Exam 2 Trauma Flashcards
What are the three parts of an initial trauma patient evaluation?
rapid overview
primary survey
secondary survey
What are the components of a rapid overview
takes a few seconds to determine if patient is unstable or stable
inability to oxygenate -> brain injury and death within 5-10 minutes
What are the components of the primary assessment?
involves rapid evaluation for function crucial to survival and include ABCDE airway patency, breathing, circulation, disability, exposure
What are the components of the secondary survey?
detailed and systemic evaluation of each anatomic region and continued resuscitation if needed
History
What are the surgical priorities in trauma patients?
- airway management-> cricothyroidectomy
- control of exsanguinating hemorrhage
- intracranial mass excision
- threatened limb or eyesight/ high risk of sepsis/ control of hemorrhage
- early patient mobilization/ better cosmotic outcome
What scale assesses disability/neurological status?
glascow coma sclae
score is sum of best score in each category
significant abnormalities on the neurological abnormalities on the neurological exam are an indication for immediate CT
timeliness of diagnosis and treatment will have a strong influence on outcome
What are the three categories for GCS scale indicate?
eye opening response
verbal response
motor response
Describe the eye opening response of GCS?
4- spontaneous opening
3-to speech
2- pain
1- no response
describe the verbal response of GCS
5- alert and oriented
4- confused
3- inappropriate speech
2- incomprehensible sounds
1- no response
Describe the motor response of GCS
6- spontaneous
5- localized to painful stimuli
4- withdraws to painful stimuli
3- abdominal flexion
2-abdominal extension
1-none
What is the goal of care for TBI
prevention of secondary brain injury resulting from edema, increased ICP, hypoxia and shock
What are the classifications of TBI
mild, moderate, severe
what are the qualifications for mild TBI
GCS of 13-15
short period of observation, usually 24 hours
What are the qualifications of moderate TBI
GCS 8-12
manifested as intracranial lesions that require surgical evacuation
early CT
high potential for deterioration requires early intubation mechanical ventilation
What are the qualification of severe TBI
GCS less then 8
carries a significant rates of mortality
care is directed at perfusion of injured brain
Guidelines for severe TBI
after primary survey approach maintain CPP
maintain CPP 60-70mmHg
Fluid resuscitation keep euvolemia
correction of anemia (hct of 30%)
paco2-> 35mmHg
insertion of ventriculostomy and control ICP
positional therapy
judicious use of anaglesisc/sedation
mannitol
hypertonic saline
Airway and Ventilatory Management TBI
hyperventilation only if herniation is imminent
hyperventilate to PaCO2 of 30 if elevated ICP is not responsive to
(sedative, CSF drainage, NM blockage, osmotic agents, barbiturate coma)
CPP=MAP-ICP
Anesthetic Management of TBI
Early control of airway
establishing cardiovascular stability
management of intracranial pressure of ICP
How can you gain early control of the airway in TBI management
orotracheal intubation to maintain SpO2 >90%
maintain normoventilation to help in teh reduction of hypercarbia and hypoxemia
Judicious use of induction agents
(propofol, etomidate)
Neuromuscular blocking agents to avoid coughing and bucking
How can establish cardiovascular stability in the TBI?
avoid intracranial hypertension (ICP>20)
avoid systolic hypotension
placement of an arterial line in addtion to standard monitors
low concentrations of sevoflurane, isoflurane, or desflurane
avoid nitrous oxide
How do manage ICP in the OR for the TBI patient?
mannitol 0.25-1.0g/kg for control of ICP
consider hyperosmolar therapy per surgeon
corticosteroids increase in mortality
Where does SCI occur mostly?
low cervical spine
What does SCI include?
sensory deficits, motor deficits, sensory and motor
What are the three factors the SCI patient depends on?
severity of the acute injury
prevention and exacerbation of the injury during rescue, transport and hospitalization
avoidance of hypoxia and hypotension
early treatment of SCI is focused on adequate perfusion to prevent secondary injury
When does autonomic hyperreflexia occur?
SCI with complete injury above T5
Discuss the management of SCI (7)
treatment aimed at preservation of adequate perfusion (avoid hypotension or correct immediately)
avoid hypoxemia (hypoxia and hypercapnia can further accentuate the damage)
MAP maintained normal to high
Neurogenic shock
adequate circulation
glucocorticoid bolis
C-spine evaluation should include all 7 cervical vertebrae
Describe intubation with an SCI
emergency intubation
awake fiberoptic intubation
use equipment and techniques that are most familiar
use of succinylcholine is allowable if less then 24 hours
What should be avoided when intubating with an SCI
simple chin lift with manual in-line stabilization
Avoid extension, flexion and rotation
Direct laryngoscopy with MILS
What is the gold standard of intubation with SCI
awake fiberoptic intubation
What are the goals of intubation with SCI?
achieve tracheal intubation while minmizing motion of C spine
preserve the ability to assess neurologic function after positioning
no evidence that DL worsens outcomes
What the three types of orthopedic and soft tissue trauma?
frequent indication for operative management in trauma patients
isolated closed
open fractures of major long bones and joints
multiple fractures of major long bones, spinal column, and joints associated with multisystem injuries
What are examples of Ortho trauma? (6)
dislocated hip, fractured pelvis, crush injuries, open fractures, long bone fractures (high DVT risk), compartment syndrome
Discuss ortho trauma and anesthesia management (4)
most frequently require GA
anesthetic requirements comparable to those of non-trauma patient
If lower requirements are being used consider if you patient has hypovolemia
controlled hypotension (MAP 20 mmHg below baseline) if not contraindicated
allow spontaneous ventilations at near end of procedure to guide narc use
What are the advantages of regional anesthesia (9)
allows for continuous mental status assessment
increased vascular flow
avoidance of airway instrumentation
improved postoperative mental status
decreased blood loss
decreased incidence of DVT
improved postoperative analgesia
better pulmonary toilet
earlier mobilization
What are the disadvantages of regional anesthesia? (6)
peripheral nerve function difficult access
patient refusal is common
requirement for sedation
longer time to acheive anesthesia
not suitable for multiple body regions
difficult to judge length of surgical procedures
What are the advantages of general anesthesia (5)
speed on onset
duration- can be maintained as long as possible
allows multiple procedures for multiple injuries
greater patient acceptance
allows for positive pressure ventilation
What are the disadvantages of general anesthesia? (4)
impairement of neurological examination
requires airway instrumentation
hemodynamic management more complex
increased potential for barotrauma
What are the four types of chest injuries?
pulmonary
traumatic aortic injury
rib fractures
cardiac injury
Describe pulmonary injuries
chest tube requirement
thoractomy
double lumen tube (but often after initial intubation via RSI and standard ETT
What are indications for thoractomy?
if drainage greater then 1500ml in first several hours
when tracheal or bronchial injury or massive air leak are noted
hemodynamic instability from thoracic injury
What injury has a high morbidity and mortality?
traumatic aortic injury
What injury needs to be ruled out if patient has suffered high energy injury Ie MVA or fall
traumatic aortic injury
How do you diagnose a traumatic aortic injury?
CXR, angiography CT and TEE
Why is surgery indicated for a traumatic aortic injury?
because it has a high risk of rupture in hours to days
What is the anesthetic treatment of a traumatic aortic injury?
partial bypass technique using inflow from the left atrium. a centrifugal pump and outflow to descending aorta
What repair is common for traumatic aortic injury?
endovascular repair
What is the most common injury from blunt chest trauma?
rib fractures
What is flail chest?
comminuted fractures of atleast 3 ribs
characterized by paradoxical respiration
consider pain management or epidural placement to maintain ventilation/perfusion
rib fractures associated with costrochondral separation
sternal fracture
What injury is functionally indisguishinable from MI?
bruising or contusion cardiac injury
How can you diagnose cardiac injury?
TTE or TEE
how do you manage cardiac injury?
as an ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances
What are special case trauma management techniques for Jehovah’s witnesses?
deliberate hypotension
use of salvaged blood cells from intraoperative or chest tube collection
early hemodynamic monitoring
post op use of erythropoeitin
What are special case trauma management techniques for the eldery?
more serious outcomes in the elderly for equivalent trauma
decreased cardio-pulmonary reserve higher incidence of post-operative mechanical ventilation
MOSF after hemorrhagic shock
post traumatic myocardial dysfunction
How does post traumatic myocardial dysfunction occur?
d/t plaques or just from stress of incidence
What is there a high incidence of with pregnant trauma patients?
spontaneous abortion, pre-term labor, premature delivery
What are anesthesia management techniques for pregnant trauma patients?
OB consult for immediate management and follow-up
requires rapid and complete resuscitation of the mother
What are the four systems analyzed for post operative extubation criteria?
mental status
airway anatomy and reflexes
respiratory mechanics
systemic stability
Describe mental status evaluation for extubation (4)
resolution of intoxication
able to follow commands
non-combative
pain adequately controlled
Describe airway anatomy and reflexes for extubation (3)
appropriate cough and gag
ability to protect airway from aspiration
no excessive airway edema or instability
Describe respiratory mechanics for extubation (3)
adequate tidal volumes and respiratory rate
normal motor strength
required FiO2 less then 50%
Describe systemic stability for extubation (3)
adequately resuscitated
small likelihood of urgent return to the operating room (at least in short term)
normovolemic, without signs of sepsis
What are the risk factors to develop ARDS after trauma? (11)
elderly
pre-existing physiologic impairment
direct pulmonary or chest wall injury
aspiration of blood or stomach contents
prolonged mechanical ventilation
severe TBI
spinal cord injury with quadriplegia
massive transfusion
hemorrhagic shock
occult hypoperfusion
wound or body cavity infection
burn with inhalation injury
What are the recommended ventilator settings for acutely injury patients?
TV 6-8ml/kg
PEEP 10-15cmH20
Limit peak pressures <40cmH20
Adjust I:E ratio as neccessary
Wean FiO2 to obtain PaO2 of 80-100 sat goal:93-97%
What are post-operative complication concerns (4)
infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS
What is the leading cause of death from 1-45 years in the US?
trauma
How much is mortality reduced with a trauma patient receives care at a level 1 trauma center?
25%
WHO estimates trauma as the leading cause of death world wide from what age range?
15-44 years
In the primary survey, what is assessed for airway patency?
obstruction
midline trachea
involves diagnosis of trauma to the airway and surrounding tissues
anticipates the respiratory consequences
contemplate airway management maneuvers
In the primary survey, what is assessed for breathing?
high flow oxygen
trachea midline
flail chest
tension, pneumothorax due to air leaking from the lung, or chest wall into the pleural space
massive hemothorax
What qualifies as a massive hemothorax?
> 1500cc blood
In the primary survey, what is assessed for circulation?
skin temperature, color, 2 large bore IVs
In the primary survey, what is assessed for diability?
GCS and glucose
In the primary survey, what is assessed for exposure?
final step
complete exposure of patient
removal of clothing and turning to examine
includes brief head to toe search for visible injuries adn deformities
When does the secondary survey begin?
after critical life saving actions have begun
intubation, chest tube placement, fluid resuscitation
What is the focus of the secondary survey? (3)
history of injury
allergies, medications, last oral intake
focused medical and surgical history
What needs to be assumed in the trauma patient’s airway evaluation?
the patient absolutely requires an airway and cannot be re-awakened electively
What is commonly required and detected during the airway evaluation of the trauma patient?
assisted or controlled ventilation
self-inflating bag with a non-rebreathing valve is sufficient after intubation and for transport
100% oxygen is necessary until ABG is complete
What are considerations for airway obstruction? (10)
airway edema/direct airway injury
cervical deformity
cervical hematoma
foreign bodies
dyspnea, hoarseness, stridor, dysphonia
subcutaneous emphysema and crepitation
hemoptysis/active oral bleeding/copious secretions
tracheal deviation
jugular vein distention
hemodynamic condition
What are considerations for airway management ? (8)
oxygen administration
chin lift and jaw thrust
full stomach
clearing of oropharyngeal airway
oral and nasal airway
immobilization of cervical spine
tracheal intubation if ventilation is inadequate
consider AW adjuncts to secure AW
When is nasal intubation or nasal airways contraindicated?
basilar skull fractures
What are the indications for ETT intubation?
cardiac or respiratory arrest
respiratory insufficiency/deteriorating condition
airway protection
need for deep sedation or analgesia (pain control)
GCS < 8
delivery of 100% FiO2 in presence of carbon monoxide posioning or 100% non-rebreather
facilitate work-up in an un-cooperative or intoxicated patient
transient hyperventilation required
Discuss the differences for trachetomy vs. cricothyroidotomy
trach: longer to perform, requires neck extension which may cause neck trauma if cervical injury is present
Cricothyroidotomy: laryngeal damage precludes the ability to perform cricothyroidectomy
What age is cricothyroidotomy CKA?
under the age of 12
Cricothyrotomy Indications
massive facial trauma/ hemorrhage
supraglottic foreign body obstruction
angioneurotic edema
inhalation thermal injury
epiglottis/ croup
What is contraindicated in trauma patients with full stomach as a definitive airway?
LMA use
eWhat are safe techniques for securing the airway in the trauma patient?
RSI with cricoid pressure and manual in line stabilization
awake intubation with topical anesthesia and sedation
What are common induction medications with dosages?
etomidate 0.2-0.3mg/kg IV
ketamine 2-4mg/kg IV
Ketamine 4-10mg/kg IM
Propofol 2mg/kg IV
What are common neuromuscular blocking drugs?
Succinylcholine 1-1.5mg/kg IV
Rocuronium 1.2mg/kg IV
What is the onset and duration of succinylcholine?
onset 30 seconds
duration 5-12 minutes
What is the onset and duration of rocuronium?
30-60 second onset
60-90minute duration
When should you have a a high suspicion for cervical spine injury?
if the victim has experienced a fall, MVA or diving incident
What provides best stabilization of the cervical spine?
semi-rigid, sandbags, backboard
What is the best for airway management with a cervical spine injury?
manual inline stabilization
Describe the airway management of head, open eye, major vessels injuries?
ensure adequate oxygenation and ventilation
deep anesthesia and profound relaxation prior to airway manipulation and intubation
without sufficient depth of anesthesia these patients may present with HTN, coughing/bucking, increased ICP/IOP and intravascular pressure
must consider the initial assessment of airway (if difficult cannot use muscle relaxants or IV induction agents)
Discuss the AW management considerations with maxillofacial injuries
blood and debris in the oropharyngeal cavity may presdispose patients to complete or partial AW obstruction
aspiration of teeth or foreign bodies
serious airway compromise may present within a few hours penetrating facial trauma
consider limitation of mandibular movement and trismus
AW management technique is based on the presenting condition
What are the three interactive factors of penetrating injury?
type of wound instrument
velocity at time of impact
characteristics of tissue through which it passes
what are clinical signs of penetrating injury to the cervical airway?
escape of air, hemoptysis, and coughing
Describe blunt injury?
direct impact, deceleration, shearing, and rotary forces
laryngotracheal damage
What are signs of blunt injury to the cervical airway?
hoarseness, mufffled voice, dyspnea, stridor, dysphagia, cervical pain and tenderness, flattening of the thyroid cartilage
What should be used to secure the airway in cervical airway injuries?
intubation of trachea should be with a fiberoptic scope or AW should be established surgically
Define breathing abnormalities
factors that alter respiration and interfere with breathing and pulmonary gas exchange after trauma
What are injuries that cause breathing abnormalities (7)
tension pneumothorax
flail chest
open pneumothorax
hemothorax
pulmonary contusion
diaphramatic rupture
chest wall splinting
What is a hemothorax?
presence of blood in the pleural cavity
What are the hallmark symptoms of a hemothorax?
hypotension
hypoxemia
tachycardia
increased CVP
What is the treatment for hemothorax?
eliminate and correct
chest tube to evacuate
What is a pneumothorax?
disruption of the parietal or visceral pleura presence of gas within a pleural space
What are the three categories of a pneumothorax?
simple
communicating
tension
When do you need to place a chest tube for a pnemuothorax?
chest tube if > 20%
Define tension pnemothorax
occurs with rib fractures and barotrauma due to mechanical ventilation
What are hallmark symptoms of pneumothorax?
hypotension
hypoxemia
tachycardia
increased CVP
diminished breath sounds on the affected side
Define hemorrhage
most common cause of traumatic hypotension and shock in trauma patient
Define circulation
failure leading to inadequate vital organ perfusion and oxygen delivery
Define resucitation
restortation of normal circulating blood volume, normal vascular tone, and normal tissue perfusion
What is the physiological response to shock
initial response to shock is mediated by the neuroendocrine system
hypotension leads to vasoconstriction and catecholamine is released
heart, kidney and brain, BF is preserved while other regional beds are constricted
traumatic injuries lead to a release in hormones that set the stage for microcirculatory response
What do ischemic cells cause during hemorrhage?
take up interstitial fluid and depleting intravascular volume
produce lactate and free radicals
How is metabolic acidosis produced during hemorrhage?
inadequate organ perfusion interferes with aerobic metabolism
producing lactic acid and metabolic acidosis
What do lactate adn free radicals cause?
direct damage to cell
a toxic load that will be washed into circulation once re-established
In addition to fluid shifts, what does an ischemic cell release during hemorrhage?
leukotrienes, interleukins
systemic inflammatory process
becomes a disease process itself
lays the foundation for multiple organ failure and high mortality rates
Describe the CNS response to shock
responsible for maintaining blood flow to heart, kidney, and brain at expense of other tissue
Describe kidney/adrenal response to shock
maintains GF durign hypotension by selective vasoconstriction and concentration of blood flow in medulla and deep cortical areas
Describe the heart’s response to shock
perserved function with an increase in nutrients blood flow and cardiac function until later stages
Describe the lung’s response to shock
destination of inflammatory byproducts
accumulate in capillary beds and results in ARDS
sentinel organ for the development of MOSF
Describe the gut/instestinal response to shock
one of earliest organs affected by hypoperfusion and may be trigger for MOSF
When does acute traumatic coagulopathy start?
begins in the early presence of reduced clot strength
resuscitation includes early treatment of ATC
Why does ATC occur
hypotension and tissue injury-> inflammatory response-> endothelial activation of protein C
hyperfibrinolysis due to APV formation
What does a base deficit reflects
severity of shock
oxygen debt
changes in O2 delivery
adequacy of fluid resuscitation
likelihood of MOF
Define mild shock
base deficit between 2-5mmol/L
Define moderate shock
a base deficit between 5-9mmol/L
Define severe shock
a base deficit between >10mmol/L
What base deficit on admission correlates with increased mortality?
base deficit of 5-8mmol/L
What is the difference between blood lactate and base deficit?
blood lactate is less specific than base deficit but nonetheless important
What do elevated lactate levels correlate to”?
hypotension
What is the normal blood lactate level?
0.5-1.5mmol/L and its half life is 3 hours
What plasma lactate level is indicative of significant lactic acidosis?
5mmol/L
What is a predictor of increased mortality after the reversal of shock?
failure to clear lactate within 24 hours
How do you assess systemic perfusion? (10)
vital signs
urine output
systemic acid-base status
lactate clearance
cardiac output
mixed- venous oxygenation
gastric tonometry
tissue specific oxygenation
stroke volume variation
acoustic blood flow
Symptoms of Shock (8)
pallor
diaphoresis
agitation or obtundation
hypotension
tachycardia
prolonged capillary refill
diminished urine output
narrowed pulse pressure
What are sites for emergency IV access
large bores IVs antecubital vein
subclavian vein (easiest to place and does not require neck manipulation in circumstance of cervical neck injury)
femoral cein
internal jugular vein
intraosseous
What are the goals for early resusucitation? (10)
maintain SBP 80-100mmHg
Maintain HCT at 25-30%
Maintain Ptt/Pt within normal range
maintain platelet count >50,000
maintain nromal serum ionized calcium
maintain core temp >35C
maintain function of pulse ox
prevent worsening acidosis
adequate anesthesia/analgesia
What are the risks of aggressive volume replacement during early resuscitation? (8)
increased blood pressure
decreased blood viscosity
decreased hematocrit
decreased clotting factor concentration
greater transfusion requirement
disruption of electrolyte balance
direct immune suppression
premature reperfusion
What are the anesthetic resuscitation goals?
oxygenate and ventilate
restoration organ perfusion
restore hemostasis/ repay oxygen debt
treat coagulopathy
restore the circulating volume
continuous monitoring of response
What are the surgery goals?
stop the bleeding
What are the goals for late resuscitation? (9)
maintain systolic blood pressure >100mHg
maintain hematocrit above individual transfusion threshold
normalize coagulation status
normalize electrolyte balance
normalize body temperature
restore urine output
maximize cardiac output by invasive/noninvasive monitoring
reverse systemic acidosis
document decrease in lactate to normal range
What are the end points for resucitation
serum lactate level <2mmol
base deficit <3
gastric intramuscosal pH
What are the three steps of shock management
control the source of the hemorrhage
begin fluid resuscitation
possibly use rapid infusing system
Describe fluid resuscitation
isotonic crystalloid
hypertonic saline- TBI
colloids- rapid plasma volume expansion
PRBCs
FFP- 2 units of FFP with every 4 Units of PRBCs when massive transfusion is anticipated or ongoing
Describe PRBCs purpose in fluid resuscitation
provided with adequate oxygen carrying capacity-mainstay of hemorrhagic shock
blood loss replacement
1:1 RBCs
3:1 crystolloid
Rh negative blood is preferable if crossmatch is not complete (ABO and Rh)
What are the two methods of hemostatic resuscitation?
damage control
goal directed
Describe damage control of hemostatic resuscitation
administration of set protocol of blood and hemostatic products to mimic whole blood
massive transfusion protocol
limited crystalloid
Describe damage control of hemostatic resuscitation
administration of set protocol of blood and hemostatic products to mimic whole blood
massive transfusion protocol
limited crystalloid
Describe goal directed of hemostatic resuscitation
utilizes point of care viscoelastic (TEG) monitoring to direct therapy
What are the two hemostatic agents used in shock?
tranexemic acid
recombinant activated human coagulation factor VII (rfVIIa)
WHen is TXA most benefical?
instituted within 1 hours of admission
What is the lethal triad?
acidosis
coagulaopathy
hypothermia
What are the major factors in induction of coagulopathy?
acidosis and hypothermia
What is the principle goal of early management of the hemorrhaging trauma patient?
avoid the development of the lethal triad
What can dilute already dysfunctional platelets?
resuscitation with fluids and PRBCs without hemostasis properties
What does hypothermia worsen?
acid base disorders
coagulopathy
myocardial dysfunction
shifts oxygen-hgb curve to left
decreases the metabolism of lactate, citrate and some anesthetic drugs
Describe the effects of hypothermia?
left shift of oxygen dissociation curve (decreased tissue oxygenation)
impairs platelet and clotting enzyme function
abnormal potassium and calcium homeostasis
causes vasoconstriction– can make BP appear higher then volume status really is
Describe coagulopathy in the trauma patientt
activation of the clotting cascade causes consumption of clotting factors
blood loss causes a loss of clotting factors
hemodilution further dilutes clotting factors
severely injured trauma patients become hypocoagulable
How much does PT/PTT increase at 29C
increased 50%
How much do platelets decrease at 29C
40% decrease
What does massive transfusion cause?
dilution of factors and platelets
Hypothermia slows
coagulation and causes sequstering of platelets
Treatment of coagulopathy (5)
avoidance or reversal of the lethal triad
judicious resuscitation avoid hemodilution
treat coagulopathy
trauma disrupts the equilibrium between hemostatic and fibrinolytic processes
changes are complex adn can either result in hypocoagulable states
