TPATC Flashcards
low ETCO2
hypocapnia. less CO2 out w/each breath
ultimate state of shock
cardiac arrest b/c there is no circulation, metabolism, and no CO2 production unless effective chest compressions
ETCO2 in severe sepsis
poor perfusion leading to buildup of serum lactate/m. acdosis
-increae minute ventilation to blow off CO2 and lower ETCO2
TRALI
transfusion related acute lung injury
-sudden resp distress within 6hrs of a b. transfusion
suspect if sudden r. distress after b. transfusion
TRALI; transfusion related acute lung injury
s/s of TRALI
within 6hrs of blood transfusion
-low bp, fever, transient leukopenia
TACO
HTN w/o fever and leukopenia after b. transfusion
difference between TRALI & TACO
both have respiratory distress due to acute onset p. edema post blood transfusion
*only TRALI has fever & leukopenia
problem of too high PEEP
low bp
indication of ETCO2 of 18mm hg
severe hypoperfusion so need IVF
what type of patients need padded stretchers
hypothermia pt b/c that decreases sensations of vibrations. ncreased sensitivity to vibrations can trigger life threatening arrythmias
s/s of flicker vertigo
N/V vertigo motion sickness lightheadedness seizures
levels of SCI that needs m. ventilation
above C4
causes of increased difficulty w/BVM
BMI over 30
Mallampati 3-4
facial hair
over 57yrs
just culture model
focuses on risk, system design, management of behavioral choices
less focus= errors, punitive
problem of rx/alcohol in your system while flying
hypoxia risk
blood donation & flying
no fly in under 72hrs post BT
1 pt donation = lose 13% b. volume
so your ability to carry oxygen is decreased and fatigue/tired
impaired alertness/performance immediately after waking
sleep intertia
space between garmets for flight suits
1/4
rules for flying w/night vision goggles
should be worn by at least 2 staff
ELT frequencies
- 025
- 5
- 0
radio in an emergency
keep on, not intermittently
timeline of survival in wilderness
3h w/o shelter
3 days w/o water
3wks w/o food
oxygen for pilots of unpressurized cabins
use oxgen continuously if flying over
when should a pilot continuously wear oxygen
if unpressurized over 12K ft
when should a pilot intermittently wear oxygen
continuous oxygen if over 12K ft
10-12K if spend over 30min at that altitutde
at what altitude do pilots start wearing oxygen
unpressurized 10-12K ft if over 30min
continuously over 12K
rate temperature changes with increase/decrease in altitude
lapse rate
manage OG/NG tube if flying
leave open b/c Boyle’s rule
Charle’s law
volume & temperature
volume & temperature
CHarles law
pressure & temperature
Gay-Lussac
Gay-Lussac Law
pressure & temperature
key feature of the Ideal Gas Law
effects of pressure are greater than the effects of temperature
*as barometric pressure decreases gas expands and temperature decreases
use of Dalton’s law in transport physiology
explains hypoxia. driving pressure to get oxygen into lungs. mountaineers
gas law that explains why mountineers get hypoxia
Dalton’s law
*% of oxygen is the ame at 21% but the pressure driving oxygen into the lungs changes
when do significant effects of altitude on the body begin
significant effects not below 12K
BUT night vision deteriorates at 5K ft
altitude where night vision decreases
5K ft
diffusion of high to low
Graham’s law
explains decompression sickness
Henry’s law
pressure above a liquid causes gas to dissolve in a liquid
Herny’s law
pressure & solubility
Henry’s law
hrs of rest prior to a flight transport mission
10hrs
what type of tissue stores nitrogen
adipose tissue acts as a reservoir of nitrogen and stores overt 1/2 of the body’s nitrogen. ability to dissolve 5-6 more nitrogen than other body tissues
barobaritrauma
form of barotrauma in which a large release of nitrogen from adipose tissue enters the bloodstream
trigger for decompression sickness
too rapid descention
fly to 30K too quickly
predisposing factors for decompression sickness
- frequent exposure to over 18K ft
- rapid rate of rise/drop
- lots of adipose tissue
- age extremes
- alcohol consumption
- preexisting ardiopulmonary disease
effects of altitude on the obese
100% oxygen for 15min prior to flight b/c nitrogen is stored in adipose tissue and could cause decompression sickness
when does everyone involved in a flight need O2 prior to flight
if over 18K unpressurized, breathe 100% oxygen for 30minutes prior to flight to provide washout of nitrogen w/oxygen
how soon after scuba diving can you fly
after 24hrs b/c compressed air causes excessive nitrogen uptake
how soon after hyperbaric chamber can you fly
12 hrs post
bends
decompression sickness in joints
s/s of skin bends
nitrogen gas bubbles under the skin or along nerve tracks
*itch, tingle, rash,, swelling
type 2 decompression sickness
chokes = lungs
CNS trauma
“chokes”
decompression sickness
- nitrogen gas bubbles in the lungs taht obstruct smaller pulmonary vessels
- burning sensation under the sternum and is associated w/coughing and sensation of suffering
CNS & decompression sickness
nitrogen bubbles in teh brain/spinal cord. obstruct blood flow to the brain and SCI
s/s of CNS decompression sickness
visual disturbance HA face/jaw pain can't hear/speak numb/tingle
treat decompression sickness-5
descend 100% oxygen splint affected limbs avoid weight bearing consider hyperbaric
4 categories of the decompression system
type 1: “bends” (joints), paresthesia (skin)
type 2: chokes (lungs) neurologic (brain/SCI)
dysbarisms
s/s from xpsoure to changing air pressure arise when expanding or contracting gas ca ‘t escape or equalize to ambient pressure
use of vasoconstrictive nasal spray during air transport
to help w/facial sinus and inner ear pressure
when does sinus squeeze occur
excrucinating pain on descent
sinus squeeze
excruciating pain on descent
inflammation of sinus cavity w/gas expansion and contraction b/c barometric pressure changes
intervention for sinus squeeze
apply direct pressure, valsalva, decongestants, descent gradually
flight transport pt w/increased lacrimination during flighyt
if can’t communicate, increased lacrimation is a sign that they may be experiencing barotrauma
tooth pain during flight
ascent -gas expansion due to changes in barometric pressure
pain decreases w/descent b/c air contracts
4 stages of hypoxia r/t altitude
inefficient
compensatory
distrubance
critical
stage 1 hypoxia
stage 1 = enefficient
up to 10K ft
slight vital sign increase
decreased night vision
stage 2 of hypoxia
compensatory 10-15K ft increased vitals increased depth RR more difficult to perform tasks
stage 3 hypoxia
disturbance 15-20K ft dizzy sleepy tunnel vision cyanosis poor muscle coordination slow thinking
stage 4 hypoxia
critical over 20K confusion LOC incapicitation
2 measures of hypoxia on personnel in flights
Effective Performance Time
Time of Useful Consciousness
Effective Performance Time
availabel time to perform flight duties in an environment w/ inadequate oxygen
loss of effective performance measured from the time oxygen is deprived to deliberate loss of function
TUC
TUC
loss of effective performance measuring the time from deprivation of oxgyen to deliberate loss of function
18K ft & TUC/EPT
20-30min
22K ft and TUC/EPT
10min
25K ft & TUC/EPT
3-5min
30K ft & TUC/EPT
1-2 min
40K ft & TUC/EPT
15-20 sec
TUC/EPT is 10 minutes
22K ft
TUC/EPT is 1-2min
30K fty
seizures in flight
flicker vertigo
what is flicker vertigo sometimes confused w/
hypoxia, seizrues
what does EMTALA say about stablization
pt does NOT need to be stablized prior to transfer and DOES say the stabilization within the capability fo the hospital must be done prior to transfer
fear that touching will lead to harm
assault
actual physical touch leading to harm
battery
spalling
pressure wave on teh air-fluid interfaces on the human body
implosion
compression of gas containing areas of the body exceeding the organ to contain the pressure (bubble wrap squeeze)
what is affected in primary blast injuries
gas filled organs (lungs, GI, lungs, tympanic membrane)
4 phases of disaster managemnet
preparednes
mitigaytion
response
recovery
START triage
simple triage and rapid assessment
4 catagories of START
delayed, urgent, emergent, expectant
goal of mass care
greatest good for the greatest number
red color in mass casualty
immediate
yellow color in mass causalty
urgent
purpose of knowing MOI
describes energy transfer
when should you suspect spleen injury post car accident
T-boned on left side b/c spleen on left
what organ injury should you suspect if a pt is T-boned on left
spleen
what injury to suspect if t-boned on right
liver, right shouldler/clavi le
interventions to do in “B” of the algorithm
needle D
seal open pneumothroax
what non-A item should you do in “A”
c-spine
hemorrhage
interventions in “C”
direct pressure
hemostatic dressing
blood transfusion/TXA
assessment in “C”
skin color skin temp moisture pulse: rate, quality, location cap refill LOC represents brainn perfusion
items in “D”
neuro
AVPU
what does LOC represent
brainperfusion
intervention to consider if mental status is decreasing
airway management
triad of death
hypothermia
acidosis
coagulopathy
“L” in sample
LMP
pregnant
last I&O
most reliable way to confirm ET placement
capnography
4 physical s/s of pain in AMS
grimacing
tearing
vital signs change
diaphoresis
order of RSI rx
pretreat
sedate
paralyze
**sedate prior to paralyze b/c most anxiolyutics/hypnotics expcept ketamine dont’ have analgesic properties
hoarse voice
suspect airway compromise
when should you be concerned about airway patency
combative, confused, injuu8resd
backup plans if intubation fails
BVM, LMA, cric
BMI that predicts difficult airway
over 30
age that predicts difficult airway
over 57yo
2 airway assessments to identify a difficult airway
Mallampati
3-3-2
3-3-2
- oral opening 3 of pt fingers (less than that can be difficult to visualize larynx)
*tip of mentum to hypoid bone (fingers in front of neck. less than 3 fingers means limited space for tongue.)(measure looks at space availabe to accommodate tongue)
2
purpose of bougie
tracheal introducer
*thread over ET, take out introducer. that’s how to change out old ET tube for a new one
complication of obtunded pt
might not have complex coordinated muscular actions to direct blood/secretions/emesis away from airway
consideration of pt needs RSI and has a chest injury
chest injuries can limit pt safe apnea time during RSI
inability to open jaw
trismus
sizing of OPA
corner of mouth to angle of mandible
assessment of BVM
ensure tongue isn’t falling back and obstructing
can use 2NPA & OPA
tip of Mac blade during intubation
vallecula
curved tip = MAC
tip of the straight miller blade
under/beyond epiglottis
intubation but can’t see vocal cords
BURP, crioid pressure, ET introducer< external laryngeal manipulation
external laryngeal manipulation
finger on teh thyroid and move until optimal position is found then hold spot until passage of ETT intubatior can put hand on assistant to bring larynx into view
well executed BURP maneuver
specific type of external laryngeal manipulation
*can improve laryngoscopic view by one COrmack-Lehane grade
tool that feels for “clicks” during intubation
bougie
clicks are against the tracheal rings
position for intubation
see a line from the air tragus to zyphoid
ramp
elevate head
sizing combitube to LMA
LMA = weight Combitube = height
insert Combitube
sized by height
blind insert
very stiff tube so soft tissue damage
basic EMT can use for CPR
contraindication of Combitube
esopheageal
ingestion of caustic substance b/c the tube is stiff and can cause trauma
how far do you insert combitube
lube
blindly until teeth are inbetween 2 black marks,
insert air
how much air is inserted into combitube
1st: 85ml. located in te posterior pharynx above the epiglottis
2nd 12ml air. esopagus
taking out combitube
deflate both balloons (one in posterior pharynx above the epiglottis, other in esophagus)
how to put in an ET tube if you have a combitube in
deflate balloon in the posterior pharynx but leave the esophagus one inflated. so you have a marker for inserting the ET tube
3 indications for cric
angioedema
facial burn
foreign body obstruction
2 types of ric
needle
surgical
why don’t kids get cric
small pliable and mobile larynx/cricoid
ETCO2 when the device is first set up
may briefly detect w/normal capnography if the tube is placed into the esophagus due to exhaled gases forced into the stomach during BVM
how to interpret properly placement of ETCO2 via capnography
need 6 breaths before the colorimeter an tell you
CXR that indicates correct ET placement
tip in teh trachea
ways to confirm ET is in correct place-5
capnography US direct visualize tube pass vocal cords ausculatate CXR
how far past the vocal cords should the ET go
2cm beyond vocal cords
2-6cm above carina
vital signs post intubation
change from negative to positive vent can precipitate low bp bc increased intrathoracic pressure of convert a simple lung injury/small pneumo to t. pneomo
goal of RSI
achieve optimal conditions for intubation w/rapid onset of paralysis and sedatives while mitigating complications
goal of preoxygenation before RSI
preoxygenate w/NC at 10L/min for minimum 3min,
washes out nitrogen and establishes an oxygen reservoir so safer for longer periods of safe apnea
RSI classes
preinduction
sedative hyponotics
neuromuscuearl bockers
timeline when you treat for RSI
1-3min prior only if you have time to spare
steps in delayed sequence intubation
- give sedative that preserves respiratory drive and airway reflex like ketamine to safely control pt
- oxygenate for 2min then give neuromuscualr blocking agent
- intubate
effect of PPV on lungs
PPV of injured lung can transform a simple pneumo to tension pneumo
why might someone develop rapid cardiovasular complications duidrng RSI
intubation postivie pressure ventilation can lead to rapid cardiovasualr collapse
“M” in LEMON
Mallenpati
“O” in Mallempati
obstruction
vitals in propofol
low bp
goal of preoxygenate prior to intubation
3 mnin nitrogen washout and get alveoli enough reserves
last step of LMA placement
inflate balloon. the amount of ml is on teh balloon itself
ECMO
extraorporeal membrane oxygenation
body contour during BVM
look for chest rise and flat abdoment
consideration of using PEEP w/m. vent
trade off between PEEP and cardiac filling pressure
what type of pressure is m. ventilation
postivie
positive pressure ventilation
transition to it when you start m. vent
- decrease muscle work
- affects venous return/CO
PaO2 considered hypoxia
less than 80mm hg
hypoxemia vs hypoxia
hypoxemia: less than normal PaO2
hypoxia: failure to deliver oxygen at the tissue level
anatomic shunting
alveoli are bypassed
right to left shunt
blood passes from R to L w/o being oxygenated
m. vent settigs that principally affect oygenation
m. vent settigns the principally affect oxygenation
FiO2
PEEP
I:E
what must be good in order for FiO2 to be helpful
FiO2 is only as good as the alveoli it reaches
*oxygen delivered to nonperfused/collapsed aleoli is unable to be diffused into the blood and is considered part of dead space ventilation
FiO2 and lung injury
avoid FiO2 over 0.6 for prolonged periods of time
normal PEEP
3-5cm water
goals of PEEP
enhances alveolar recruitment
improved gas exchange
PEEP setting for hypoxia
6-10mm hg
for hypoxia, atelectasis, p. edema
auto-peep
unintentional air trapping which occurs when inspiration begins before the previous bcomes breath expiration has ended
compliations of PEEP
increased intrathoroacic pressure
increase ICP
PEEP & ICP
increases
not normally a reason to withhold peep is needed b/c hypoxia might be worse for a pt w/TBI than the mild increase in ICP
PEEP’s effect on the heart
increases intrathroacic pressure which impeds b. flow from the vena cava so affects preload and decreases CO
PEEP in a shock state
b/c of increased intrathroacic pressure decreases CO, you may need to stop PEEP and initaite aggressive IVF
when would you use PEEP over 20
- normally 3-5cm water
* ARDS may need over 20
PEEP in ARDS
in ARDS, may need PEEP as high as 20mm water due to noncaridogenic p. edema and poor lung compliance
indication of longer expiratory time
poor lung ompliance (over 1.2 sec in adults)
indication of shorter inspiratory time
under 0.9sec in adults.
shorter inspiratory time in COPD b/c need more time to exhale r/t air trappign
how to adjust I:E time on m. ventilator
change I time or RR
Ve formula
Ve (minute ventilation)
= RR x exhaled tidal vomume
normal Ve
10ml/lg of ideal body weight
calculate male predicted body weight
50 + 2.3(height in in) -60
calculate female predicted body weight
45.5 + 2.3(height in) -60
calculate M/F predicted body weight
__ + 2.3(height in in) -60 = _____
M = 50
F= 45.5
produces ETCO2
product of ventilation, perfusion, metabolism
tool to determine ROSC during chest ompression
ETCO2
application fo ETCO2
- verify/continuously monitor ET tube placement
- gague effectiveness/progonosis during cardiac arrest
- ROSC during chest compressions
- adequacy fo vnetilation
high ETCO2
hypercapnia
hypoventilation
low ETCO2
hypocapnia
hypervwnetilation
interventions of ETCO2 is too high/low
adjust Vt or F
avoid lowing Vt too much b/c that can lead to nonalveolar or dead space ventilation
difference between pPlat and PIP
pPLAT: pressure in lower airways/alveoli
PIP: measures pressure in upper airway/bronchus
ventilator setting that measures pressure in the lower airway/alveoli
pPLAT
when is pPLAT measured
breaht hold maneuver
ventilator setting that measures pressure in the upper airways/bronchus
PIOP
complications of high airway pressure
acute lung injury
negative affect preload
intervention if PIP is high due to DOPE or bronchospasms
tital volume should be increased to at least 8ml/kg of predicted body wt, slow F, decrease inspriatory time to 1:4
cause of pPLAT high
over 30
*lower airway complicaiton issues
pneumoT, ARDS, pneumonia, excessive Vt, overventilation,
action to take if pPLAT is high despte normal Vt
decrease Vt to 4-6ml/kg of predicted body wt
increase F to meet Vt needs
causes of low PIP
displaced ET tube
too small ETT w/air leak or uninflated/ruptured balloon
equipment fail like circuit leak
underventilation w/insufficent Vtt
insert LMA
blindly as far as you can. inflate using ml ari written on ballon
assumption you should make about all truma pt
assume all are in shock
shock
inaedequate oxygen supply for metabolic needs so energy production shifts to anaerobic
*a continuum of pathyphysilogy changes caused by hypoperfusion to cells
2 primary means of compensating in shock
activated SNS, fluid shifts
what happens when the body is experiencing widespread hypoperfusion
hyperglycemia and that shifts the osmotic gradient within the vascualr space in an effort to pull fluids from teh other 2 compartment
SCI w/risk for respiratory compromsie
above T6
SCI where you have complete ventilation paralysis
over C5 so m. ventilator
what happens in neurogenic shock
unopposed PNS response post injury T6 and above
Temp in SIRS criteria
over 100.4
under 96.8
HR in SIRS
over 90
SBP in SIRS
below 90
RR in SIRS
over 20
PaCO2 in SIRS
below 32
WBC in SIRS
over 12
under 4
glucose in SIRS
hyperglycemia in absence of diabetes
s/s of hypoperfusion
high lactate
abnormal base deficit
low urine output
AMS
what happens in severe sepsis
organ dysfunction
hypoperfusion
low bp
what happens in septic shock
low bp
high lactate/base deficit despite adequate IVF resuscitaiton
why would you intubate for sepsis
optimizes oxygen delivery even if pt has optimal airway
when do you use NE in septic shock
if IVF of 20ml/kg doesn’t achieve MAP of at least 65, add NE
early vs of shock
elevated
shock index -3
-detect changes in cardiovasuclar system prior to systemic low bp
HR/SBP
helps predict need for blood products
calculate shock index
HR/SBP
helps predict the need for blood products in shock
shock index = HR/SBP
normal adult shock index
HR/SBP
normal is 0.5-0.7
over 0.9 increases risk of mortality in shock and you should give blood products
FAST
focused assessment with sonography for trauma
- look at 4 spots: perispelnic, pelvis, perihepatic, pericardium
- dark (anechoic) stripe in teh dependent areas = free fluid
dark strip in FAST
free fluid = anechoic
morrison’s pouch
between liver and right kidney
how do you gauge effectiveness of shock resuscitation
lactate
base deficit
both are normal if below 2
intervention for tachycardia
IVF to r/o dehydration
weak peripheral pulse in shock
vasoC b/c SNS activation
“C” assessment
skin color
temp
central/peripheral pusles
cap refill
body temperatur e and IVF
hypothermia makes you less responsivenes sto IVF resuscitation
best IV gague in trauma
shoert tubing, large gague so all infuses faster
consideration if give lot of IVF in trauma
bust clot
no oxygen carrying capacity
when do you do permissive hypotension post trauma
penetrating trauma w/o brina injury
SBP 80-100 until bleeding is control
BP control in TBI
no permissive hypotension! avoid cerebral hypoperfusion bc/ cerebral perfusion pressure of at least 60 is needed
why don’t you do permissive hypotension in TBI
b/c CPP of at least 60 is needed for brain perfusion
contraindication to permissive hypotension
TBI b/c need CPP of at elast 60 to perfuse the brain
CPP needed to perfuse the brain
at least 60
reverses warfarin
vitamin K
FFP
lifespan of plt
10 days
relationship betwene IVF resuscitation and coaguulopathy
- consumption of clotting factor
- clotting factor dilution
intervention for high INR
INR over 1.5 = transfuse FFP of at least 15ml/kg
definition of massive transfusion
replace pt complete blood volume in 24hrs
10 units for audlts
characteristics of 1 unit whole blood
500ml
hct 40%
plt 175K
fibrogen 1500mg
electrolyte imbalance with blood transfusions
lwo CA
DIC
active bleeding b/c consumption of coagulation factors, widespread depletion of plt, diffuse fibrolsysis
*bleed form all orifics
consider if a trauma pt is bleeding from all orifices
DIC
abruptio placentae, head injyr, sepsis, cancer, sna,e bites
suspicion if bleeding from orifices/IV
DIC
LOC in early versus late shock
early = hyperarousal late= hypoarousal
labs that guides resuscitation of shock
lactate
base deficit
3 categories of Rx that mask shock s/s
BB
antidysrhythmiss
antiHTN
what cardiac med class might not work for obese
inotrophs might not work b/c already increased contractility form increase dCO needs
most critical mass transfusion complication
cogulopathy
principle goal of shock
restore cellular perfusion
electrocal current & dysrhythmias
AC more likely to cause VF than DC
complications of lightening strikes
respiratory arrest in pt struck by lightening (electrical burn) b/c it tempoarily renders the medulla oblongata inactive from teh electrical discharge disrupting neurologic implu.ses
dessication
drying
s/s of electrical injury
LOC
paralysis of extremities
myoglobinuria
cardic/resp arrest at scene
what type of energy is lightening
high voltage DC which can depolarize the myocaridum leading to cardiac arrest from sustained asystole
skin complication of alkali burns
liquefication necorsis
liquefication necorsis
alkali burns
3 ways chemical burns harm skin
denature tissue proteins
liquefaction necrosis
dessication fo celsl
use for hydrofluoric acid
etched glass
teflon
leather tanning
Resut remover
first aid for chemical burns
flick power away
rinse w/water
effect of hydrofluoric acid on thge body
fluoride ion binds w/free calcium in teh blood depleating serum Ca
s/s: dysrhythmias, low bp, low Ca
electrolyte affected by hydrofluoric acid
fluoride ion binds with free Ca = low Ca
only skin burn that requires a neutralizing agent
hydrofluoric burns need topical Ca gel
- unusual treatment b/c other topicals cause heat production
- cover w/gauze to hold the gel in palce
second degree frostibite
clear fluid blisters
swelling
red-blue-gray discoloration
appearence of blisters in frostbite
1st: none
2nd: clear
3rd: bloody purpole
appearance of 4th degree frostbite
black hard mummified gangrene necrosis
when do you delay frostbite rewarming
if you suspect risk of refreezing
treat frostbite
104F water until pink/perfusion
no dry heat/rub/massage
TBSA of burns where the body will have systemic responses
over 20%
G tube for burns
use a g tube for over 20% TBSA b/c risk of ileus. over 20% has systemic responses
metabolism in burns
hypermetabolism which increases oxygen consumption
difference in cause in burns based on relation to glottis
above glottis = thermal
below glottis = chemical
question to ask someone who is burned
location and considered in a confined space w/productions of compustion
priority in thermal injury to upper airway
risk of edema/obstruction so prioritize patent airway
excessive discharge of mucous from the bronchi
bronchorrhea
treatment if circumferential burn around chest
escharotomy to release tight leathery eschar. expect chest wall expansion to immedialtely improve
result of CO poisioning
hgb bound to CO so tissue hypoxia
half life of carbon monoxide
1/2 life of CO is 4hr on room air
40 min nonrebreather
23 minutes in hyperbaric chamber
products of incomplete combusion
CO
cyandide
s/s of cyanide poisioning
fire in enclosed space RR changes SOB CNS exictation HA eye/mucous irritability
CNS in cyanide poisioning
CNS exictaiton
rx for cyanide
hydoxocobalamin
hydroxocobalamin
cyanide poisning
suspect if lactate over 10
cyandie poisining
IV and burned skin
can put an IV through burned skin
cold water/climate and burns
vasoC
decrease circualtion
hypothermia
pediatric burn chart
Lund-Browder
rx if burn injury
may need higher than normal doses of opioids b/c hypermetabolism
IVF choice for burns
LR
first priorities in burns
stop burning process
airway
pathology of burn injuries -4
hypovolemia from fluyid los
increased capillary permeability
third spacing
vasoD
interventions in “C”
start IV/IVF
after IVF, check to see if hemodynamic status improves
intubation strategy if pregnant
nasal isn’t reommended b/c increased blood volume and vasoD. capillaries ai
options to drop the trachea into view during intubation
jaw thrust
BURP
cricoid pressure
external laryngeal manipulation
normal acid-base status in pregnany
compensated r. alkalosis is normal in late pregnancy
site for thoracostomty if pregnant
3-4th intercostal antierior midclavi ualr b/c uterus forces diaphragm to rise 4cm so go higher to prevent internal organ damage w/procedure r/t expanding uterus
NORMAL = 5th ICS
CO increase in pregnancy
25-50%
blood volume expansion in pregancy
40-50% by 34wga
H&H in pregnanccy
sblood volume increases 40-50% by 34wga but no increase in RBC so H&H shows dilutional anemia
hemodynamic state in pregnancy
high flow = increased b. volume
low resistance = low SVR
shock state reverses low flow/high resistance and decreases b. flow to uterus
pulse pressure in pregnancy
normal is wide pulse pressure r/t low SVR
what does placental/uterus pressure depend on
MAP
hypovolemic shock & pregnancy
pregnancy may lose up to 35% of bood loss (class II-III) prior to shoing s/s of shock
- moms vs look normal but fetal destress/underpfused placenta
- mom/fetus tachycardia prior to BP drop
pulse pressure in hypovolemia
wide pulse pressure in hypovolemia
CPR on pregannt woman
manually displace uterus to the side
blood loss into the retroperitoneal space
retroperitoneal space can hold up to 2L
how frequently does the entire blood supply pass thorugh uterus
under 10min
when does the uterus rise out of the pelvis
12wga
wga when the uterus is at the level of U
20wga
GPTAL
gravity term preterm abortions living children
what should you note when you look at the stomach of a trauma pregnant woman
contour
monitor pregnant women post trauma
4hr
s/s of abruptio placentae
tender tuerus vag beed mom shock 600-800ml/min so rapid exsanguation visible vag bleed or hiding behind life-threatning to both
type of pregnancy bleeding that can be hiddening and lead to death
abruptio placentae
why is perimortem c-sec so quick
5min for fully intact fetus
mom may immprove b/c immediate increase in venous return to heart, in crease CO, decrease O2 demand
Chance fraccture
horizontal freaccture of hte vertebral body due to hypoflexion of the spine
how fast does an airbag go off
150mph
SCIWORA
ska-wohr-ah
SCI w/o radiographic abnormalities
most common cause of airway obstruction in kids
CO
5 s/s of adequate circualtion
normal mental status adequate perfusion warm extremities Cap refill under 2 sec normal urine oputyut 0.5
pediatric IV bolus
20ml/kg
temperature & resuscitation success
hypothermia has an adverse effect on eresuscitaiton and potentioal for coagulaopathies
rx for seizure control in kids
benzos
axonal shearing
condition of damage to axons, as a result of being rtwisted and disconencted in a violent agitating motion
Rx for seizure control
benzos = immediate phenyotin= prolonged
MOI suspicious for SCI
high speed MV falls over 3x height axial load diving penetrating wound enar SCI sports injury to head/neck focal point/tender intoxication unresponsiveness motor/sensory deficit
when can you get CT
onlyy if hemodynamically stable
if not, FAST
vital signs out of range
hemodynamically unstable
intervention if obvious deformity
neuro check
intervention if rapid extremity swelling
more frequent neuro checks
fix a fracture
reduction
epidural hematoma
meningeasl aretery
by the temporal bone secureed tightly in place by dura
*temporal bhone
suspect if a person has a blow to the side of their head
epidural hematoma: meningeal artery by temporal bone
most common site of epidural hematomas
meningeal artery is by the temporal bone
injury associated to a blow to the meningeal artery
epidural hematoma
where is CSF located
subarachnoid space: pia & arachnoid
how many cervical vertebrae
C7
how many thoracic vertebrae
T12
how many lumbar vertebrae
L5
C1
atlas. supports head
C2
axis
C1-2
atlas
axis
secretes catecholamines
adrenals
role of the spinal cord
regulates body movements, fun tions, transmits nerve impusles
how does hyperoxia affect the body
hyperoxia is associated w/contributing to oxygen free radical damage
what also decreases when BP decreases
cerebral perfusion pressure
CPP: represents the pressure bradient driving cerebral blood flow
calculate CPP
ICP-MAP
ICP-MAP
cerebral perfusion pressrue
normal ICP
0-15mm hg
BP goal in early TBVI
SBP above 90
early TBI interventions
focus on optimizing CPP
SBP not below 90
CPP at least 60
GCS of coma
8
interventions in high ICP
hyperventilate
mannitol
increased HOB
prolonged posttrauma coma post TBI
diffuse axonal injury
CT in diffuse axonal injury
normal/brain appears unusually swollen w/loss of normal gray-white distribution
intervention for subdural hemorrhage
may need to evacuate the hematoma b/c pressure, edema, and toxic effects of blod on brain tissue
suspect subdural hematoma
neuro changes
unexplained HA
personality change
seizures
laceration of temporal
epidural heamtoma = laceration of meningeal artery/meningeal aretery
predicts favorable outcome for epidural hematoma
90-100% if no LOC
BUT…can create a lesion that expands and pushes tghe brainstem down into herniation. pressure on teh reticualr formation so LOC
classic s/s of epidural hematoma
33% have classic LOC, lucid, coma
head injury with LOC, lucid, coma
epidural hematoma
endstage of epidural hematoma
coma. untreated mass lesion pushes down into brainstem, 3rd crainial nerve so iipsilatereal pupil dialtion, presure on reticualr formation so LOC
s/s of near terminal epidural hematoma
untreated lesion expands and pushes brainstem down into herniation
pressure on reticualr formation so LOC
pressure on 3rd CN so ipsilatereal pupil dialtion & contralateral motor weakness/hyperreflexia
outcome of subarachnoid hemorrhage
most are vegetative state/seivere disability
s/s of basilar skull fracture
periorbital ecchymosis
battle sign
CSF leak
battle sign in…
basilar skull fracture
causes of secondary SCI trauma
ischemia
edema
hypoxia
injury r/t inadequate spinal immobilization
Brown-Sequard
hemisection of spinal cord
ipsilateral-paralyusis
contralateral-decreased sensitivity to pain/temp
side of paralysis in Brown-Sequard
ipsilateral
decreased sensitivity to pain/temp in Brown-Sequard
contralateral
best RSI for head inuury
Ketamine
when is Ketamine ideal for RSI
head injury
best RSI for head injury
Ketamine b/c it won’t worsen CPP
positioning for TBI
HOB up and head midline
promotes venous drainage. even brief assymetry impacts ICP by reducing venous return
what level of SCI is associated with neurogenic shock
above T6
vasopressors are need for SCI neurogenic shock
loss/disrpution of descending SNS pathway
- low bp due to massive vasoD despite normal b. volume
- peripheral vaso D, brady C, hypothermia
BP in neurogenic
neurogenic shock loses SNS. low bp b/c masive vasoD despite normal blood volume
peripheral vasoD
bradyC
causes transient spikes in ICP
position
suction
cough
2 signs of impending herniateion
pupil changes
possturing
CO2 on cerebral blood flow
hypocapia changes cerebral blood flow by 4% for 3very 1mm hg in PaCO2
Cushing’s triad
HTN
bradycardia
irregular respirations
*sign of impending herniation
sign of an impending herniation
Cushing s HTN bradycardia irregular resp
vertebrae at nipple line
T4
dermatome of nipples
T4
dermatome of great toe
L4
use of peneyotoin in seizures
decrease seisure in first 7 days
clear SCI
NEXUS - National Emergency Xrayography utilizaiton study
NEXUS 5 criteria
to r/o SCI no midline tender w/palp no AMS from trauam/intoxic/rx no s/s referable to neck injury, paralysis, sensory no distracting painful injury last: ROM w/collar off
occurs in 25% of subarachnoid hemorrhages
up to 25% have seizures
cause of acidosis in shock
hypoperfusion
bleeding into the pleural space
each pleural space has the capacity to hold up to 3L blood
where do you bleed if a pelvic fracture
retroperiotneal space
bruising at U
CUllens
flank/groin bruise
Grey Turner
retroperitoneal hemorrhage
3 causes of pleural friction rub
PE
pneumonia
pleurissy
normal percussion over liver
dull
normal percussion over stomach
dull
normal percussion over intestines
dull
percussion over stomach that indi cates gastri dilation
tympany
bad percussion over lungs
hyperresonance - overinflation of lungs
location of pneumothraox
air betwen the viscaeral and parietal
most common cause of pneumothraox
rib fracture punctures the lung also
“paper bag” effect
when does the lung collapse
lungs collapse when air enters the ptential space betwen the visceral and parietal pleura
location of chest tube in pneumothroax
4-5th intercostal space anterior midaxilary
percussion of a pneumothorax
hyperresonance
what happens in sucking chest wound
air colection in the pelural space so lung collapse due to loss of negative pressure *need occlusive dressing toi create flutter valuve
intervention for sucking chest wound
occlusive dressing traped to create flutter valve
what happens when air collects in the pleural space
lung collapse (pneumothraox) b/c loss of negative pressure
pathology of t. pneumo
mediastinal shift affects vena cava
-dec rease venous return to heart
-decreased preload/BP/CO/SVR leading to hypoxia
= obstrucctive shock
shock in pneumothroax
obstructive
how does m. ventilation cause t. pneumothorax
positive pressure
percussion of t. pneumothraox
hyperinflatiohn/hyperresonance on affected siede w/desita nc/absen LS
site for needle D
needle to convert t. pneumo to simple pneumo
*2nd ISVCS midclaviular followed by CT
percussion in the different types of pneumothorax
tension = hyperresonance hemo= dull
BP if hemothroax
permissive hypotension
noteworthy chest tube drainage
ovaer 1500ml immediately
200ml/hr for 2-4hrs
considered “massive” hemothroax
over 2.5L
hypovolemia/hypoxai
suspect massive hemothrax
1.5L chest tube drainage imemdiately
no breath sound
dull percussion
s/s hypovolemic shock
CXR s/s of hemothroax
blunting of costphrenic angle on upright radiograph
dx hemothroax on CXR
blunting of hte costophrenic angle on upright radiograph
-supine might make the 1L look hazy
what is the most hazardous component of a helicopter
tail rotor = 2000rpm
load passenters into a helicoper while it is running
hot loading
how to approach a helicopter on a hill
approach/depart from downhill in crouched ppsition
how to appreach a helicopter w/brades running
crouched psition
wind gusts may drop blades to choulder level
when do helicopter blades flap down
startup/shutdown at lower speeds
wind gusts
speed of helicopter blades
main rotor = 400rpm
rotor tips=500rpm
helicopter shopping
if a company declines a mission do to a factor like weather, LZ availability…safety, other agencies approached must be told about why they were refused
tactical breathing
targeted reduction in HR/stress during acute stress
“box breathing”: breathe in 4 seconds, hold 4 sec, exhale 4 sec,
regulates SNS surge and keeks HR range for the situation
bandwith for aviation related communication
GVHF 118-136mHz
mHZ of radio signal bandwith that follows a straight line
very high frequency low band FM
20-50mHz
very high frequency (high band versus low band FM)
high band (148-174mhz) = straight line low band (30-50): follows the curvature of the earth
radio that follows the curvature of hte earth
very high frequency low band FM (30-50mHz)
warning sign if you are near a downed power line
- lower extremity tingle signals energized groun
- current enters throu one foot, pases through lwoer body, leaves thorugh the other foot
- INtervention: bend one leg at knee, grasp the foot of that leg with one hand, turn around, and hop to a safe place on one foot (purposeP to ensrue the body does not complete a circiut between secitons of the round energized w/different voltages
- similarily, don’t leave a vehilce until conductions that are either touching or surrounding teh wreckage can be denergerized
important thing to remember about downed aircraft if military
avoid front/rear b/c externally mounted tanks or pods b/c they may be containers for missles or rockets
awareness when extracating pt from car
don’t mechanically dispalce/cut through the sterign columnb until the system has been deactivated
some airbags may take 30min to deploy
basic principle of extrication from car
remove vehicle from around vicftim, not victim rrom vehicle
trigger for flicker vertigo
sunlight flickers through the rotor blades of helicpoper/airplane propeller or via the rotating beacons agaisnt overcast sky
worst case presentaiton of decompression sickness
coma
basic of what happens in decompression sickness
supersaturated tissue w/N
immediate inte4rvention for rapid decompression
100% oxyten
oxyten on yourwelf the4n pt
descend to 10K ft
s/s of slow decompression
gradual. s/s same as hypoxai. cool
check cabin altometer
tactical military aircraft
don’t use isobaric b/c added wt severely limits aircraft range and the large prssure differential increases the danger of rapid decompression during combat situations
pressurization of commercial panes
pressurize to 5-8K ft when aircraft ascends to 40K ft
plane nose up/down
yaw
plane nose fore-aft
roll
plane nose right-left
pitch
3 directional planes for a plane’s nose
roll = longitudinal (fore/aft)
pitch- lateral (R-L)
yaw= verticle (up/down)
3rd law motion
for every action there is an equal and opposite reaciton
first law of motion
law of intertia (stay at rest)(
mass
measure of the intertia of an object. its resistance to acceleration
acceleration
rate of change of velocity of an object
vector cquality
3 examples of vector quantities
acceleration
velocity
force
velocity
rate(magnitude) of a chance of distance for an object to rravel
vector quality
1Hz = __
cycle per sec
effect of hypothermia
increases metabolic rate, energy needs, oxygen consuption
relationship in temperature and altitude
temp decrease by 1C for ever 330ft increase in altitude
flying post surgery
24-48hr b/c insufflation
G tube not clampted
fly post dental work
72hr
tooth pain during flight
ascent
helps with descent
tooth pain during descent
usually barosinusitis
barodontalgia (toothpain) on ascent
help tooth pain in flight
worse w/ascent
decent relief
how to prevent ear block during flight
valsalva
delayed ear block during flight
breathing 100% oxygten during flight. aas ear clears during descent, 100% oxygen is forced into middle ear cavity. pt may be symptom free immediately after flight but they will have ear pain from negative pressure in the cavity if the oxygen in the middle ear isn’t repalce w/air
Politzer bag
helps w/ear block
-olive tip is placed in one nostril, the nose is compressed between the air medical crew member’s fingers, pt is instructed to say “kick, kick kick” while the bag is wqueezed, increasing the pressure in the nasopharhygeal caivyt to the point at which teh suschacian tube is opend and the middle ear is ventilated
intervention for ear block whikle flying
mild vasoC spray to vasoC
higher altitude until symptomo lessens
flying when you have a cold/upper respiratory issue
-monitor closely during ascent/descent for swollen eustachian tube which interfers w/normal equalizaiton pressure
should pt be awake or asleep during descent
awake so they can clear their ears in a normal manner to prevent ear block
ear blcok
failure of middle ear space to ventilate when going from high to low
0pressure in the middle ear becomes increasingly negative
-tympanic membraen is depressed inward and becomes inflammed/petechial hemorrhage
why shouldln’t you chew gum while fying
gum chewing is not recommended as a method of pressure equalization bc/ it causes swallowing of air, cuasing gastric distension and discomfort
pop ear on descent
yawn valsalva swallow move lower jaw BVM topical vasoconstrictors
how to correct hypoxia when altitude is over 40K
cannot be corrected wo addition of positive pressure
cyanosis as a sign of hypoxia
cyanosis is unreliable as a sign of hypoxia b/c SpO2 must be below 75% in people w/normal hgb before it is deteched
consider if pt has tunnel vision
hypoxia
er if pt ha a change in judgment or behavior
hypoxai
