Study Day 3 Knowledge Questions Flashcards
What are the four key symptoms of an immune response?
- Redness
- Swelling
- Heat
- Pain
What cells release histamine?
Mast Cells
What does histamine do?
- Vasodilation (capillary endothelial cells)
- Increase permeability
Vasodilation causes swelling at the site of the response (eg injury) which is the cause of increased permeability. Increased permeability allows for t-cells, b-cells and netutrophils to move from the capillaries to the interstital fluid to fight the antigen.
What is the inflammation cascade?
- Stimuli (internal or external)
- Chemokines notice something is wrong and send a signal - activating the mast cells
- Mast cells release histamine
- Vasodilation/increased permeability occur (swelling). This allows t-cells, b-cells and neurophils to cross from capillary to interstitial fluid.
- Those cells fight the stimuli and restore balance.
Major Trauma VSS
HR <60 or >120
RR <10 or >30
SBP <90
SP02 <90%
>16yo GCS<13
<15yo GCS<15
Major Trauma Specific Injuries
All penetrating injuries (except isolated superficial limb injuries)
Blunt Injuries
- serious injury to a single body region such that specialised care may be required that life, limb or long-term quality of life may be at risk
- significant injury involving more than one body region
Specific Injuries
- Limb amputation or limb threading injury
- suspected spinal cord injury or spinal fracture
- Burns >20% TBSA (>10% if <15) or suspected respiratory tract burns
- High voltage >1000volts
- serious crush
- major compound fracture or open disclocation
- fracture to 2 or more fracture or open disc location
- fracture pelvis
Time to reach highest level of trauma service for major trauma patients
Within 60 minutes
Major Trauma High Risk Mechanism
5x vehicle
2x height
1x explosion
Motor / cyclist impact >30km
High speed MCA >60km
Pedestrian impact
Ejection from vehicle
Prolonged extraction
Fall from height >3m
Stuck on head by object falling >3m
Explosion
High Risk Major Trauma Co-Morbidities
Age <12 or >55
Pregnant
Significant underlying medical condition
New born and small infant VSS
HR 110-170
BP >60
RR 25-60
Large infant VSS
HR 105-165
BP >65
RR 25 - 55
Small child VSS
HR 85-150
BP >70
RR 20-40
Medium child VSS
HR 70-135
BP >80
RR 16-34
Paediatric Trauma VSS
Critical 02 Illnesses
SMASKS
S Shock
M Major trauma / head injury
A Anaphylaxis
S Severe sepsis
K Ketamine sedation
S Status Epilepticus
Why is myasthenia gravis a precaution for midazolam?
This condition can weaken the lung and diaphragm. Midazolam has been shown to worsen this
What is the condition myasthenia gravis
Myasthenia gravis is caused by an error in the transmission of nerve impulses to muscles. It occurs when normal communication between the nerve and muscle is interrupted at the neuromuscular junction—the place where nerve cells connect with the muscles they control
Conditions regardless of sp02 3x3
Pregnancy:
- cord prolapse
- port partum haemorrhage
- shoulder distocia
Other:
- cluster headache
- decompression illness
- toxic inhalation
Chronic hypoxaemia conditions
COPD, neuromuscular disorders, cystic fibrosis, bronchiectasis, severe kyphoscoliosis, obesity
What are we titrationing to with chronic hypoxaemia?
88-92%
Autonomic Dysreflexia Pathophysiology
Autonomic dysreflexia (hyperreflexia) occurs in people with spinal cord injuries at level of T6 or above, which is above the level of the sympathetic outflow tract. This is a syndrome of massive reflex sympathetic discharge. Any strong stimulus occurring below the level of the injury can trigger autonomic dysreflexia including bowel distension or impaction, appendicitis, labor and delivery, and any sources of pain or infection. 2/3 of pregnant patients with spinal cord injury will develop autonomic dysreflexia during labor.
Signs and symptoms of airway burns
RUES FOB
R Resp distress (dyspnea +/- wheeze and associated tachycardia, stridor)
U Facial and upper airway oedema
E Evidence of burns to upper torso, neck, face
S Sooty sputum
F Singed facial hair (nasal hair, eye brows, eye lashes, beards)
O Hypoxia (restlessness, irritability, cyanosis, decreased GCS)
B Burns that have occurred in an enclosed space
Fentanyl over Morphine
CNS HH
C Contraindicated to morphine
N Nausea and/or vomiting
S Short duration (dislocation)
H Hypotension
H Severe headache
Why is monoanime oxidase inhibitors a precaution for fentanyl
Significant interaction and side effects, can cause serotonin syndrome due to the similar mechanisms
Monoanime oxidase inhibitor mechanism of action
They are best known as effective antidepressants, especially for treatment-resistant depression and atypical depression
An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain chemicals available to effect changes in both cells and circuits that have been impacted by depression.
Tornadoes de Pointes
A form of vetricular tachycardia - more common in those with long QT or after taking certain medications
Phenylketonuria (PKU)
an inherited disorder of protein metabolism in which the absence of an enzyme leads to a toxic buildup of certain compounds, causing intellectual disability
Aspartame
An artificial sweetener
Long QT Syndrome
Rare inborn heart condition in which delayed repolarization of the heart following a heartbeat increases the risk of episodes of torsade de pointes and other life threatening arrhythmias. Prolongation of the QT interval is a diagnostic of the condition
Dosage for lignocaine and ceftriaxone
Adults:
IV 1g ceftriaxone made up to 10 with water for injection
IM 4ml w/3.5ml lignocaine
Paediatrics:
IM 50mg/kg made to 4ml w/3.5ml lignocaine
What is a subtle status seizure and why?
Subtle status epilepticus represents the late stage of undertreated previous overt generalized convulsive status epilepticus and always requires aggressive ICU treatment.
4 types of seizures
Absence seizure . This is also called petit mal seizure
Atonic seizure. This is also called a drop attack
Generalized tonic-clonic seizure (GTC). This is also called grand mal seizure.
Myoclonic seizure. This type of seizure causes quick movements or sudden jerking of a group of muscles
Classifying Status Epilepticus
siezure >5minutes, 2 seizures w/o recovering to baseline or >2minutes without recovery
Postictal Symptoms
headache, confusion, generalized muscle ache, drowsiness, incontinence
SIGNS OF compartment syndrome (5 Ps)
pain
pallor (pale skin tone)
paresthesia (numbness feeling)
pulselessness (faint pulse)
paralysis (weakness with movements
What causes undifferentiated nausea and vomiting?
- secondary to opioid analgesia
- secondary to cytotoxic drugs or radiotherapy
- severe gastroenteritis
Cushing triad
hypertension, reflex bradycardia, respiratory depression
- sign of increased intracranial pressure (constricts arterioles - cerebral hypoperfusion - sympathetic response causes HTN)
Why does GTN cause tachycardia
Vasodilation and pooling reduces preload and afterload reducing blood pressure, the body responds by increasing HR to compensate to maintain CO (SV x HR = CO)
Why can’t we give GTN to patient tachycardia >150
HR is so quick that it is not allowing ventricles to fill with blood, by reducing preload this will further reduce the amount that the ventricles fill.
Why can’t you give GTN to patients taking ricoguat or PDE5 inhibitors?
Ricoguat is a antihypertensive medication that together with GTN can cause significant BP drops. PDE5 medications are also exacerbated by GTN as they are vasodilators.
When to suspect respiratory tract burns
B Burns to upper torse/neck/face
Ooedema of face and neck
Ssinged facial hair
Ssooty sputum,
H hypoxia
E enclosed space burns
R respiratory depression
BOSS HER
What type of fluid loss is involved in burns?
Both absolute and relative fluid loss. Absolute due to weeping therefore loss of fluid volume via burn wounds. Relative due to massive inflammation due to damaged skin cells that causes fluid shifts out of vessels into interstitial space.
Why should you elevate limbs of burn?
Reduce swelling and odema
What is the difference between T1DM and T2DM?
The main difference between the type 1 and type 2 diabetes is that type 1 diabetes is a genetic condition that often shows up early in life, and type 2 is mainly lifestyle-related and develops over time. With type 1 diabetes, your immune system is attacking and destroying the insulin-producing cells in your pancreas, whereas type 2 diabetes mellitus is characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production
What are the four principles of major trauma
Identify and manage conditions that are life threatening, pain management is the cornerstone of trauma care, mortality increased by acidosis/coagulopathy/hypothermia, minimize time from injury to definitive care
AEIOUTIPS
Alcohol
Epilepsy
Insulin
Overdose/oxygenation
Uremia/underdose
Trauma
Infection
Psychiatric / poisoning
Stroke/shock
Paediatric Paracetamol dose
15mg/kg
Paediatric Fentanyl Dose
small child 25mcg/IN
medium child 25-50mcg IN
why do we administer Ondansetron IV slowly over 30 seconds?
slow administration reduces and allows us to visualise adverse effects
What is the dose of ondansetron for pediatrics?
2mg for small child, 4mg for medium child
What is the main focus for paediatric nausea and vomiting?
Oral rehydration
What is hyphema?
A collection of blood in the anterior chamber of the eye generally due to trauma, ondansetron given prophylactically for this injury/eye injured patients as well as spinal patients
Paediatric GCS
eyes: same
verbal: 5 appropriate words/smile, 4 cries but consolable, 3 persistently irritable, 2 moans to pain
motor: obeys command is “spontaneous
Septicaemia signs
fever, rigor, joint and muscle pain
cold hands and feet
tachycardia, hypotension
tachypnoea
Why is morphine precautioned for respiratory tract burns?
Nausea Vomiting would be detrimental in the setting of respiratory tract burns
Allergic reactions further oedema of airway
What body temperature do you stop cooling burns
35 degrees
Wallace Rule of Nines
estimates percentage of total body surface area burned in adults
Paediatric Rule of Nines
10 year old- same as adult // head 9 // body 18 // arms 9 // legs 18 // groin 1
9 year old // +1 head // NIL groin
8 year old // +1 head // - .5 legs
Continue same pattern to age 1
1 year old // head 18 // body 18 // arms 9 // legs 14
Why is “respiratory tract burns” a precaution for morphine?
There is more likely to be a histamine release and further occlusion of the airway. Hence why morphine is more commonly seen as an allergy rather than fentanyl.
Jackson’s burn model
Surrounding the central zone of necrosis is a zone of ischemia in which there is a reduction in the dermal circulation. This is damaged but potientially viable tissue. This ischemic zone may progress to full necrosis unless the ischemia is reversed. If the ischemia is not relieved, for example when resuscitation and wound care are suboptimal, then persisting ischaemia will worsen, and the burn depth will increase.
At the periphery of the burn is a third zone of hyperaemia characterised by a reversible increase in blood flow and inflammation.
Zone of coagulation: dead tissue, irreversible loss.
Zone of stasis: decreased tissue perfusion, potentially salvageable
Zone of hyperaemia: will recover unless added insult to wound
Why don’t we walk anaphylactic patients
Empty vena cava syndrome. Drop in blood pressure
