CT Trauma Critical Care

Question 1

what percent of patients with ruptured heart s/p trauma survive

Answer 1

Between 30-40% of all patients with ruptured hearts will arrive at the hospital alive and will be able to undergo diagnostic evaluation. Some autopsy series reports, however, are more pessimistic.

Question 2

What is the most commonly injured chamber of the heart in survival blunt trauma injury ?

Answer 2

The most commonly injured chamber in survivable blunt cardiac trauma is the right atrium. Repaired atrial injuries have better outcomes than ventricular injuries in blunt trauma cases.

Question 3

Bronchial rupture - how to handle

Answer 3

• Dont: -
• Maneuvers such as direct laryngoscopy and flexible bronchoscopymay not yield adequate information about the patient’s airway. -
• Standard orotracheal intubation can be dangerous if there has been substantial separation of the trachea from the larynx. -

DO: -

• safest tracheostomy under local anesthesia. -
• Subsequent bronchoscopy is mandatory to determine whether or not the patient has a tracheobronchial injury. -
• Intubation over a flexible bronchoscope is sometimes possible but it does not provide as rapid and safe an approach to securing the airway as a tracheostomy.

Question 4

Antibody in HIT

Answer 4

heparin/platelet factor 4 complex

Question 5

Percentage of patients with HIT that develop HITT (HIT with Thrombosis)

Answer 5

Approximately 50% of patients with HIT develop signs of thrombosis (HITT).

Question 6

Risk of thrombosis in patient’s with HIT?

Answer 6

The risk of thrombosis remains quite high (20-50%) in patients with HIT who merely have cessation of heparin as their therapeutic intervention.

Question 7

FDA Approved agents for the treatment of HIT

Answer 7

Direct thrombin inhibitors (3)

1. lepirudin: longest half-life (40-120 minutes)
2. bivalirudin: (Angiomax) shortest T1/2
3. argatroban

Question 8

Direct thrombin inhibitor with the longest half life

Answer 8

• lepirudin, longest half-life (40-120 minutes)

Question 9

where are direct thrombin inhibitiors excreted

Answer 9

kidneys

Question 10

When is Angiomax best used? What kind of precautions should be taken ?

Answer 10

- bivalirudin (Angiomax):

direct thrombin inhibitor that is readily reversible and its half-life is the shortest of these three drugs. -

when can it ideally be used? - It may be the drug of choice in patients where bleeding is a serious risk, - Other Cautions? - especially if renal function is impaired. Its dose, however, must be adjusted for renal insufficiency - ,

Question 11

Inhibitors of thrombin in plasma

Answer 11

• In plasma, Thrombin is inhibited by: - antithrombin - heparin cofactor II

Question 12

• What is “heparin resistance.”?

Answer 12

• What is “heparin resistance.”? - syndrome of acquired antithrombin deficiency associated with CPB

Question 13

Mechanism of acquired heparin resistance?

Answer 13

-decreased antithrombin levels during and after CPB rise in the thrombin-antithrombin complex (TAT) levels. - DECREASED ANTITHROMBIN LEVELS - taken up by used AT reserve - More importantly, activation of hemostasis during CPB in heparin-resistant patients is attributed to stimulation of the tissue factor pathway.

Question 14

How to treat AT deficiency when going on bypass

Answer 14

• Anticoagulation during CPB with unfractionated heparin (UFH) should be supplemented with either: antithrombin concentrates , a short-acting direct thrombin inhibitor (e.g. bivalirudin), a short-acting platelet glycoprotein IIb/IIIa antagonist.

Question 15

Aortic isthmus

Answer 15

Rapid deceleration and the application of shearing forces mean that thoracic aortic injuries typically arise from the isthmus

the area distal to the left subclavian artery and proximal to the third intercostal artery

Question 16

anacrotic notch

Answer 16

The anacrotic notch seen on the arterial pulse wave occurs secondary to the presystolic rise in pressure during the first phase of ventricular systole (i.e., isovolumetric contraction). It always occurs before the opening of the aortic valve.

Question 17

when does an IABP fire

Answer 17

In a properly timed waveform, as shown, the inflation point lies at or slightly above the dicrotic notch.

Question 18

CVP tracing of tricuspid regurgitaion

Answer 18

CVP Tracing of tricuspid regurgitaion

Question 19

Normal CVP waveform

Answer 19

Question 20

Normal CVP waveforem

what does the a wave mean?

Answer 20

Presystolic a wave: produced by venous distention consequent to right atrial contraction.

Large a waves: indicate that the right atrium is contacting against increased resistance (tricuspid stenosis, pulmonary stenosis, pulmonary hypertension).

The a wave is absent in patients with atrial fibrillation and junctional rhythm.

Question 21

CVP wave form tracing

Answer 21

c wave: produced by bulging of the tricuspid valve into the right atrium during ventricular systole.

Question 22

cvp waveform tracing

x-descent - what is it ?

what happenes in constrictive pericarditis and severe TR?

Answer 22

x descent: is due to a combination of atrial relaxation and downward displacement of the tricuspid valve.

constrictive pericarditis, there is accentuation of the x descent while it is reversed with severe tricuspid regurgitation: reversed

Question 23

CVP wave form

• V wave
• what happens in TR

Answer 23

v wave: which results from increasing blood in the right atrium during ventricular systole, is prominent with tricuspid regurgitation.

Question 24

Timing of TRALI

Answer 24

occurs during or within six hours after a transfusion

Question 25

What blood products present the highest risk for TRALI ?

Answer 25

from multiparous donors

Question 26

Mortality from TRALI

Answer 26

1. estimated at 5%
2. much more optimistic than ARDS.