resuscitation Flashcards
major trauma
life threatening injury
may result in disability
ISS > 15
major trauma centre
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
Injury severity score
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)
trauma surveys
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
Priorities in airway and c-spine
cervical spine protection alongside airway management
RSI - agitation, low / declining GCS, oxygenation, ventilation failure, humanitarian
challenges - MILS, facial injury, laryngeal injury, decompensation
Lethal 6 injuries
- airway obstruction
- tension PTX
- open PTX
- Massive harm-thorax
- cardiac tamonade
- flail Chet
pre-hospital interventions
haemorrhage - pressure, tourniquet, binder
intubation
thoracotomy
IV IO access
volume resuscitation
critical care priorities
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
Pelvic injury
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
Blast injury
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
resuscitative thoracotomy
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
massive haemothorax
1.5L on insertion of drain or
200ml/hr
likely arterial –> surgery
definitions of major haemorrhage and massive transfusion
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
damage control resuscitation
permissive hypotension - circulatory support titrated to central pulse
haemostatic resuscitation - blood products, minimise crystalloid, prevent coagulopathy
damage control surgery
damage control surgery
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
trauma induced coagulopathy
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
investigation of major haemorrhage
source as per history and examination
CT as guided by stability
x-match
POC - ABG (hb, calcium)
Visoelastic testing
clotting studies / platelet count
Severe bleeding management
- source control - direct pressure, surgical, IR
- General measures - avoid hypothermia, hypocalcaemia, acidosis. transfusion of blood products according to thresholds. permissive hypotension.
- blood products
- 1:1:1
- cryoprecipitate / fibrinogen concentrate
- PCC e..g warfarin therapy - pharamcological - dsmopressin, TXA
DOAC reversal agents
dabigatram: idarucizumab
rivaroxaban, apixaban: andexenet alpha
major haemorrhage transfusion targets
Hb > 100 (ongoing active bleeding)
Hb > 70 when controlled
Platelets > 75
INR < 1.5
fibrinogen > 1.5
Ca > 1
options to rise fibrinogen by 1g/l
FFP 15ml/kg
cryoprecipitate 2 pools
fibrinogen concentrate 3-4g
complications of major haemorrhage
- hypo perfusion (AKI, ALI, CNC, MI, GI ischaemia, MODS)
- coagulopathy - trauma induced, consumptive, dilutional
- hypothermia
- biochemical - hypocalcaemia, acidosis, hyperkalaemia
- transfusion reactions
transfusion in critical care
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
drowning
primary respiratory impairment following submersion in liquid.co
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
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
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
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
concerns regarding management of burns
- other injuries
- airway / inhalation injuries
- difficult airway
- inhaled substance toxicity
- fluid shifts
- pain
estimating burns %
Wallace rule of 9
Lund-Browder chart
mersey burn app
include partial and full thickness only
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
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)
revised baux score
age + % TBSA + 17 for inhalation injury
point of futility now 160
challenges of ongoing burns care
- skin integrity
- pain
- frequent dressing changes
- sepsis
- inhalation injury
- hyper metabolism
- psychosocial
- significant LOS
- nutrition
nutrition in burns
started within 12 hours
protein 1.5-2g/kg/day
oxandrolone - increase protein synthesis
Sources of electrical injury
faulty equipment
complication of therapeutic electricity e.g. diathermy, DCCV
domestic appliances
lightening strike
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
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
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
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
removal of cvc
trendelenburg position
firm pressure 5 mins
occlusive dressing
remain flat for 1 hour
VGE diagnosis
clinical. TTE / TOE
suspected in periprocedural stroke
cvs - dyspnoea, pain, shock mill wheel murmur
neuro - reslteless, anxiety, focal neurology
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
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
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
hypothermia classifications
core body temp < 35
32-35 mild
mod 28 -32
severe < 28
causes of hypothermia
excess heat loss - surgery, trauma, environmental, skin disease
insuffivient production - hypometabolism e.g. hypothyroid
disordered thermoregulation - intoxication, hypothalmic disease
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
cardiac arrest in hypothermia
3 shocks for VF then stop until temp > 30
no drugs until 30
double interval 30 -35
warming hypothermic patients
passive - remove cold clothing, blankets, warm environment
active - forced air warmers, warm IV fluid, intravascular devices, extra-corporeal
core vs peripheral temperature
1-2 degree higher core
core includes deep structures - intra-abdominal
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
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
MH presentation
unexplained tachycardia
rising ETCO2
rise in temperature
muscle rigidity
can be fulminant, mild, moderate, massetter spasm with or without rhabdo, peripherative death
