hemorrhagic shock, C-spine, anaphylaxis

Question 1

what is Morrison’s pouch

what does it indicate if free fluid is found here?

Answer 1

hepatorenal space

indicates intra-abdominal hemorrhage secondary to solid organ injury

Question 2

algorithm for management of trauma pt

Answer 2

ABCs (ask pt name and look for tracheal deviation)
-IV access, begin rapid infusion NS
cardiac monitor, supplemental oxygen
-control obvious hemorrhage with direct pressure
-FAST exam, Chest, Pelvis/C-spine XR, CT scan
-establish definitive hemostasis (OR/IR), ongoing fluid/blood resuscitation

Question 3

how to determine trauma pt’s level of functioning and get a rapid/relevant hx

Answer 3

GCS, the "AMPLE" hx guide
Allergies
Meds
PMHx (significant)
Last meal
Event recall (leading up to accident)

Question 4

FAST exam looks for free fluid in ?

Answer 4

Morison pouch, splenorenal and supra-splenic space, pelvis, and pericardial space

Question 5

ultrasound can also be used for rapid identification of ?

Answer 5

pneumothorax, hemothorax, cardiac activity, and central line placement if needed

Question 6

Shock is divided into three stages

Answer 6

Compensated (SNS–>^HR, contractability, vasoconstriction; angiotensin–>fluid retention)
Progressive (arterial pressure falls)
Irreversible

Question 7

The normal manifestations of shock do not apply to ?

Answer 7

pregnant women, athletes, and individuals with altered autonomic nervous systems (older patients, those taking B-blockers)

Question 8

the 1st and 2nd most common causes of death in trauma pts

Answer 8

TBI then hemorrhagic shock

Question 9

ATLS Classification of Hemorrhage

Answer 9

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104716039&gbosContainerID=70&gbosid=218344

Question 10

tibial or humeral fractures can be associated with ? of blood loss, whereas femur fractures can be associated with up to ? of blood in the thigh. Pelvic fractures may result in ?

Answer 10

750 mL (1.5 units of blood)
1500 mL (3 units of blood)
even more blood loss—up to several liters can be lost into a retroperitoneal hematoma

Question 11

HCT/Hbg in acute hemorrhage?

Answer 11

may or may not be decreased as they measure concentration, not actual amounts

Question 12

hemorrhagic shock results in metabolic acidosis..good laboratory measures to get?

Answer 12

lactate and base deficit levels

• however, not true representations of tissue hypoxia as they are global indices of tissue perfusion and normal values may mask areas of under perfusion
• but normalization within 24 hrs is a good prognostic indicator of survival

Question 13

lactate is not a reliable value in what patients?

Answer 13

patients with liver dysfunction (hepatically metabolized)

Question 14

What is considered the best clinical estimate of preload?

Answer 14

Left-ventricular end-diastolic volume

via pulmonary artery catheter (PAC)

Question 15

recent alternatives to PAC for measuring preload

Answer 15

ultrasound to assess intravascular volume status by examining the respiratory variation of the IVC (more variation signifying low intravascular volume), or by calculation a ratio of the diameter of the IVC to the aorta

Question 16

fluid resuscitation in hemorrhagic shock

Answer 16

NS or LR, give 3 mL replacement for each 1 mL of blood loss: for each 1 L infused, 300 mL stays in the intravascular space while the remainder leaks into the interstitial space

Question 17

A blood transfusion is indicated if ?

Answer 17

the patient persists in shock despite the rapid infusion of 2 to 3 L of crystalloid solution, or if the patient has had such severe blood loss that cardiovascular collapse is imminent (if cannot type/cross match, O- blood for females, O+ for males)

Question 18

Should non-blood product colloid solutions such as ? be used in the acute setting?

Answer 18

albumin and hetastarch or dextran
they are not superior to crystalloid replacement in the acute setting and have the potential for large fluid shifts and pulmonary or bowel wall edema

Question 19

what may be used to retain fluid in the intravascular space in trauma situations with no access to blood products, such as in military settings?

Answer 19

Hypertonic solutions such as 7.5% saline

Question 20

why permissive hypotension in hemorrhagic shock?

Answer 20

artificially increased BP by aggressive fluid resuscitation may disrupt endogenous clot formation and promote further bleeding
-fluids often cooler than body temp, which may result in hypothermia

Question 21

Patients in whom permissive hypotension should not be practiced

Answer 21

patients with TBIs who require maintenance of their cerebral perfusion pressure; patients with a history of HTN, CHF, CAD, in whom hypotension will be poorly tolerated and may produce other medical problems such as stroke or MI

Question 22

BP at rest typically does not decrease until class ?hemorrhagic shock, when ? of blood is lost

Answer 22

III

1500 to 2000 mL (30%-40% of blood volume)

Question 23

Class I hemorrhagic shock is well compensated associated with ? EBL and what changes in vitals?

Answer 23

750 mL EBL or less, with no effect on blood pressure and minimal effect on heart rate

Question 24

Class II shock is associated with ? EBL, is associated with what vital changes?

Answer 24

750 to 1500 mL

tachycardia but normal BP at rest, and low urine output

Question 25

evaluation of neck pain

Answer 25

Either three views of the C-spine (AP, lateral, and odontoid views) or CT of the cervical spine (CT preferred) if no bony fractures or dislocation and midline tenderness persists, then obtain flexion/extension x-rays or MRI of the C-spine to help differentiate ligamentous injury/spinal instability from soft tissue contusion

Question 26

C-spine radiography is indicated for asymptomatic trauma patients unless they meet all of the following criteria (Nexus low-risk criteria)

Answer 26

(1) No posterior midline cervical tenderness (2) No evidence intoxication (3) Normal level of alertness (4) No focal neurologic deficits (5) No painful distracting injuries (Canadian C-spine rule (CCR) even better)

Question 27

anterior vs posterior vs central cord injuries

Answer 27

anterior: can cause complete motor paralysis, loss of pain/temp posterior: (Brown-Sequard) causes paralysis, loss of vibratory sensation and proprioception ipsilaterally and loss of pain/temp sensations contralaterally central: produced by injuries to the corticospinal tract, which produces great UE weakness in comparison to the LE

Question 28

among patients presenting with intact neurological status to the ED, the incidence of acute C-spine fracture or spinal injury is ?

Answer 28

less than 1%

Question 29

patient classifications in C-spine injuries

Answer 29

asymptomatic: CCR temporarily non-assessable (intox/distracting injuries): reassess or tx as obtunded symptomatic (neck pain, midline tenderness, or neuro s/s): tx as above (neck pain) obtunded: CT of the C-spine

Question 30

Canadian C-spine Rule (CCR)

Answer 30

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=141651404&gbosContainerID=70&gbosid=218346

Question 31

From C1 to C7, nerve root exit ? the level of the vertebrae, and from C8 and lower, the nerve roots exit ? the vertebrae

Answer 31

above | below

Question 32

most reliable way to detect hypoventilation is by

Answer 32

PaCO2 measurements on ABG | accessory muscles of resp. innervated via thoracics

Question 33

In SCI pts, good to maintain MAP of ? to maximize spinal cord perfusion If needed, patients with isolated spinal cord injuries may benefit from initiation of ? Bradycardia associated with neurogenic shock can be addressed with ?

Answer 33

85 to 90 mm Hg vassopressors such as dopamines or norepinephrine atropine

Question 34

steroids in SCIs?

Answer 34

- only some benefits for individuals when the treatment was initiated within 3 hours of the injury - increased rates of sepsis and other steroid complications - should not be initiated for patients in the ED prior to discussions with the trauma and/or spine specialists who will ultimately manage the patient after ED discharge

Question 35

Orthopedic injuries to the upper extremities are categorized by ?

Answer 35

the bone, location (proximal, midshaft, or distal), presence or absence of joint involvement, degree of angulation, extent of comminution, and whether the fracture is open or closed

Question 36

fractures that involve both the ulna and radius are considered? while Injuries that involve only one of the two bones are generally stable and are treated by ?

Answer 36

unstable fractures and are less amendable to closed fixations; therefore, many of these fractures are managed by ORIF closed manipulation, cast immobilization under conscious sedation or US-guided regional nerve blocks

Question 37

most commonly encountered distal radial fracture: fracture of the distal radial metaphysic with dorsal displacement of the distal fragment

Answer 37

Colles-Pouteau fracture

Question 38

The decision to treat patients by closed reduction and fixation versus operative reduction and fixation are determined by ?

Answer 38

the degree of alignment, age, and functional status of the patients

Question 39

Distal radius fractures occur most commonly in who?

Answer 39

bimodal pattern with peaks in late childhood and after the sixth decade of life

Question 40

management of anaphylaxis

Answer 40

airway management and early administration of epinephrine volume resuscitation with crystalloid, nebulized beta agonists (dilation), nebulized racemic epinephrine (decrease laryngeal edema), corticosteroids (blunt immune response), antihistamines (including H2 blockers: Diphenhydramine and ranitidine), and removal of any remaining antigen (ie, the bee stinger)

Question 41

Patients may lose over ? of their blood volume to extravasation in the first ten minutes of their allergic reaction

Answer 41

30% | Decreased vascular tone and increased capillary permeability lead to cardiovascular compromise and hypotension

Question 42

cytokines involved in anaphylaxis

Answer 42

Leukotriene C4, prostaglandin D2, histamine, and tryptase | Elevated tryptase levels confirm the diagnosis

Question 43

symptoms of anaphylaxis

Answer 43

angioedema, urticaria, erythema, and pruritus hypotension and tachycardia bronchospasm and bronchorrhea, edema in the URT severe: nausea, cramping, and diarrhea

Question 44

how does Epinephrine help in anaphylaxis

Answer 44

acts as a pressor for hemodynamic support, a bronchodilator to relieve wheezing, as well as to counteract released mediators and prevent their further release

Question 45

Epi dosing

Answer 45

initially IM: anterior thigh with the more concentrated 1:1000 dose at 0.3 to 0.5 mL every 5 minutes if no response or CV compromise, IV IV is more rapid, but take care in elderly and those with CV risk factors SEs: HTN, tachycardia, dysrhythmias, MI

Question 46

IV Epi dosing

Answer 46

ampules of epinephrine have 1 mg of medication (1 mL of 1:1000 = 1 mg of medication; 10 mL of 1:100,000 = 1 mg of medication). One method of administration is to place 1 mg (1 ampule) of epinephrine into 1 L of intravenous fluid (equivalent to 1 μg/mL) and infuse to 1 to 4 cc/min (1-4 μg/min)

Question 47

What has been proposed for individuals on B-blockers in the event they are unresponsive to epinephrine?

Answer 47

glucagon- may overcome hypotension by activating adenyl cyclase independent of the beta receptor

Question 48

Pitfalls in Anaphylaxis

Answer 48

Failure to recognize the symptoms of anaphylaxis Underestimating the severity of laryngeal edema and failure to secure the airway early Reluctance to administer epi early in the course of illness Forgetting to remove the allergen; eg, the IV drip of PCN or bee stinger Lack of appropriate patient education Failure to prescribe an epi auto-injector prior to discharge