/or stenting of proximal CCA
Otherwise partial or complete sternotomy to get control of base of carotid artery
73
Intimal flap 1 cm in size to ICA, neurologically intact
Antiplatelet
| Re-image in 1 week to ensure lesion does not degenerate into pseudoaneurysm
74
R sided Zone 1 hematoma - Exposure of IVC
Confirm w/anesthesia they are ready for blood loss/all caught up
R sided medial visceral rotation starting at white line of toldt at cecum and following all the way up
Kocher maneuver
Distal control of IVC
Open hematoma, evacuate blood, use spongesticks to get proximal and distal control
75
Complete injury IVC below renal vv
Longitudinal venotomy along anterior wall of IVC through injured segments to allow access to posterior wall of IVC
Eval injuries - if posterior segment is easily approximated with 3-0 prolene
If anterior segment cannot be closed without stricture, use patch angioplasty once debrided to healthy edges
76
Unable to primarily repair IVC injury
If HD unstable - ligate IVC, prophylactic fasciotomies
| If stable - attempt to construct ringed PTFE graft slightly smaller than IVC to keep flow rates high
77
Injury at confluence of IVC - how to help visualize?
Right to left medial visceration
May have to divide R common iliac artery to fully expose problem (repair or reconstruct at end of case, make sure patient is heparinized)
78
If there is a need for ex fix and concomitant vascular injury, what is the order of steps?
Shunt first
Ex fix (ortho)
Definitive repair
79
GSW to LE with high suspicion for arterial injury - OR plan?
Longitudinal incision just below inguinal ligament
Follow down to CFA, loop it out proximally for inflow control
Dissect distally to get control of SFA and profunda
Heparinize pt
Clamp all 3 inflow vessels
Long incision over area of concern based on trajectory of bullet
Isolate SFA proximally and distally to lesion
Same with femoral vein
80
2 cm defect of SFA with small piece of backwall intact, distal vessel thrombosed - OR plan?
Interposition bypass of SFA
Contralateral reverse greater saphenous vein
Prior to doing so, place shunt to regain distal perfusion to extremity
Prior to shunt, fogarty embolectomy to outflow tract using 3 fogarty
Ensure good inflow, place argyle shunt into inflow, tie silk sutures to hold in place
Confirm shunt with doppler
81
Interposition bypass - OR
Harvest long segment of gr saphenous vein
Remove shunt, ensure good forward and backbleeding
Debride vessel to healthy portion and spatulate ends
Reverse vein and sew proximally and distally with 5-0 prolene once shunt is removed
Check pulses
Evaluate total time til revascularization to determine if fasciotomy is needed
82
Compromised outflow of all 3 below-knee vessels - next step in OR?
Below knee pop a cutdown
Selective embolectomy of tibial vessels
Patch pop a
83
Injury to right ventricle
Use finger or foley catheter to control bleeding
Repair defect with pledgeted 3-0 prolene suture in horizontal mattress fashion, taking care to ID and protect coronary vessels q
84
About to start resuscitative thoracotomy
Ask team to place chest tube on R side
Intubate pt
Obtain central venous access
Begin massive transfusion
85
Indications for resuscitative thoracotomy in penetrating trauma
Pulseless + CPR <15 min
86
Contraindications to resuscitative thoracotomy
W/o signs of life at scene of injury
| PResent in asystole without pericardial tamponade
87
Indication for resuscitative thoracotomy in blunt trauma
Pulseless + CPR <10 min and/or signs of life
88
Signs of life
```
pupillary response
presence of carotid pulse
extremity movement
cardiac electrical activity
spontaneous ventilation
measurable or palpable BP
```
89
Resuscitative thoracotomy - steps
Position pts left arm above their head
Scalpel to incise medial aspect of sternum across to bed
With chest wall exposed, heavy scissors to cut intercostal musculature staying along superior aspect to avoid neurovascular bundle
Place finochietto retractor and open chest widely
Open pericardial sac avoiding phrenic nerve and start cardiac massage, make repairs as needed
Cross clamp aorta
Address any injuries to lung
90
Zone 1 hematoma near duodenum - OR/exposure
Ensure good IV access, plenty of blood on hand, anesthesia is ready, and call for 2nd partner to help
ID supraceliac aorta and have vascular clamp on hand
Right-->left medial visceral rotation by taking down white line and performing kocher maneuver
91
How to determine if CBD involved in duodenum & identify ampulla
Pass a fogarty catheter into duo via cystic duct
92
Unable to perform primary closure of duodenum and injury distal to CBD
Perform duodenoduodenostomy or roux en y duodenojejunostomy and leave drains adjacent to repair
Pass NJ while in OR
93
Upper esophageal injury exposure- OR
Bump under shoulders
Head turned away from injury
Prep entire neck and chest prior to incision along anterior border of SCM
Transect platysma, retract SCM and open carotid sheath to allow for visualization of IJ, vagus and carotid a
Medialize thyroid and laryngeotracheal complex and ligate middle thyroid v., inf thyroid a and omohyoid muscle
Can place NG to help ID esophagus
94
2 cm defect to lateral esophagus - OR
40Fr Bougie
2 layer primary repair using absorbable suture
Ensure to expose entire mucosal defect (may need to enlarge muscular defect)
Leave multiple drains in area
95
Tracheal injury (+ esophageal injury) - OR
Repair with absorbable suture
| Use muscle buttress to separate repairs (strap muscle)
96
CT scan shows thickened thoracic esophagus with small flecks of air adjacent to it + loculated collections in pleural space - concern of?
Missed aerodigestive injury - start w/esophagram + water soluble contrast
97
Fluid collection s/p angioembolization for liver trauma - ddx?
Bile leak
| Hematoma
98
Large laceration involving R lobe of liver - next steps (OR)?
Manually compress liver to allow anesthesia time to catch up
| Extend incision to xiphoid process, divide falciform ligament and place self retaining retractor
99
Ways to control liver bleeding
```
Energy devices (argon beam, electrocautery)
Vessel clips
Tissue staplers
Suture ligation of vessels
Packing
Hemostatic agents - combat gauze
Approximation of parenchyma by suturing capsule together using large chromics
Pringle maneuver for inflow control
```
100
Preperitoneal packing - OR
lower midline incision that doesnt violate peritoneum
retract the bladder
pack preperitoneal space and pelvis with lap pads
3 on each side (6 total)
close skin
101
Continued pelvic bleeding s/p ex lap without identified source
Stabilize fracture - bedsheet, pelvic binder, etc
IR - stat angio + embolization
zone 3 reboa
expose and ligate hypogastric a
102
REBOA - OR
Insert fem a line
Upsize to reboa insertion catheter by exchange over wire
flush catheter and ensure balloon deflated
connect pressure port of catheter to pressure transducer
advance peel away sheath to cover curled tip of catheter and advance to approx 46 cm for zone 1 and 26 cm for zone 3
inflate with saline - 8 cc for zone 1, 2 cc for zone 3, carefully incr volume as needed to ensure occlusion
secure
mark time and proceed to OR or IR
103
REBOA - anatomic landmarks for estimation
mid sternum for zone 1
| umbilicus for zone 3
104
Physiol changes in pregnancy (3rd trimester)
mild tachycardia
plasma volume expands
tachypnea
hypotension
105
Special H&P trauma eval for pregnancy pt
Check fundal height, assessing for uterine tenderness
Check for vaginal bleeding, amniotic fluid
Type and screen, fibrinogen
Notify OB team and plan for fetal monitoring and HR/contractions
106
At what age is fetus considered viable
23 weeks
107
Type & screen in preg patient - Rh negative
1 dose of anti d immunoglobulin and have KB test sent ( to see if additional rhogam needed)
108
how to perform retrograde cystography
foley inserted
400 cc of dilute contrast instilled into bladder by gravity
foley clamped
xray or CT image obtained
109
3 cm laceration through dome of bladder- repair?
carefully examine bladder -esp neck and urethral orifices
close defects in 2 layers using running absorbable suture
foley to stay x 2 weeks
110
workup for rectal injury - secondary survey to include?
DRE
111
imaging to eval for renal injury
CT pyelography - 3 phases
non contrast
corticomedullary phase
delayed expiratory phase *best for urinary leak
112
options for coumadin reversal
4 factor PCC
FFP
vitamin K
113
Quickly assess severity of TBI
GCS + pupillary exam
| Ask about last time received sedatives/paralytics (which dont affect pupillary response!)
114
Rocuronium - onset, duration
30 sec onset, 30 min duration
115
ETomidate - onset, duration
60 sec on set, 5 min duration
116
Etomidate - onset, duration
60 sec on set, 5 min duration
117
Ketamine - onset, duration
30 sec onset, 10 min duration
118
reversal of xarelto, eliquis, arixtra
PCC or adnexa
119
reversal of pradaxa
praxibind
120
TBI + spleen injury - what do you fix first?
spleen
121
traumatic splenectomy - OR
ex lap
place lap pads behind spleen to elevate and medialize, carefully taking down attachments to diaphragm, kidney and colon in the process
once medialized, ID, control and transect hilar vessels with laparoscopic stapler (or clamp and suture ligate individually)
transect short gastrics with vessel sealers
carefully examine hilar and short gastrics to ensure hemostasis
122
Assess brainstem function
testing respiratory drive, pupillary light, corneal cough and gag reflexes
123
Brain death pre-requisites
American academy of neurology 2010 guidelines
prerequesites must be met: coma 2/2 known cause, neuroimaging that explains coma, SBP >100 mm Hg for which pressors may be used,absence of CNS depressing drugs in system, core temp >36 celsius, absence of spontaneous respirations
124
Pt doesnt meet criteria for brain death testing - other options?
Ancillary testing, such as brain perfusion scan, cerebral angiography, transcranial doppler, CTA, MRA
125
PE consistent with brain death
nonreactive pupils, absent corneal, oculovestibular, oculocephalic, gag and cough reflexes, absent motor response to noxious stimuli in all 4 limbs, absent facial movements to noxious stimuli at supraorbital and TMJ
apnea testing confirms absence of spontaneous respirations in the setting of documented pCO2 rise which includes pCO2 >60 or increase in baseline >20 mmHg
126
qSOFA score components
AMS
SBP < or = 100 mmHg
RR > or = 22 breaths/min
127
Goals of resuscitation to be attained during first 6 hours after recognition of sepsis
```
CVP 8-12
MAP >65
UOP >0.5 mL/kg/hr
ScvO2 of 70% or SvO2 of 65%
Normalization of lactate
```
128
% of calories that should come from carbs
60%
129
% of calories that should come from fat
25-30%
130
% of calories from protein
10-15%
131
how many kcal is dextrose
3.4 kcal/g
132
how many kcal is protein
4 kcal/g
133
how do you calculate nitrogen balance
protein intake divided by 6.25 - (UUN + 4)
134
Post op oliguria - H&P, first step s
```
Assess volume status (CVP, swan, echo)
Baseline renal function/trend
Perioperative events - large volume resusc/transfusions?
HoTN (ptx, MI, PE?)
Review meds potentially toxic to kidneys
Is foley patent
check bladder pressure
```
135
REason for decreased ventilator volumes and elevated airway pressures in ACS
Pulmonary compliance suffers as PVR increased due to increased intrathoracic pressures
136
Open pelvic fx - surgical tx for the belly?
Diverting sigmoid colostomy regardless of rectal injury
137
Late finding in compartment syndrome
absence of pulses
138
Sensory finding corresponding to anterior compartment
first web space (deep peroneal nerve)
139
sensory finding corresponding to lateral compartment
dorsum of foot (superficial peroneal nerve)
140
sensory finding corresponding to deep posterior compartment
sensation of plantar surface (tibial nerve)
141
How to measure compartment pressure
use solid state rtransducer intracompartmental cathteer
attach 16-g needle to an A line setup with 3 way stopcock
using sterile saline, xero monitor, and inject 1 cc into compartment
142
surgical decompression for compartment syndrome of extremity when compartment pressures are > than?
40 mm Hg
| or within 30 mm Hg of distalic BP
143
LE fasciotomy
Make 2 incisions
1st incision from knee to ankle, centered between anterior and lateral compartments
Divide fascia 1 cm above and below intermuscular septum to free anterior and lateral compartments
Avoid superficial peroneal n in lateral compartment
2nd incision from knee to ankle and 2 cm posterior to the posteromedial border of the tibia
Avoid saphenous vein
Divide fascia overlying gastroc and soleus muscles (medial compartment)
Detach soleus from posterior tibia to reach fascia of deep compartment and incise
144
Surgical treatment for duodenal injury - exposure
R/o injury to pancreas and adjacent ductal and major vascular structures
Extended Kocher fro mporta hepatis to superior mesenteric vessels (posterior duo)
Extended mobilization from L side as well to divide LoT in order to see D3/D4
Add Cattell-Braasch maneuver (mobilize entire right colon out of retroperitoneum to look at ureter, vena cava, right kidney)
145
Intraoperatively diagnosed intramural hematoma of duodenum
explore and rule out full thickness laceration ro leak
146
simple laceration of duodenum - repair?
primary with two layer closure transversely +/- omental patch
147
large laceration to seocnd portion of duodenum or unable to do primary repair
roux en y reconstruction
148
Lower 1/3 ureteral injury
ureterneocystostomy +/- psoas hitch
149
middle 1/3 ureteral injury
end-to-side ureteroureterostomy to other ureter
150
proximal 1/3 ureteral injury
nephrostomy tube in ipsilateral kidney
151
injury to renal vein - stable vs unstable pts
repair in stable
| otherwise ligate
152
renal a injury - stable vs unstable
repair in stable
| otherwise nephrectomy
153
what must you remember to check on PE in a pelvic fx
meatus, rectum
154
deep liver laceration - OR
finger fx and ligation of indivdual vessels
liver suture to reapproximate injured area
pack laceration with vascularized tongue of omentum mobilzied from transverse colon
155
ext3ensive liver injury (bilobar, hepatic venous injury ,retrohepatic cava) - OR
mobilize liver
gauze packing anteriorly and posteriorly to tamponade bleeding
temporary abdominal wall closure
angioembolization via IR
return to OR in12-36h after resuscitation
plan to ask for help and have amble blood products available
offer to transfer with open abdomen to higher level of care at level 1 trauma center
156
hepatic v injury - OR
pringle maneuver to control INFLOW - if bleeding stops, its from hepatic artery and/or portal vein
consider total hepatic isolation and/or atriocaval shunt
Place tourniquet around infrahepatic IVC, perform median sternotomy, open pericardium, place Rummel tournqieut around intrapericardial IVC then try an atriocaval shunt by placing chest tube down through hole in RA and below level of liver injury
157
Post op liver trauma mgmt
Consider ERCP esp if bile leaking from drains
| fever is common so work up for all infectious causes
158
Blood at urethral meatus - next step?
urethrogram first - if positive, suprapubic cystostomy
| if negative, cystogram
159
zone 1 neck
clavicles to cricoid
| proximal carotid, subclavian, vertebrals, esophagus, trachea, brachial plexus, spinal cord, thoracic duct, upper lung
160
zone. 2 neck
cricoid to angle of mandible
| carotid, vertebral, jugular, larynx, esophagus, trachea, vagus, recurrent laryngeal, spinal cord
161
zone 3 neck
angle of mandible to base of skull
| pharynx, distal carotid, vertebrals, parotid, cranial nn
162
incision/mgmt of zone 1 injury to neck
typically requires median sternotomy to access R subclavian and innominate
Trap door may be needed to access left subclavian artery if left of midclavicular line
163
incision/mgmt of zone 2 injury to neck
cervical incision like CEA along anterior border of SCM
| isolated trachea injury can do collar incision
164
incision/mgmt of zone 3 injury to neck
cephalad extension of unilateral cervical neck incision
| non operative mgmt and IR embolization preferred if possible
165
Indications for IVC filter
pts with recurrent PE despite therapeutic anticoagulation
pts who have undergone mechanical thrombolysis or surgical embolectomy
pts who cannot be anticoagulated
166
alternative to abthera
ioban over drains hooked to suction
167
alternative to abthera
ioban over drains hooked to suction
168
right subclavian - proximal exposure
takeoff of innominate
| median sternotomy
169
right subclavian - distal control
axillary
170
6 steps for vascular OR scenario
```
diagnose the rpoblem
locate the problem - CTA is ideal
heparinize pt
fix the problem
completion angiogram
consider fasciotomy
```
171
left subclavian - proximal exposure
anterolateral thoracotomy in 2nd intercfostal space
172
left subclavian - distal control
axillary
173
suprahepatic IVC - where do you put your clamp
between diaphragm and heart
can do thoracotomy
ID where phrenic nerve/artery are and lacerate diaphragm parallel to that and access with satinsky clamp
174
infrahepatic IVC - be mindful of?
renal vein
175
principals in repair of kidney
use pledgets
| leave drain
176
zone 3 penetrating - explore?
yes
177
exposure: ascending aorta
median sternotomy
178
exposure: transverse aortic arch
median sternotomy +/- neck extension
179
exposure: descending thoracic aorta
left posterolateral thoracotomy (4th ICS)
180
exposure: innominate artery
media nsternotomy with right cervical extension
181
exposure: left CCA
median sternotomy with leftcervical extension
182
exposure: pulmonary artery (main, intrapericardial)
median sternotomy
183
exposure: pulmonary artery (right or left hilar)
ipsilateral posterolateral thoracotomy
184
exposure: pulmonary vein
ipsilateral posterolateral thoracotomy
185
undiagnosed injury to the chest: exposure
left anterolateral thoracotomy
186
conduit of choice in vessels >5 mm
prosthetic graft
187
tracheostomy - OR
Vertical midline incision
Divide platysma and straps
Develop pretracheal space at leve lof cricoid cartilage
Divide isthmus using electrocautery
Place 2-0 prolene through 3rd tracheal ring laterally on each side (deflate your ETT cuff)
Use scalpel to incise between rings 2&3 and 3&4, divide 3rd ring to make H shape
Tracheal spreader
Withdraw ETT and insert tracheostomy tube
Confirm ET CO2
2-0 prolene to reapproximate above and below tube and secure to skin
188
cricothyroidotomy - OR
Use a 10 blade to make vetrtical incision from prominence of thyroid cartilate to below level of cricoid
Use curved hemostat to pop through cricothyroid membrane
Advance a 15 Fr Bougie through opening into trachea
6-0 ETT over the bougie into trachea and inflate balloon
Confirm ET CO2
Use 0 silk to secure ETT
189
Total inflow occlusion to heart
SVC and IVC at intrapericardial location
| Can only do so for 1-3 min
190
Repair of atrial injury - what suture
2-0 monofilament in running or interrupted
| Make sure to debride
191
Repair of ventricular injury - what suture
2-0 monofilament with pledgets
192
Rapid sequence intubation
Preoxygenate
Etomidate 0.3 mg/kg
Succinylcholine 1 mg/kg
193
RSBI goal in SBT
<105
194
Indications for RRT in ARF
```
Volume overload
Hyperkalemia
Metabolic acidosis
Uremia
Azotemia
```
195
Electrolyte disturbances in adrenal dysfunction in ICU
hypoglycemia
hyponatremia
hyperkalemia
196
supraceliac aorta control
lesser sac opened by dividing gastrohepatic ligament, dissect down onto superior aspect of pancreas
Mobilize pancreas
Divide crura
