Special Populations Exam 2 Flashcards
In Trauma this is a continuous, priority driven process of patient assessment, resuscitation, and reassessment.
Rapid overview
Initial evaluation
In trauma, ____ ____ is designed to assess and treat life threatening injuries rapidly?
Primary survey
What are the 4 leading causes of death in trauma patients?
airway obstruction
respiratory failure
hemorrhagic shock
brain injury
All trauma patients are considered what?
Full stomach
RSI
Intubation for patient with cervical spine injury in C-collar?
Video laryngoscopy vs fiberoptic intubation
Manual in line stabilization
avoid nasal intubation
This condition is a life-threatening emergency where a large air collection in the pleural space compromises respiration and cardiac function.
Clinical diagnosis
- cyanosis, tachypnea, hypotension, neck vein distention, tracheal deviation.
- requires needle decompression
Tension Pneumothorax
This condition is when an injury creates a hole in the chest wall that allows air from the environment to enter the pleural cavity.
- 3 sided dressing and chest tube
Open pneumothorax
This condition may occur when 3 or more ribs are broken in at least 2 places. Causes a segment of the chest wall to move independently of the rest of the chest wall.
Paradoxical movement.
Increased dead space, decreased intrathoracic pressure.
Flail chest
What is the most common cause of shock in trauma patients?
Blood loss
hypovolemic shock
What is the #1 cause of death in trauma patients?
TBI
What can initially be used to assess the adequacy of tissue perfusion in a trauma patient?
Capillary refill of > 2 secs may indicate poor perfusion.
What must be considered if a patient presents with pale, cold extremities and in shock?
Pericardial tamponade must be ruled out
In primary survey if GCS < what need to intubate?
< 8
GCS score of 15
Alert
normal
GCS score of 12-13
Verbally responsive
GCS score of 5-6
Physically responsive
GCS score of 3
Unresponsive
What 2 things are terrible for an injured brain?
Hypoxia
Hypotension
Injured brain, maintain MAP to what?
Maintain SpO2 to what?
MAP > 80
SpO2 > 92%
Treatment of high ICP?
Head elevation
Temporary hyperventilation
Mannitol/Furosemide
Increase Sedation
Spinal shock can result in what?
Hypotension from vasodilation and bradycardia
Catecholamine surge - Pulmonary edema
At what cervical level does an injury impair respiration?
C4 or above
The purpose of this is to obtain a detailed history, perform a head to toe exam, reassess vital signs, and obtain pertinent lab and imaging studies to identify injuries and metabolic abnormalities?
Secondary survey
What factor has the greatest effect on IV catheter flow rate?
Radius
Short and fat = better
What are the 2 induction agents of choice for trauma patients?
Etomidate 0.2-0.3 mg/kg
or ketamine 1-2mg/kg
What MAC should you keep patient at if TBI is suspected?
0.5 MAC
avoid nitrous
What ratio of RBCs, plasma and platelets mirror the content of whole blood?
1:1:1
If patient has low fibrinogen what should be administered for treatment?
Cryoprecipitate.
Acidosis, Coagulopathy, and Hypothermia is known as what?
The lethal triad
How much calcium should be given for every 2-3 units of blood product?
0.5-1g
What drugs are used in attempt to offset the body peripheral vasoconstriction response in order to increase microcirculatory perfusion?
Titrated opioids or volatile agents
need SBP > 90
What is a temporizing measure of support for vital organ perfusion, decrease the amount of bleeding distal to the occluded site?
REBOA
Resuscitative endovascular balloon occlusion of aorta
What should be avoided for resuscitation for polytrauma in neurosurgical procedures?
Avoidance of colloids
This condition is associated with Hypotension, bradycardia, and hypothermia.
Injury above T6 level
Most common in complete C-spine transection.
MAP goal 85
Spinal shock
Rule of nines for burn measurement is not accurate in which patients?
Children and Obese
Mortality from burns is caused by which 3 primary factors?
Inhalational injury
>40% burned
Age > 60 yrs
Full thickness burns are what %?
> 10% TBSA
Partial thickness burns are what %?
> 25% TBSA
Major burns exceeding 25% cause a cytokine mediated inflammatory response 2- phase? What happens in the first 24-48 hrs
Burn shock (ebb) phase
decreased cardiac output and blood flow in the first 48 hours.
What happens in 48-72 hours following a major burn of >25%?
Hypermetabolic (flow) phase
Increased O2 consumption, CO2 production and cardiac output and enhanced blood flow to all organs
T/F
Carbon monoxide has 200x greater affinity for Hgb than O2?
True
Carbon monoxide shifts oxygen dissociation curve which way?
To the LEFT
holds onto oxygen
Any inhalation injury with anion gap metabolic acidosis despite adequate oxygen delivery can cause what?
Cyanide toxicity
What is the gold standard of inhalation injury ventilatory support?
Tidal volumes < 6 mL/kg ideal body weight
Plateau airway pressures < 30 cm H2O adults.
What is the parkland formula for fluid resuscitation?
Volume of crystalloid= 4mL x % TBSA x kg
Half given in first 8 hours
Half given in next 16 hours
Goal for urine output in patients?
0.5-1 mL/kg/hr
Which receptors are down regulated in burn patients?
Beta receptors
Blood loss estimate is ____% loss for ___% burn excised?
2.6% loss for 1% excised
Burn patients have a
____ of nicotinic receptors
____ binding of alpha-1 glycoproteins
_____ to non-depolarizer NMBA
Upregulation
Increased
Resistance
Which drug should be avoided after 48hrs post burn injury and for at least 1 year?
Succinycholine
All of the following statements regarding manual in-line stabilization (MILS) during laryngoscopy and tracheal intubation are true, EXCEPT:
A. MILS must be performed whenever the rigid cervical collar is removed from any trauma patient with potential cervical spine or spinal cord injury.
B. MILS facilitates direct laryngoscopy and tracheal intubation by improving the laryngoscopist’s view of the vocal cords.
C. During rapid sequence induction, MILS should be the sole responsibility of one properly trained provider.
D. Patients with cervical spinal cord injury rarely have worsening of their neurologic function when laryngoscopy and tracheal intubation are performed with MILS.
B
Because properly applied MILS limits both flexion and extension of the cervical spine and atlantooccipital joint, laryngoscopic view of the vocal cords may be restricted and increase the difficulty of tracheal intubation.
A 32-year-old unhelmeted female bicyclist is struck by a car at an urban intersection, evaluated at the scene by prehospital emer- gency medical providers, and transported to the hospital on a backboard with a rigid cervical collar. In the emergency department, her airway, breathing, and vital signs are within normal range, and she has a grossly deformed right ankle that appears to be dislocated. On neurologic examination, she speaks no words or sentences, and can only grunt and moan. She withdraws each extremity to pinprick; her eyes are closed and only open when her right leg is moved. Her Glasgow coma scale (GCS) score is:
A. 6
B. 8
C. 10
D. 12
B
The neurologic examination translates into a Glasgow coma scale motor score of 4, a verbal score of 2, and an eye score of 2, for a total Glasgow coma scale score of 8
You are asleep in the on-call room at 3:00 a.m. when you receive a call from the operating room notifying you that a 37-year-old woman with a single, high- caliber gunshot wound to the epigastrium just arrived in the emergency room. Because of her unstable vital signs (blood pressure 72/38, heart rate 132, respiration rate 36), the patient will be transported to the operat- ing room within the next 10 minutes for an exploratory laparotomy. The “Emergency and Trauma Anesthesia Checklist” can guide your rapid preparation for this procedure in which of the following areas?
A. Drugs for general anesthesia induction and tracheal intubation
B. Drugs and equipment for intraoperative resuscitation
C. Preparation of operating room equipment and anesthesia workstation
D. All of the above
D
The “Emergency and Trauma Anesthesia Checklist” can be of particular value in preparing to anesthetize a critically ill patient on short notice or in the middle of the night by providing a specific list of trauma-specific equipment and procedures that should be available
Which of the following statements regarding “hypotensive resuscitation” of the hemodynamically unstable trauma victim is TRUE?
A. The hemodynamic goal of the resuscitation is a lower-than-normal blood pressure that still provides sufficient perfusion to vital organs until hemostasis is achieved, after which the blood pressure is normalized.
B. Hypotensive resuscitation is of potential value in patients with traumatic brain injury (TBI).
C. The hemodynamic goal of the resuscitation is normal, age-appropriate blood pressure until hemostasis is achieved, after which the blood pressure is pharmacologically reduced to lower-than- normal levels that still provide vital organ perfusion.
D. Hypotensive resuscitation is of greater value in patients with blunt abdominal trauma than those with penetrating trauma.
A
Hypotensive resuscitation temporarily targets a lower-than-normal blood pressure until major hemorrhage is controlled and is more likely to burn injuries >48 hours old because of quantitative and qualitative changes in neuromuscular acetylcholine receptors that accompany burn injuries.
The concept of “1:1:1 volume resuscitation” in hypovolemic, hypotensive trauma victims refers to administering equivalent numbers of units of packed red blood cells, fresh frozen plasma, and platelet. TRUE or FALSE?
A. True
B. False
A
The goal of 1:1:1 volume resuscitation is to maintain proper oxygen carrying capacity (i.e., red cell mass) and normal coagulation function and to avoid the anemia and dilutional coagulopathy that can occur with high-volume isotonic crystalloid resuscitation. Studies in both military and civilian populations suggest that this resuscitation strategy improves survival compared with high-volume crystalloid resuscitation.
When caring for trauma and burn patients, unintended hyperkalemia can result in all of the following clinical settings EXCEPT:
A. Administration of six units of 23-day-old packed red blood cells to a 3-year- old girl with a traumatic leg amputation from a lawn mower accident
B. Rapid administration of 12 units of 2-day-old packed red blood cells containing citrate preservative to a 53-year-old woman undergoing emergent splenectomy for blunt abdominal trauma
C. Hemolytic transfusion reaction in a 23-year-old woman who received improperly cross-matched packed fresh frozen plasma following traumatic brain injury
D. Succinylcholine administration to a 44-year-old man with 43% total body surface area flame burn on day 5 of hospitalization
B
Hyperkalemia can occur when potassium is released from lysed red blood cells, such as following transfusion in small children of old units of packed red blood cells (that may have undergone lysis during prolonged storage) or acute, immune-mediated hemolysis. Succinylcholine can precipitate hyperkalemia in patients with large burn injuries >48 hours old because of quantitative and qualitative changes in neuromuscular acetylcholine receptors that accompany burn injuries.
A 35-year-old male competitive bicycle racer sustains an isolated closed pelvic fracture (iliac wing and pubic ramus) in a bicycle crash. Assuming that his preinjury hematocrit was 45% and that during the first 24 hours of his hospitalization he maintained normal vital signs while being resuscitated to euvolemia with isotonic crystalloid only, what is his predicted hematocrit on day 2 of hospitalization?
A. 45%
B. 35%
C. 25%
D. 15%
C
Pelvic fractures are accompanied by significant internal hemorrhage—2 to 3 L due to bleeding from the large bone fragments, as well as injury to nearby retroperitoneal veins. Because approximately half the patient’s blood volume could be lost into the pelvis, crystalloid resuscitation to euvolemia would be expected to dilute his remaining red cell mass to a hematocrit approximately 50% below his baseline.
A 3-year-old, 21-kg girl sustains a 29% total body surface area burn after pulling a pot of boiling water off the stove. Using the Parkland formula for postburn fluid resuscitation, what volume of isotonic crystalloid should she receive in the first 8 hours of hospitalization?
A. ∼400 mL
B. ∼800 mL
C. ∼1,200 mL
D. ∼2,400 mL
C
The Parkland formula (Table 32-6) calculates isotonic fluid resuscitation for the first 24 hours after injury as 4.0 mL × body weight (kg) × %TBSA burn. Thus, the total 24-hour resuscita- tion volume would be (4 × 21 × 29) = 2,436 mL. Since half of this volume is to be administered in the first 8 hours, her 8-hour fluid volume would be (2,436/2) = 1,218 mL.
A 75-year-old otherwise healthy woman is rescued from a house fire and arrives shortly thereafter at the hospital receiving supplemental face-mask oxygen at 10 L/min. She has no apparent burn injuries, but is lethargic and coughing up carbonaceous sputum. Which of the following laboratory assessments would you NOT EXPECT to observe?
A. Pulse oximetry reading of 95%
B. Carboxyhemoglobin level of 26%
C. Arterial blood gas with partial pressure of oxygen (PO2) of 57 mm Hg
D. Co-oximeter measured arterial oxyhemoglobin saturation of 72%
C
With a history of smoke inhalation in an enclosed space and carbonaceous sputum, significant inhalation injury is likely, including carbon monoxide poisoning. Carbon monoxide poisoning would be reflected in an elevated carboxyhemoglobin and a low oxyhemoglobin saturation, both measured by arterial blood co-oximetry in the laboratory. Peripheral pulse oximetry is typically normal because this device only measures the relative values of oxyhemoglobin and deoxyhemoglobin, and does not measure carboxyhemoglobin. Arterial PO2 would be normal because carboxyhemoglobin does not affect the partial pressure of oxygen dissolved in the plasma.
In a mass casualty incident, patients are triaged based on the severity of their injuries. In general, those with the most severe, multiple injuries and near death receive the highest priority for care. TRUE or FALSE?
A. True
B. False
B
Because emergency medical care resources are limited and insufficient to treat all victims of mass casualty incidents, those with the most severe injuries and near death (e.g., cardiac arrest) are managed expectantly. Instead, the highest priority for care is given to those who are in need of emergent surgery to save life, limb, or eyesight.
As a result of trauma a 60-year-old patient is undergoing an emergent leg amputation in the hospital. An indication for transfusion of whole blood is:
A. A hemoglobin level of <5 g/dL
B. A blood pressure of <70/50 mm Hg for
10 minutes
C. Ongoing blood loss exceeding 8,000 mL
D. None of the above
D
Whole blood is only indicated in rare circumstances (such as a war zone) where there is no ability to separate whole blood into components or to store those components. Hemorrhage from trauma can be effectively treated with PRBC and crystalloid fluids, with plasma given if there is evidence of a coagulopathy or factor deficiency.
A otherwise healthy 25-year-old woman is admitted to the hospital with clinical and radiographic signs of appendicitis. Workup yields the following data: blood pressure 115/85 mm Hg, heart rate 110, tempera- ture 39°C, white blood cell count 12,000, hemoglobin 7.5 g/dL, urinalysis normal. The most appropriate next step is:
A. Proceed urgently to perform an appendectomy
B. Administer erythropoietin and then pro- ceed to surgery
C. Transfuse 2 units of PRBCs and then proceed to surgery
D. Delay surgery for 24 hours to determine the cause of the anemia
A
In an otherwise healthy patient who is hemodynamically stable, there is no need to treat moderate anemia with a hemoglobin >7 g/dL. It is important to determine the cause of the anemia, but surgery need not be delayed to perform the evaluation.
All of the following are indications for transfusion of fresh frozen plasma EXCEPT:
A. Dilutional coagulopathy
B. A deficiency of coagulation factors
C. Hypovolemia with a normal hemoglobin
D. Bleeding due to a warfarin overdose
C
Indications for FFP are treatment of dilutional coagulopathy, factor deficiency, and as a second- line agent for warfarin reversal. FFP should not be administered solely for volume replacement.
The recommended indications for platelet transfusion include all of the following EXCEPT:
A. Patient having intraocular surgery; platelet count 75,000 per microliter
B. Asymptomatic patient; platelet count 25,000 per microliter
C. Patient scheduled for resection of abdominal aortic aneurysm; platelet count 40,000 per microliter
D. Patient scheduled for resection of intracranial meningioma; platelet count 80,000 per microliter
B
Bleeding during craniotomy or intraocular procedures is a serious complication. The threshold for platelet transfusion is more liberal at <100,000 per microliter. For patients having other major surgical procedures the threshold for platelet transfusion is <50,000 per microliter. Patients who are not bleeding will usually not incur spontaneous hemorrhage until the platelet count is <10,000 per microliter.
A 25-year-old man is seriously hemorrhaging secondary to trauma. Until his blood type can be identified, which of the following would be the BEST choice of blood for transfusion until type-specific blood is available?
A. Type O Rh-positive
B. Type A Rh-negative
C. Type B Rh-negative
D. Type AB Rh-negative
A
In an emergency, uncross-matched type O blood is best as a “universal donor” for patients of unknown blood type. While Rh-negative blood is preferred, particularly for women of child- bearing age, administration of Rh-positive to men
Which of the following is a sign of an acute hemolytic transfusion reaction during general anesthesia?
A. Tachycardia
B. Hypotension
C. Bleeding
D. All of the above
D
Unfortunately, there is no precise sign for diagnosis of AHTR in the anesthetized patient. Tachycardia and hypotension could be secondary to AHTR or hypovolemia from surgical hemorrhage. Bleeding could be due to surgery or due to AHTR-induced DIC.
