Trauma Flashcards
1
Q
trauma is the leading cause of death between ____ years of age in the US
A
1-45
2
Q
receiving care at a level 1 trauma center reduces mortality from unintentional injury by ____%
A
25%
3
Q
what are the 3 sequential components of evaluation?
A
rapid overview, primary survey, secondary survey
4
Q
rapid overview determines
A
if the patient is stable or unstable and should be completed within a matter of seconds
5
Q
inability to oxygenate can lead to brain injury and death within
A
5-10 minutes
6
Q
primary survey involves
A
rapid evaluation for functions crucial to survival (ABCDE)
7
Q
ABCDE stands for
A
airway patency, breathing, circulation, disability, and exposure
8
Q
secondary survey involves
A
a detailed and systematic evaluation of each anatomic region and continued resuscitation if needed
9
Q
things to consider/look for in terms of breathing
A
high oxygen flow, trachea midline, flail chest, tension pneumothorax, massive hemothorax
10
Q
if someone is agitated think ….
A
hypoxia!
11
Q
What are the 3 “responses” we assess using the glasgow coma score?
A
eye opening response, verbal response, and motor response
12
Q
Eye opening response scoring using GCS
A
4= spontaneous 3= to speech 2= to pain 1= none
13
Q
verbal response scoring using GCS
A
5 = orientated to name 4= confused 3= inappropriate speech 2= incomprehensible sounds 1= none
14
Q
motor response scoring using GCS
A
6= follows commands 5= localizes to painful stimuli 4= withdraws from painful stimuli 3= abnormal flexion (decorticate) 2= abnormal extension (decerebrate) 1= none
15
Q
if GCS is less than 8…
A
intubate!
16
Q
What does “exposure” mean in our ABCDE primary survey steps?
A
removal of clothing and log rolling the patient to examine posterior side
looking for visible injuries or deformities head to toe
17
Q
the secondary survey begins after ___
A
critical life saving actions have begun (intubation, chest tube placement, fluid resuscitation)
18
Q
the focus for the secondary survey is
A
history of injury, allergies, medications, last oral intake, focused medical and surgical history
19
Q
airway evaluation involves the diagnosis of
A
trauma to the airway and surrounding tissue
20
Q
what should we assume when contemplating airway management maneuvers
A
the patient absolutely requires an airway and cannot be re-awakened electively
21
Q
most trauma patients require ____ (regarding airway)
A
assisted or controlled ventilation, self inflating bag with a nonrebreathing valve is sufficient after intubation and for transport, and 100% oxygen is necessary until ABG is complete
22
Q
airway obstruction considerations
A
edema, direct injury, cervical deformity, cervical hematoma, foreign body, dyspnea, hoarseness, stridor, dysphonia, subcutaneous emphysema, hemoptysis, bleeding, tracheal deviation, JVD
23
Q
if someone has an active bleeding airway what equipment may not be the best option to use?
A
fiberoptic
24
Q
what are considerations after placing a nasal airway?
A
nasotracheal tubes are smaller and increase resistance, puts at risk of sinusitis
needs to be changed sooner rather than later
25
what is a contraindication for nasal intubation
basilar skull fracture
26
signs of a basilar skull fracture
battle sign, racoon eyes, leaking of blood or csf from ears
27
indications for ETT intubation
cardiac or respiratory arrest, respiratory insufficiency, airway protection, need for deep sedation or analgesia, GCS <8, delivery of 100% FiO2 in carbon monoxide poisoning, facilitate work up in an uncooperative or intoxicated patient, transient hyperventilation required
28
tracheotomy vs cricothyroidotomy
tracheotomy - takes longer, requires neck extension
| cricothyroidotomy - contraindicated in kids <12 years old, laryngeal damage
29
how long can a cricothyrotomy be left in place?
up to 72 hours
30
what is not a definitive airway?
LMA
31
full stomach is a consideration for
all trauma patients and impacts airway intervention
32
high suspicion for cervical injury if victim has experienced
a fall, MVA, diving accident
33
to rule out cervical injury
complete xray C1-C7 and patient not obtunded or under the influence of drugs to confirm no neck pain
34
what is the most desirable airway management for cervical injury
oral tracheal intubation
35
patients with head, open eye, or major vessel injuries can present with ____ without sufficient depth of anesthesia
hypertension, coughing/bucking, increased ICP, IOP, intravascular pressure
36
maxillofacial injuries and airway management
blood and debris may predispose the patient to complete or partial airway obstruction
aspiration
airway compromise can occur within a few hours of trauma
limit mandibular movement
37
a penetrating injury causing a cervical airway injury the damage depends on 3 interactive factors including
type of wounding instrument, velocity at time of impact, characteristics of tissue through which it passes
38
clinical signs of penetrating injury include
escape of air, hemoptysis, and coughing
39
blunt injuries causing a cervical airway injury includes
direct impact, deceleration, shearing, and rotary forces
40
clinical signs of blunt injury includes
hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain and tenderness, flattening of the thyroid cartilage
41
airway management of a cervical airway injury
intubation of the trachea should be with a fiberoptic scope or airway should be established surgically
42
factors that alter respiration and interfere with breathing and pulmonary gas exchange after trauma include
tension pneumothorax, flail chest, open pneumothorax, hemothorax, pulmonary contusion, diaphragmatic rupture, chest wall splinting
43
hemothorax hallmark symptoms
hypotension, hypoxemia, tachycardia, increased CVP
44
3 types of pneumothorax
simple, communicating, and tension
45
treatment of pneumothorax
chest tube is pneumothorax is >20%
46
hallmark symptoms of tension pneumothorax
hypotension, hypoxemia, tachycardia, increased CVP, diminished breath sounds on the affected side
47
flail chest results from
comminuted fractures of at least 3 ribs, rib fractures associated with costrochondral separation, sternal fracture
48
most common cause of traumatic hypotension and shock in trauma patients is
hemorrhage
49
shock causing circulatory failure leads to
inadequate vital organ perfusion and oxygen delivery
50
resuscitation refers to
the restoration of normal circulating blood volume, normal vascular tone, and normal tissue perfusion
51
physiologic initial response to shock
hypotension leads to vasoconstriction and catecholamine release, heart, kidney, and brain blood flow is preserved while other regional beds are constricted
52
ischemic cells respond to hemorrhage by
taking up interstitial fluid and depleting intravascular volume and producing lactate and free radicals
53
inadequate organ perfusion interferes with
aerobic metabolism leading to lactic acid production and metabolic acidosis
54
lactate and free radicals can cause
direct damage to cells, and a toxic load that will be washed into circulation once re-established
55
hormones that are released in response to pain/hemorrhage
renin/angiotensin, vasopressin, ADH, growth hormone, glucagon, cortisol, epi/norepi
56
CNS response to shock
responsible for maintaining blood flow to the heart, kidney, and brain at expense of other tissue
57
Kidney/adrenal response to shock
maintains GF during hypotension by selective vasoconstriction and concentration of blood flow in medulla and deep cortical areas
58
heart response to shock
preserved via an increase in nutrient blood flow and cardiac function until later stages
59
lung response to shock
destination of inflammatory byproducts which will accumulate in capillary beds and result in ARDS
it is the sentinel organ for the development of MOSF
60
gut/intestinal response to shock
one of the earliest organs affected by hypo-perfusion and may be a trigger for MOSF
61
acute traumatic coagulopathy begins
in the early presence of reduced clot strength
62
patho behind acute traumatic coagulopathy
hypotension and tissue injury --> inflammatory response --> endothelial activation of protein c --> hyperfibrinolysis
63
base deficit reflects
the severity of shock, oxygen debt, changes in O2 delivery, adequacy of fluid resuscitation, likelihood of multi-organ failure
64
base deficit in mild shock
2-5 mmol/L
65
base deficit in moderate shock
6-14 mmol/L
66
base deficit in severe shock
greater than 14 mmol/L
67
admission base deficit of _____ mmol/L correlates with increased mortality
5-8
68
blood lactate level is less specific than ____
base deficit
69
elevated lactate correlates to
hypoperfusion
70
normal plasma lactate level
0.5-1.5 mmol/L
71
half life of plasma lactate
3 hours
72
plasma lactate greater than ___ mmol/L indicates significant lactic acidosis
5
73
failure to clear lactate within ___ hours after reversal of shock is predictor of _____
24; increased mortality
74
what is an accurate marker of systemic perfusion but is difficult to obtain?
mixed venous oxygenation
75
symptoms of shock
pallor, diaphoresis, agitation or obtundation, hypotension, tachycardia, prolonged capillary refill, diminished urine output, narrowed pulse pressure
76
goals for early resuscitation
SBP 80-100 mmHg, Hct 25-30%, PTT and PT in normal range, plt count >50,000, normal serum ionized calcium, core temp >35, function of pulse ox, prevent increase in lactate, prevent worsening acidosis, adequate anesthesia/analgesia
77
risks of aggressive volume replacement during early resuscitation
increased blood pressure, decreased blood viscosity, decreased hematocrit, decreased clotting factor concentration, greater transfusion requirement, disruption of electrolyte balance, direct immune suppression, premature reperfusion
78
anesthesia resuscitation goals
oxygenate and ventilate, restore organ perfusion, restore homeostasis/repay oxygen debt, treat coagulopathy, restore the circulating volume, continuous monitoring of the response
79
surgery resuscitation goals
stop the bleed
80
goals for late resuscitation
SBP >100 mmHg, maintain Hct above individual transfusion threshold, normalize coagulation, electrolytes, and body temp, restore urine output, maximize cardiac output, reverse systemic acidosis, document decrease in lactate
81
end point for resuscitation
serum lactate level <2 mmol/L, base deficit <3, gastric intramucosal pH > 7.33
82
what fluids can be used in fluid resuscitation?
isotonic crystalloids, hypertonic saline, colloids, prbcs, plasma
83
how much can a rapid infuser system infuse fluids?
1,500 mL/min
84
Rh ____ blood is preferable if crossmatch is not complete especially in women of childbearing age
negative
85
2units of FFP with every ___ units of RBCs when massive transfusion is anticipated
4
86
TXA
antifibrinolytic
| is of benefit when given within one hour of admission
87
a fluid inflation system/rapid infuser is compatible with
crystalloid, colloid, prbcs, washed salvaged blood, and plasma
88
lethal triad
acidosis, hypothermia, coagulopathy
89
hypothermia worsens
acid base disorders, coagulopathy, myocardial function, shifts oxyhemoglobin curve to the LEFT, decreases the metabolism of lactate, citrate and some anesthetics
90
hypothermia causes vaso____
vasoconstriction
| BP may drop as patient warms
91
activation of the clotting cascade in the trauma patient causes
consumption of clotting factors
92
severely injured trauma patients become
hypocoagulable
93
at 29 degrees C PT and PTT
increase 50%
94
at 29 degrees C platelets
decrease 40%
95
surgical priorities in trauma patients (most important to least)
airway management (cricothyroidotomy), control of exsanguinating hemorrhage, intracranial mass excision, threatened limb or eyesight, high risk of sepsis, control of ongoing hemorrhage, early patient mobilization, better cosmetic outcome
96
significant abnormalities on the neurological exam are an indication for
immediate cranial CT
97
the goal of care after TBI is
the prevention of a secondary brain damage resulting from intracranial bleeding, edema, increased ICP, and hypoxia and shock
98
mild TBI
GCS 13-15
| short period of observation (24 hours)
99
moderate TBI
GCS 9-12
manifested as intracranial lesions that require surgical evacuation
early CT
high potential for deterioration requires early intubation and mechanical ventilation
100
severe TBI
GCS <8
significant rate of mortality
care is directed at perfusion of injured brain
101
Severe TBI guidelines
maintain CPP 50-70, keep euvolemic, correct anemia, PaCO2 35, insertion of ventri and control ICP, positional therapy, judicious use of analgesics and sedation, mannitol, hypertonic saline
102
TBI airway and ventilatory management
hyperventilation only if herniation is imminent
| hyperventilate to PaCO2 of 30 if increased ICP is not responsive to other modalities
103
anesthetic management of TBI
early control of airway
establishing cardiovascular stability
use low concentrations of volatile anesthetics
avoid nitrous oxide
104
mannitol dosing
0.25- 1 g/kg
105
where do most spinal cord injuries occur?
at the low cervical spine
106
outcome of the spinal cord injury patient depends on 3 factors
severity of the acute injury, prevention of exacerbation of the injury during rescue, transport, and hospitalization, and avoidance of hypoxia and hypotension
107
autonomic hyperreflexia develops in
85% of spinal cord injury patients with complete injury above T5
108
emergency intubation considerations for spinal cord injury
100% oxygen, simple chin lift with manual in line stabilization, avoid extension, flexion, and rotation
109
awake fiberoptic intubation considerations for spinal cord injury
oral vs nasal
| oral is challenging but better if the patient requires postop ventilation
110
orthopedic types of injuries
isolated closed
open fractures of major long bones and joints
multiple fractures of major long bones, spinal column, and joints associated with multisystem injuries
111
why does a dislocated hip need to be fixed urgently
can develop avascular necrosis of the femoral head
112
fractured pelvis requires ____ and are at high risk of ___
stabilization; bleeding (T&C for 4 units)
113
long bone fractures are high risk for
DVT
114
advantages of regional anesthesia
```
allows for continued mental status assessment
increased vascular flow
avoidance of airway instrumentation
improved postop mental status
decreased blood loss
decreased incidence of DVT
improved postop analgesia
better pulmonary toilet
earlier mobilization
```
115
disadvantages of regional anesthesia
peripheral nerve function difficult to assess
patient refusal is common
requirement for sedation
longer time to achieve anesthesia
not suitable for multiple body regions
difficult to judge length of surgical procedures
116
advantages of general anesthesia
speed of onset
duration can be maintained as long as needed
allows multiple procedures for multiple injuries
greater patient acceptance
allows for positive pressure ventilation
117
disadvantages of general anesthesia
impairment of neurological examination
requires airway instrumentation
hemodynamic management more complex
increased potential for barotrauma
118
types of chest injuries
pulmonary, traumatic aortic injury, rib fractures, cardiac injury
119
management of pulmonary injuries
chest tube, thoracotomy, double lumen tube (after initial intubation via RSI with standard ETT)
120
Thoracotomy indication(s)
- if drainage greater than 1500 mL in first several hours
- when tracheal or bronchial injury or massive air leak
- hemodynamic instability from thoracic injury
121
traumatic aortic injury
high incidence of morbidity and mortality
must be ruled out if patient has suffered a high energy injury such MVA or fall
diagnosis is made through CXR, angiography, CT and TEE
surgery is indicated due to high risk of rupture in hours to days
endovascular repair is common
122
anesthetic treatment for traumatic aortic injury
include partial bypass technique using inflow from the left atrium, a centrifugal pump and outflow to descending aorta
123
most common area for aortic injury
distal to left subclavian artery (most immobile part of aorta)
happens with side impact (T bone)
chance of rupture is high
124
rib fractures are
the most common injury from blunt chest trauma
125
flail chest
comminuted fractures of at least 3 ribs
characterized by paradoxical respiration
consider pain management or epidural placement to maintain ventilation/perfusion
126
cardiac injury
penetrating trauma (high pre-hospital mortality)
cardiac tamponade
bruising or contusion is functionally indistinguishable from MI
TTE or TEE can be used to diagnosis
127
management of cardiac injury
as ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances
get cardiology consult
128
Jehovah's witness considerations
deliberate hypotension
use of cell saver may be accepted by patient
early hemodynamic monitoring
postop use of erythropoietin
129
elderly considerations
more serious outcomes in the elderly for equivalent trauma
decreased cardiopulmonary reserve higher incidence of postop mechanical ventilation
multiorgan system failure after hemorrhagic shock
post traumatic myocardial dysfunction
130
pregnancy considerations
high incidence of spontaneous abortion, preterm labor, or premature delivery
OB consult for immediate management and follow up
requires rapid and complete resuscitation of the mother
left lateral uterine displacement
131
criteria for extubation postop
mental status, airway anatomy and reflexes, respiratory mechanics, systemic stability
132
criteria for extubation mental status considerations
resolution of intoxication, able to follow commands, non-combative, pain adequately controlled
133
criteria for extubation airway anatomy and reflexes considerations
appropriate cough and gag, ability to protect airway from aspiration, no excessive airway edema or instability
134
criteria for extubation respiratory mechanics considerations
adequate tidal volume and respiratory rate
normal motor strength
required FiO2 less than 50%
135
criteria for extubation systemic stability considerations
adequately resuscitated
small likelihood of urgent return to the operating room
normovolemic (no signs of sepsis)
136
risk factors for development of ARDS after trauma
elderly, preexisting physiologic impairment, direct pulmonaryy or chest wall injury, aspiration of blood or stomach contents, prolonged mechanical ventilation, severe traumatic brain injury, spinal cord injury with quadriplegia, massive transfusion, hemorrhagic shock, occult hypoperfusion, wound or body cavity infection
137
recommended vent settings in acutely injured patients
```
tidal volumes 6-8 mL/kg
PEEP 10-15 cm H2O
limit peak pressures to < 40 cm H2O
adjust I:E ratio as necessary
wean FiO2 to obtain PaO2 of 80-100 (sats 93-97%)
```
138
postoperative complication concerns
infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS
