Patient Assessment/Management Flashcards
1
Q
In the setting of cardiac arrest, the approach of ABCDE changes to what? (2)
A
- “the CABs”: chest compressions, airway, and breathing
- CAB can also be applied in massive trauma situations, in the setting of massive blood loss to treat hypovolemic shock
2
Q
Name: Signs of Airway Obstruction (4)
A
- Agitation, confusion,“ universal choking sign”
- Respiratory distress
- Failure to speak, dysphonia, stridor
- Cyanosis
3
Q
Describe: (A) Airway (4)
A
- assume a cervical injury in every trauma patient and immobilize with collar
- assess ability to breathe and speak
- can change rapidly, thereforere assess frequently
- assess for facial fractures/edema/burns (impending airway collapse)
4
Q
Describe: Airway management (14)
A
- Basic Airway Management
* protect the C-spine
* head-tilt (if C-spine injury not suspected) or jaw thrust to open the airway
* sweep and suction to clear mouth of foreign material
- Basic Airway Management
- Temporizing Measures
* nasopharyngeal airway (if gag reflex present, i.e.conscious)
* oropharyngeal airway (if gag reflex absent, i.e. unconscious)
* “rescue” airway devices (e.g. laryngeal mask airway, Combitube®)
* transtracheal jet ventilation through cricothyroid membrane (last resort)
- Temporizing Measures
- Definitive Airway Management
* ETT intubation within-line stabilization of C-spine
* orotracheal ± RSI preferred
* nasotracheal may be better tolerated in conscious patient
* relatively contraindicated with basal skull fracture
* does not provide 100% protection against aspiration
* surgical airway (if unable to intubate using oral/nasal route and unable to ventilate)
* cricothyroidotomy
- Definitive Airway Management
5
Q
Name: Contraindications to Intubation (2)
A
supraglottic/glottic pathology
6
Q
Name Indications for Intubation (5)
A
- Patent airway
- Protects against aspiration
- Positive pressure ventilation
- Pulmonary toilet (suction)
- Pharmacologic administration during hemodynamic instability
7
Q
Name Rescue Techniques in Intubation (4)
A
- Bougie (used like a guidewire)
- Glidescope®
- Lighted stylet (uses light through skin to determine if ETT in correct place)
- Fiberopticintubation – (uses fiber optic cable for indirect visualization)
8
Q
Describe: (B) Breathing (5)
A
- Look
- mental status (anxiety, agitation, decreased LOC), colour, chest movement (bilateral vs. asymmetrical), respiratory rate/effort, nasal flaring
- Listen
- auscultate for signs of obstruction (e.g. stridor), breath sounds, symmetry of air entry, air escaping
- Feel
- tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds, subcutaneous emphysema
- Breathing Assessment: objective measures of respiratory function: rate, oximetry, ABG, A-agradient
- Management of Breathing
- nasal prongs→ simple face mask → non-rebreather mask→ CPAP/BiPAP (in order of increasing FiO2)
- Bag-Valve mask and CPAP to supplement in adequate ventilation
9
Q
Definition of Shock (1)
A
inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)
10
Q
Name categories of shock (4)
A
- Hypovolemic
- Cardiogenic
- Distributive (vasodilation)
- Obstructive
11
Q
Name examples: Hypovolemic shock (4)
A
- Hemorrhage (external and internal)
- Severe burns
- High output fistulas
- Dehydration (diarrhea, DKA)
12
Q
Name examples: Cardiogenic shock (5)
A
- Myocardial ischemia
- Dysrhythmias
- CHF
- Cardiomyopathies
- Cardiac valve problems
13
Q
Name examples: Distributive (vasodilation) shock (3)
A
- Septic
- Anaphylactic
- Neurogenic (spinal cord injury)
14
Q
A
15
Q
Name examples: Obstructive shock (5)
A
- Cardiac tamponade
- Tension pneumothorax
- PE
- Aortic stenosis
- Constrictive pericarditis
16
Q
Shock in a trauma patient is ___ until proven otherwise
A
Shock in a trauma patient is hemorrhagic until proven otherwise
17
Q
Describe EARLY and LATE Clinical Evaluation of shock
A
- Early:
- tachypnea, tachycardia, narrow pulse pressure, reduced capillary refill, cool extremities, and reduced central venous pressure
- Late: hypotension and altered mental status, reduced urine output
18
Q
Describe: Estimation of Degree of Hemorrhagic Shock
A
19
Q
Describe: Management of Hemorrhagic Shock (6)
A
- clear airway and assess breathing either first or simultaneously
- apply direct pressure on external wounds while elevating extremities. Do not remove impaled objects in the emergency room setting as they may tamponade bleeds
- start TWO LARGE BORE (14-16G ) IVs in the brachial/cephalic vein of each arm
- run 1-2 L bolus of IV Normal Saline/Ringer’s Lactate (warmed, if possible)
- if continual bleeding or no response to crystalloids, considerp RBC transfusion, ideally crossmatched.
- If crossmatched blood is unavailable, consider O- for women of childbearing age and O+ for men. Use FFP, platelets or tranexamic acid in early bleeding consider common sites of internal bleeding (abdomen, chest, pelvis, long bones) where surgical intervention may be necessary
20
Q
Describe: (D) Disability (4)
A
- assess LOC using GCS
- pupils
- assess equality, size, symmetry, reactivity to light
- unequal or sluggish suggests local eye problem or lateralizing CNS lesion
- relative afferent pupillary defect (swinging light test) – optic nerve damage
- extraocular movements and nystagmus
- fundoscopy (papilledema, hemorrhages)
- reactive pupils + decreased LOC: metabolic or structural cause
- non-reactive pupils + decreased LOC: structural cause (especially if asymmetric)
21
Q
Name items in Glasgow Coma Scale ()
A
Eyes+Verbal+Motor=Total
22
Q
Describe: Exposure/Environment (5)
A
- expose patient completely and assess entire body for injury; log roll to examine back
- Digital rectal exam
- keep patient warm with a blanket ± radiant heaters; avoid hypothermia
- warm IV fluids/blood
- keep providers safe (contamination,combative patient)
23
Q
Describe 3:1 rule in use of isotonic crystalloids
A
Since only 30% of infused isotonic crystalloids remains in intravascular space, you must give 3x estimated blood loss
24
Q
Name: Common Sites of Bleeding (5)
A
- External(e.g.scalp)
- Chest
- Abdomen (peritoneum, retroperitoneum)
- Pelvis
- Long bones
25
Q
Describe rules in Fluid Resuscitation (6)
A
- Give bolus until HR decreases,urine output increases, and patient stabilizes
- Maintenance: 4:2:1 rule
- 0-10 kg: 4 cc/kg/h
- 10-20 kg: 2 cc/kg/h
- Remaining weight: 1 cc/kg/h
- Replace ongoing losses and deficits (assume 10% of body weight)
26
Q
If Unilateral, Dilated, Non-Reactive Pupil, Think what? (3)
A
- Focal mass lesion
- Epidural hematoma
- Subdural hematoma
27
Q
Describe: Resuscitation (7)
A
- done concurrently with primary survey
- attend to ABCs
- manage life-threatening problems as they are identified
- vital signs q5-15 min
- ECG, BP, and O2 monitors
- Foley catheter and NG tube if indicated
- tests and investigations: CBC, electrolytes, BUN, Cr, glucose, amylase, INR/PTT, β-hCG, toxicology screen, cross and type
28
Q
Contraindications to Foley Insertion (3)
A
- Blood at urethral meatus
- Scrotal hematoma
- High-riding prostate on DRE
29
Q
Name: NG Tube Contraindications (2)
A
- Significantmid-face trauma
- Basal skull fracture
30
Q
Describe: AHA CPR Guidelines with 2015 updates
A
31
Q
Describe: Secondary Survey (3)
A
- done after primary survey once patient is hemodynamically and neurologically stabilized
- identifies major injuries or areas of concern
- full physical exam and x-rays (C-spine, chest,and pelvis required in blunt trauma, consider T-spine and L-spine if indicated)
32
Q
Describe HISTORY of Secondary survey (6)
A
“SAMPLE”:
- Signs and symptoms
- Allergies
- Medications
- Past medical history
- Last meal
- Events related to injury
33
Q
Describe: Four areas of FAST (Figure)
A
34
Q
Describe PHYSICAL EXAM in secondary survey (17)
A
- Head and Neck: palpation of facial bones,scalp
- Chest
- inspect for midline trachea and flail segment: ≥ 2 rib fractures in ≥ 2 places; if present look for associated hemothorax, pneumothorax, and contusions
- auscultate lung fields
- palpate for subcutaneous emphysema
- Abdomen
- assess for peritonitis, abdominal distention, and evidence of intraabdominal bleeding
- DRE for GI bleed, high riding prostate, and anal tone
- Musculoskeletal
- examine all extremities for swelling, deformity, contusions, tenderness, ROM
- check for pulses (using Doppler probe) and sensation in all injured limbs
- log roll and palpate thoracic and lumbar spines
- palpate iliac crests and pubic symphysis and assess pelvic stability (lateral, AP, vertical)
- Neurological
- GCS
- full cranial nerve exam
- alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities with
- progressive deterioration in breathing indicating a failing CNS
- assess spinal cord integrity
- conscious patient: assess distal sensation and motor function
- unconscious patient: response to painful or noxious stimulus applied to extremities
35
Q
Describe INITIAL IMAGING in secondary survey (17)
A
- non-contrast CT head/face/C-spine (rule out fractures and bleeds)
- chest x-ray
- FAST or CT abdomen/pelvis (if stable)
- pelvis x-ray
36
Q
Name the best imaging modality for intracranial injury (1)
A
Non-contrast head CT
37
Q
Describe ethical considerations with: Jehovah’s Witnesses (7)
A
- Capable adults have the right to refuse medical treatment
- May refuse whole blood, pRBCs, platelets, and plasma even if life-saving
- Should be questioned directly about the use of albumin, immunoglobulins, hemophilic preparations
- Do not allow autologous transfusion unless there is uninterrupted extra corporeal circulation
- Usually ask for the highest possible quality of care without the use of the above interventions (e.g. crystalloids for volume expansion, attempts at bloodless surgery)
- Patient will generally sign hospital forms releasing medical staff from liability
- Most legal cases involve children of Jehovah’s Witnesses; if life-saving treatment is refused, contact CAS
