OnlineMedEd: Surgery: Trauma - "Shock"

Question 1

What three categories does Dustyn give for airway status?

Answer 1

• Patent: speaking full sentences, bilateral breath sounds, no accessory muscle use
• Urgent: expanding hematoma, inhalational injury, cutaneous emphysema
• Emergent: gurgling, apneic

Question 2

What GCS score indicates intubation?

Answer 2

Less than 8 (intubate!)

Question 3

The two important parameters of breathing are ________________.

Answer 3

ventilation (moving CO2 out) and oxygenation

Question 4

Control ventilation with _____________.

Answer 4

minute volume and RR

Question 5

Control oxygenation with _____________.

Answer 5

PEEP and FiO2

Question 6

ETCO2 (end-tidal CO2) measures _____________.

Answer 6

the exhaled CO2 –an indicator of correct ET tube placement

Question 7

Shock is defined (usually) as SBP less than ________ or MAP less than _________.

Answer 7

90; 65

Question 8

Urinary output less than __________ is a sign of poor renal perfusion (potentially shock).

Answer 8

0.5 mL/kg/hr

Question 9

Review the levels of oxygen support.

Answer 9

1) Bag-valve mask
2) ETT
3) Cric (emergent)
4) Trach (OR, non-emergent)

Question 10

List the four factors that determine MAP.

Answer 10

MAP = HR x preload x contractility x SVR

Preload x contractility = SV
SV x HR = CO

Question 11

Explain obstructive shock and the two examples.

Answer 11

Obstructive disorders are those that obstruct blood from getting to the heart:

• Tamponade (RV)
• Tension pneumothorax (RV or LV)

Question 12

Go through the variables of MAP and the disorders that affect each.

Answer 12

•HR: SVT (too fast), heart block (two slow)
•Preload:
- IVVD: hypovolemia, hemorrhage, third spacing
- Obstruction: tamponade, tension pneumothorax
•Contractility: CHF, MI, myocardial contusion
•SVR: sepsis, anaphylaxis, spinal cord injury, drugs (anesthesia)

Question 13

External traumas are obvious –not going to miss the GSW. You need to have a higher index of suspicion for ______________.

Answer 13

intraperitoneal bleeding, because much blood can collect in the peritoneum

Question 14

What signs/symptoms will be seen in hemorrhagic shock?

Answer 14

• Increased HR
• Normal cardiac and pulmonary exam
• Flat neck veins
• Normal Hgb at first (because plasma is lost too)

Question 15

How do you work up and manage intraperitoneal bleeding?

Answer 15

• Diagnose with US
• Take to OR immediately
• Start 2 IVs, give IVF, type and cross, give PRBCs

Question 16

Tension pneumothorax should be treated initially with ______________.

Answer 16

needle decompression in the 2nd intercostal space

Chest tube will follow, but do needle decompression before anything else –even the CXR.

Question 17

Why does tamponade affect the right heart more than the left?

Answer 17

The right heart is thin and floppy, while the left heart is thick and strong. The incoming blood thus preferentially affects the right heart.

Question 18

Beck’s triad is _______________.

Answer 18

hypotension, JVD, and distant heart sounds

Question 19

What does the “warm vs. cold extremities” tell you?

Answer 19

It tells you if the shock is due to decreased vascular resistance: decreased SVR will lead to warm shock –because there is lots of blood from the heart –while other kinds of shock (cardiogenic, hypovolemic, obstructive) lead to increased SVR and thus cold extremities.