Exam 4 Trauma Flashcards
*what are the three components of the lethal triad in a bleeding patient?
COAGULOPATHY (d/t loss of clotting factors)
Lactic ACIDOSIS (d/t loss of blood volume)
Decreased myocardial performance (empty tank)
at increased risk of HYPOTHERMIA
*Hemorrhagic shock: Blood loss of 1 L classified as…
Class II
(Class II: 750-1500)
Hemorrhagic shock: Blood loss of 1700 mL classified as…
Class III
(Class III: 1500-2000)
Hemorrhagic shock: Blood loss of 800 mL classified as…
Class II
(Class II: 750-1500)
*Hemorrhagic shock: Blood loss of 3 L classified as…
Class IV
(Class IV: >2000)
Hemorrhagic shock: Blood loss of 400 mL classified as…
Class I
(Class I: up to 750)
*IMIST Abbreviation
*NOT primary survey, but useful handover tool
I: Identification (of patient)
M: Mechanism (medical complaint)
S: Signs (VS/GCS)
T: Treatment (Trends and response to tx)
Components of the Primary Survey*
ABCDE
A: Airway (and cervical spine control)
B: Breathing (and oxygenation)
C: Circulation (and hemorrhage control)
D: Disability
E: Exposure
In addition: GCS Status and NAKED to perform full-body exam
What is performed in a secondary exam?
Systematic overview
*List 7 patient conditions that may require endotracheal intubation:
- MAXILLOFACIAL TRAUMA
- Major hemodynamic instability
- Low SaO2
- Burns
- HEAD INJURY
- Intoxicated/behavioral/safety issues
- Transport (radiology/OR/ICU/external)
When making decisions on managing a patient’s airway consider the following THREE items:
- Airway burns
- Oral trauma
- Direct airway injury
*What is the objective of manual in-line stabilization?
to minimize movement of the cervical spine during laryngoscopy
List 3 life-threatening breathing abnormalities:
Tension PTX
FLAIL CHEST
Open PTX
*FLAIL CHEST
Cx: chest injury and rib fractures at more than 2 sites of at least 3 adjacent ribs or rib fractures with associated costochondral or sternal fracture
S/S: PARADOXIC MOVEMENT OF THE CHEST AT THE SITE OF RIB FRACTURE (“paradoxical right-sided breathing”)
Characteristics: During inspiration, chest wall moves inward, during expiration, moves outwards
Tx: PPV
Management of flail chest and underlying contusion
may develop ARDS
treat pain with epidural LA and opioids
supplemental O2, pain relief, if mechanical ventilation is required add PEEP, avoid N2O
Management of hemothorax
Thoracotomy and chest tube
supplemental O2, pain relief, if mechanical ventilation is required add PEEP, avoid N2O
*List 4 life-threatening conditions of hemodynamic shock/differential diagnoses of shock in the trauma patient:
- Massive hemorrhage
- TENSION PNEUMOTHORAX
- TAMPONADE
- Severe cardiac contusion
*Necessary SEVEN anesthesia induction agents in trauma and their rationales:
- KETAMINE: sympathomimetic
- Etomidate: cardiovascular stability
- Opioids: cardiovascular stability but may cause bradycardia
- SUCCINYLCHOLINE: RSI
- Non-depolarizers: paralysis
- Benzodiazepines: amnesia
- SCOPOLAMINE: amnesia
Do not give NaHCO3 (Sodium bicarb) unless…
pH is < 7.20 because dissociates to bicarbonate ion and CO2 which may worsen acidosis
Phase 1 of Major Traumatic Resuscitation:
Life-threatening uncontrolled hemorrhage
Priority: stop the bleeding
Phase 2 of Major Traumatic Resuscitation:
Ongoing hemorrhage – not immediately life-threatening, partial surgical control
Priority: tailored resuscitation
*What is used to guide/tailor fluid requirements during Phase 2 of Major Traumatic Resuscitation?
SERIAL LACTATE/BASE EXCESS
HR + BP ARE NOT INDICATIVE OF FLUID RESUSCITATION
What is used to guide coagulation and blood products during Phase 2 of Major Traumatic Resuscitation?
TEG/ROTEM to guide coagulation products
ABG to guide RBC transfusion
*Phase 3 of Major Traumatic Resuscitation:
HEMORRHAGE CONTROLLED
Priority: Restore physiology; step-wise deepening of anesthesia
Low-dose vasoactive infusions can be considered to counteract anesthesia-induced vasodilation
When performing MTP, what is a critical piece of equipment?
Rapid infuser + warmer
delivers large amounts of warmed blood products very quickly and safely
*administration of PRBC + FFP (TWO):
use a fluid warmer
use a rapid infuser system
*administration of platelets (speed + temp):
administer slowly (30-60 min)
administer at room temperature
1st cooler of MTP
4 units PRBC
4 units FFP
2nd cooler of MTP
4 units PRBC
4 units FFP
6 units platelets
*Trauma patient coming in from ER
FOLLOW MTP
Cornerstones of Damage Control Resuscitation (DCR):
- Early use of blood products
- Limited crystalloids and colloids
- Early hemostasis
*Lab values for DCR:
PT < 14
PLT > 50
HCT > 25
Hct values between what range are targeted in controlling hemorrhage?
18-25%
TEG Phase 1:
Preclot
deficiencies require: Prothrombin complex concentrate and FFP
TEG Phase 2:
Formation
deficiencies require: cryoprecipitate/fibrinogen concentrate/platelet concentrate
TEG Phase 3:
Stability
treated with: antifibrinolytic product
TEG: R Time
time until initial fibrin formation
*PROLONGED R TIME on TEG, what do you administer?
FFP
*DEFICIENT R TIME on TEG, what is it and how do you treat?
Hypercoagulable state (either due to DIC or thrombosis). Administer anticoagulant for thrombosis or can ADMINISTER FFP FOR DIC (or platelets, cryo)
What does MA represent on TEG?
strength of the fibrin clot and platelet bonding
*LOW MA ON TEG, what is it and what do you administer?
means a decrease in platelet number or function
ADMINISTER PLATELETS OR DDAVP
*Manifestations of high thoracic (T4 and above) and cervical spinal cord injury and rationale
Significant bradyarrhythmia and AV Block
Mechanism: owing to disruption of sympathetic cardiac accelerator fibers, unopposed parasympathetic response
Management of T4+ and cervical SCI
administration of isotonic fluid, vasopressors, and inotropes
MAP should be kept 85-90 mm Hg to maintain adequate spinal cord perfusion
What can occur with direct laryngoscopy and intubation of patients with cervical or high thoracic injuries?
Exaggerated bradycardic response and hypotension
*SCI: Succinylcholine
May be used within first 24 H of injury
Avoid after 48 H of injury because of the risk of severe hyperkalemia
Nine s/s of PTX
- Dyspnea
- Cyanosis
- Hypoxia
- Agitation
- Diaphoresis
- Tracheal deviation to contralateral side
- Distended neck veins
- Mediastinal shift
- Tachypnea
*PTX treatment (needle decompression)
Needle decompression: placement of large-bore needle (14 G) through the SECOND INTERCOSTAL SPACE MIDCLAVICULAR LINE
Definitive PTX treatment
Chest tube placed at 4th and 5th ICS anterior to midaxillary line
Nitrous in PTX?
No, expands pneumo
*Cardiac tamponade: Beck’s Triad
HYPOTENSION
NECK VEIN DISTENTION (JVD)
DISTANT/MUFFLED HEART TONES
*Cardiac Tamponade anesthetic considerations (4) and what NOT to do
- Etomidate or Ketamine
- INOTROPES*
- INCREASE PRELOAD*
- Fluid resuscitation
NOT vasopressors!!!
Cardiac tamponade video: what is of utmost importance and what should be avoided?
Preserving CO most important
Avoid propofol, cardiac depressants, and PPV if possible
*List some KEY POINTS in pediatric trauma (4):
- LATE PHYSIOLOGIC DECOMPENSATION*
- potentially difficult IV access, consider IO
- Look out for NONACCIDENTAL INJURY*
- any blood loss is significant
Blood volume estimate of a preterm neonate:
95 mL/kg
Blood volume estimate of a full-term neonate:
85 mL/kg
*Blood volume estimate of an INFANT:
80 mL/kg
i.e. 22-lb 10-month old EBV would be…..
22 lb = 10 kg
10 kg x 80 mL/kg = 800 mL*
Blood volume estimate of an adult male:
75 mL/kg
Blood volume estimate of an adult female:
65 mL/kg
*What are the key points for trauma in pregancy?
- Normal signs of blood loss are late (look to urine output or fetal distress)
- FETAL DISTRESS IS FIRST SIGN OF MATERNAL COMPROMISE*
- Don’t forget left tilt uterine displacement to reduce aortocaval compression
- Reduced FRC - rapid desaturation
*Describe how anatomy increases the risk injury in a pregnant patient in their 3rd trimester:
BLADDER IS AT INCREASED RISK OF INJURY (not protected by uterus and fetus)
PLATELETS* (?)
To prevent longer-term impact on future pregnancies, an Rh-negative mother should be given
Anti-D immunoglobulin (can temporarily increase platelets?)
