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resuscitation Flashcards

1
Q

major trauma

A

life threatening injury
may result in disability
ISS > 15

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2
Q

major trauma centre

A

hospital providing tertiary trauma care characterised by
- training
- 24/7 trauma lead and team
- specific specialties within 30 mins - neuro, spine, vascular, general, trauma, ENT, IR, anaesthesia, ICM
- resuscitative thoracotomy
- major haemorrhage
- relevant diagnositcs

TARN
- trauma audit and research network
- independent clinical audit with performance report and standards.
- e.g. RSI < 45 mins, CT < 1 hr if GCS < 13, consultant within 5 mins

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3
Q

Injury severity score

A

anatomical 6 regions
- face
- head and neck
- thorax
- abdomen and pelvis
- extremeties
- external

each region - abbreviated injury scale 1-6
square the 3 highest scores and add together - max 75
if any 6 = 75 (unsurvivable)

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4
Q

trauma surveys

A

primary = identify immediately life threatening injuries c-ACBCE
secondary = meticulous head-toe examination for other potential causes of severe illness
tertiary = documentation of all injuries post investigation

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5
Q

Priorities in airway and c-spine

A

cervical spine protection alongside airway management
RSI - agitation, low / declining GCS, oxygenation, ventilation failure, humanitarian
challenges - MILS, facial injury, laryngeal injury, decompensation

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6
Q

Lethal 6 injuries

A
  • airway obstruction
  • tension PTX
  • open PTX
  • Massive harm-thorax
  • cardiac tamonade
  • flail Chet
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7
Q

pre-hospital interventions

A

haemorrhage - pressure, tourniquet, binder
intubation
thoracotomy
IV IO access
volume resuscitation

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8
Q

critical care priorities

A

initial
- assess resucitation needs and correct
- correct coagulopathy
- reverse O2 debt
ongoing
- reassessment
- secondary / tertiary survey
- definitive management of haemorrhage
- analgesia
- acid base status
- nutritional status

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9
Q

Pelvic injury

A

Tile categories
A - stable
B - rotationally unstable, vertically stable open book
C - rotationally and vertically unstable

pelvic binder - greater trochanters, remove 24hrs max
CT angio
fixation
IR embolisation of bleeding vessel
damage control and packing

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10
Q

Blast injury

A

blast wave - rapidly expanding then contracting wave of energy
primary - direct effect of abnormal pressure
secondary - surrounding objects become projectile
tertiary - impact of person against surrounding object
secondary and tertiary lead to multi-trauma - shearing effects at tissue interfaces and direct injury

blast lung - disrupted alveolar-capillary membrane. haemorrhage, inflammation. ARDS, haemoptysis, air leak.
gas exchange failure, systemic gas embolism

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11
Q

resuscitative thoracotomy

A

penetrating chest trauma
- peri-arrest unable to go to theatre
- cardiac arrest with other signs of life
- established cardiac arrest, short down time
unlikely to be successful in penetrating trauma > 15 mins cpr, blunt trauma > 10 mins cpr

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12
Q

massive haemothorax

A

1.5L on insertion of drain or
200ml/hr
likely arterial –> surgery

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13
Q

definitions of major haemorrhage and massive transfusion

A

Major haemorrhage:
50% circulating volume in 2 hours
100% in 24 hours
150ml.min
haemodynamic instability
Massive transfusion
whole blood volume in 24 hours
50% blood volume in 4 hours
40ml/kg in paediatrics

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14
Q

damage control resuscitation

A

permissive hypotension - circulatory support titrated to central pulse
haemostatic resuscitation - blood products, minimise crystalloid, prevent coagulopathy
damage control surgery

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15
Q

damage control surgery

A

goal is to provide physiological and metabolic stability, not anatomical
- haemorrhage control
- decompression of compartments
- decontamination of wounds
- splinting of fractures
operating time < 90 mins

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16
Q

trauma induced coagulopathy

A

imbalance of pro and anti coagulants
hyperfibrinolysis
raised anticoagulant factors
platelet dysfunction
exacerbated by hypothermia, citrate, dilution
INR > 1.2

diamond of death
- hypothermia
- acidosis
- coagulopathy
- hypocalcaemia

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17
Q

investigation of major haemorrhage

A

source as per history and examination
CT as guided by stability
x-match
POC - ABG (hb, calcium)
Visoelastic testing
clotting studies / platelet count

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18
Q

Severe bleeding management

A
  1. source control - direct pressure, surgical, IR
  2. General measures - avoid hypothermia, hypocalcaemia, acidosis. transfusion of blood products according to thresholds. permissive hypotension.
  3. blood products
    - 1:1:1
    - cryoprecipitate / fibrinogen concentrate
    - PCC e..g warfarin therapy
  4. pharamcological - dsmopressin, TXA
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19
Q

DOAC reversal agents

A

dabigatram: idarucizumab
rivaroxaban, apixaban: andexenet alpha

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20
Q

major haemorrhage transfusion targets

A

Hb > 100 (ongoing active bleeding)
Hb > 70 when controlled
Platelets > 75
INR < 1.5
fibrinogen > 1.5
Ca > 1

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21
Q

options to rise fibrinogen by 1g/l

A

FFP 15ml/kg
cryoprecipitate 2 pools
fibrinogen concentrate 3-4g

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22
Q

complications of major haemorrhage

A
  1. hypo perfusion (AKI, ALI, CNC, MI, GI ischaemia, MODS)
  2. coagulopathy - trauma induced, consumptive, dilutional
  3. hypothermia
  4. biochemical - hypocalcaemia, acidosis, hyperkalaemia
  5. transfusion reactions
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23
Q

transfusion in critical care

A

restrictive - 70g/l
liberal - 80/90g/l in ACS

TRICC - 70 vs 100 - lower in hospital mortality
TRISS 70 vs 90 septic shock - no difference in mortality

24
Q

drowning

A

primary respiratory impairment following submersion in liquid.co

25
cold water shock
phases of following immersion in cold water - respiratory and autonomic 1. cold shock 0-3min - thermoreceptors sensing rapid kin cooling and increase CO. inhalation gasp, tachypnoea, impaired breath holding, tachycardia vasoconstriction 2. short term immersion 3-15 min - extremity cooling, tetany from hyperventilation, shivering, swimming failure 3. long term immersion > 15 mins - hypothermia, ataxia, dysarthria 4. circumrescue collapse - hypovolaemai , sympathetic slump
26
subermision injury
protective measures - initial breath holding - overwhelmed by co2 retention causing inhalation and mass aspiration - laryngospasm and bronchospasm - hypoxia, failed gas exchange - hyperaemic LOC, cardiac arrest - lung injury - surfactant washout, bronchospasm alveolar oedema
27
resuscitation in drowning
general trauma, risk assessment, supine, dry, warm, remove clothing cardiac arrest - warming - defibrillate 3 times then stop until temp > 30 - adrenaline every 8-10 mins 30-35 degrees, withhold below 30
28
critical care management drowning
LPV haemodynamics neuroprotection electrolyte abnormalities antimicrobials if contaminated water poor prognostics - immersion > 10 mins - time to BLS > 10 mins - core temp > 33 on arrival - water temp > 10 degrees
29
concerns regarding management of burns
- other injuries - airway / inhalation injuries - difficult airway - inhaled substance toxicity - fluid shifts - pain
30
estimating burns %
Wallace rule of 9 Lund-Browder chart mersey burn app include partial and full thickness only
31
pathophysiology
zone of coagulation - direct injury leading to tissue death zone of stasis - vasoconstriction, hypo perfusion - vulnerable to ischaemia, necrosis, infection zone of hyperaemia - inflammation, vasodilation, vascular permeability systemic effects - SIRS - burns shock - rhabdo - hypermetabolism
32
burns patient management
respiratory support per inhalation injury fluid per parkland formula. albumin if > 6ml/kg/%TBSA immediate surgery - fasciotomy, escharotomy metabolic modulation - early feeding, analgesia, temp control early excision to reduce necrotic load toxin - carbon monoxide give O2 until < 3%. tydroxycobalamin if worsening lactic acidosis (cyanide)
33
revised baux score
age + % TBSA + 17 for inhalation injury point of futility now 160
34
challenges of ongoing burns care
- skin integrity - pain - frequent dressing changes - sepsis - inhalation injury - hyper metabolism - psychosocial - significant LOS - nutrition
35
nutrition in burns
started within 12 hours protein 1.5-2g/kg/day oxandrolone - increase protein synthesis
36
Sources of electrical injury
faulty equipment complication of therapeutic electricity e.g. diathermy, DCCV domestic appliances lightening strike
37
injury mechanisms in electrical injury
- resistive coupling - tissue completes a circuit - capacitive coupling - tissue acting as capacitor - processes - electrocution, burns, burns from electrical fire, traumatic complications (falls) electricity disrupts intrinsic electrical currents - myocardium, voltage gated channels. thermal injury from conversion of energy to heat
38
factors affecting severity of electrical injury
- voltage - current type (AC worse than DC) - duration - current path e.g. through myocardium - environment - humidity - pre-morbid state
39
Venous gas embolism
entrainment of gas from environment into the circulation with systemic effects. air / o2 / co2 / helium arterial - coronary / cns ischaemia. cvs procecudres, pulmonary veins e.g. chest trauma, paradoxical from right-left shunt venous - embolises to RA / RV / lungs - obstructive shock, right heart failure. venous line insertion, insufflation of body cavities procedures - sitting craniotomy, posterior fossa, laparoscopy, cvc insertion
40
pathophysiology of gas embolism
gas bubbles act as foreign substance - coagulation cascade activated, microcirculation dysfunction damage to BBB, raised ICP arterial - large volume - coronary, cerebral embolism and death. 0.02ml/kg potentially fatal large volume venous - cardiac output cessation
41
removal of cvc
trendelenburg position firm pressure 5 mins occlusive dressing remain flat for 1 hour
42
VGE diagnosis
clinical. TTE / TOE suspected in periprocedural stroke cvs - dyspnoea, pain, shock mill wheel murmur neuro - reslteless, anxiety, focal neurology
43
VGE management
prevent further entrainment - flood surgical field, seal defect, check infusion devices reduce embolism size - 100% FiO2, aspirate cvc supportive care - durant maneouvre (left lateral decubitus) - cpr may break up hyperbaric oxygen - reduces size of embolism, denitrogenation, improve o2 delivery to ischaemic penumbra
44
Fat embolism syndrome
syndrome following identifiable insult associated with release of fat into circulation orthopaedic trauma - femoral / pelvic mechanical theory - small emboli cause platelet aggregation, pulmonary capillary obstruction. large emboli causing macrovascular obstruction biochemical theory - fat --> FFA, glycerol, proinflammatory cascade
45
FES symptoms
12-72hr post insult hypoxaemia, neurological features, petechiae Gurd criteria 1 major + 4 minor major - petechial rash, respiratory symptoms, CNS signs minor - tachycardia, retinal fat deposits, pyrexia, fat in sputum, thrombocytopenia management supportive early fracture fixation reduces risk
46
hypothermia classifications
core body temp < 35 32-35 mild mod 28 -32 severe < 28
47
causes of hypothermia
excess heat loss - surgery, trauma, environmental, skin disease insuffivient production - hypometabolism e.g. hypothyroid disordered thermoregulation - intoxication, hypothalmic disease
48
clinical effects of hypothermia
A - loss of cough reflex B - depression, hypoventilation. apnoea < 24 C - mild - vasoconstriction then tachycardia --> bradycardia. < 33 - bradycardia, AF. VF/VT < 28 D - mild - reduced CMRO2, loss of pupil response and tendon reflexes with severe E - 7% BMR per 1 degree. shivering at 35 degrees, lost at 32 F - diuresis other - increased blood viscosity, reduced WCC, impaired immunity
49
cardiac arrest in hypothermia
3 shocks for VF then stop until temp > 30 no drugs until 30 double interval 30 -35
50
warming hypothermic patients
passive - remove cold clothing, blankets, warm environment active - forced air warmers, warm IV fluid, intravascular devices, extra-corporeal
51
core vs peripheral temperature
1-2 degree higher core core includes deep structures - intra-abdominal
52
elevated temperature definitions
hyperthermia - imbalance of heat production, regulation and loss, temp > 37.5. no response to antipyretics and extreme elevation more common. heat stroke, thyrotxocosis, NMS, MH fever - hypothalamic set point raised. infectious, non infectious (VTE, drug reaction, autoimmune, neoplastic) pyrexia - elevated measured temperature hyperpyrexia - temp > 41
53
MH
progressive drug reaction caused by specific anaesthetic agents MH susceptibility is genetic predisposition to develop MH when n contact with trigger autosomal dominant RYR1 / DHPR receptors
54
MH presentation
unexplained tachycardia rising ETCO2 rise in temperature muscle rigidity can be fulminant, mild, moderate, massetter spasm with or without rhabdo, peripherative death
55

FFICM (14 decks)

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