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N934 Advanced Principles II - Christine > Trauma > Flashcards

Trauma Flashcards

1
Q

trauma is the leading cause of death between ____ years of age in the US

A

1-45

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2
Q

receiving care at a level 1 trauma center reduces mortality from unintentional injury by ____%

A

25%

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3
Q

what are the 3 sequential components of evaluation?

A

rapid overview, primary survey, secondary survey

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4
Q

rapid overview determines

A

if the patient is stable or unstable and should be completed within a matter of seconds

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5
Q

inability to oxygenate can lead to brain injury and death within

A

5-10 minutes

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6
Q

primary survey involves

A

rapid evaluation for functions crucial to survival (ABCDE)

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7
Q

ABCDE stands for

A

airway patency, breathing, circulation, disability, and exposure

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8
Q

secondary survey involves

A

a detailed and systematic evaluation of each anatomic region and continued resuscitation if needed

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9
Q

things to consider/look for in terms of breathing

A

high oxygen flow, trachea midline, flail chest, tension pneumothorax, massive hemothorax

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10
Q

if someone is agitated think ….

A

hypoxia!

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11
Q

What are the 3 “responses” we assess using the glasgow coma score?

A

eye opening response, verbal response, and motor response

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12
Q

Eye opening response scoring using GCS

A 
4= spontaneous
3= to speech
2= to pain
1= none
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13
Q

verbal response scoring using GCS

A 
5 = orientated to name
4= confused
3= inappropriate speech
2= incomprehensible sounds
1= none
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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
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15
Q

if GCS is less than 8…

A

intubate!

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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

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17
Q

the secondary survey begins after ___

A

critical life saving actions have begun (intubation, chest tube placement, fluid resuscitation)

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18
Q

the focus for the secondary survey is

A

history of injury, allergies, medications, last oral intake, focused medical and surgical history

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19
Q

airway evaluation involves the diagnosis of

A

trauma to the airway and surrounding tissue

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20
Q

what should we assume when contemplating airway management maneuvers

A

the patient absolutely requires an airway and cannot be re-awakened electively

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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

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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

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23
Q

if someone has an active bleeding airway what equipment may not be the best option to use?

A

fiberoptic

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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

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25
Q

what is a contraindication for nasal intubation

A

basilar skull fracture

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26
Q

signs of a basilar skull fracture

A

battle sign, racoon eyes, leaking of blood or csf from ears

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27
Q

indications for ETT intubation

A

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

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28
Q

tracheotomy vs cricothyroidotomy

A

tracheotomy - takes longer, requires neck extension

cricothyroidotomy - contraindicated in kids <12 years old, laryngeal damage

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29
Q

how long can a cricothyrotomy be left in place?

A

up to 72 hours

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30
Q

what is not a definitive airway?

A

LMA

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31
Q

full stomach is a consideration for

A

all trauma patients and impacts airway intervention

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32
Q

high suspicion for cervical injury if victim has experienced

A

a fall, MVA, diving accident

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33
Q

to rule out cervical injury

A

complete xray C1-C7 and patient not obtunded or under the influence of drugs to confirm no neck pain

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34
Q

what is the most desirable airway management for cervical injury

A

oral tracheal intubation

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35
Q

patients with head, open eye, or major vessel injuries can present with ____ without sufficient depth of anesthesia

A

hypertension, coughing/bucking, increased ICP, IOP, intravascular pressure

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36
Q

maxillofacial injuries and airway management

A

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

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37
Q

a penetrating injury causing a cervical airway injury the damage depends on 3 interactive factors including

A

type of wounding instrument, velocity at time of impact, characteristics of tissue through which it passes

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38
Q

clinical signs of penetrating injury include

A

escape of air, hemoptysis, and coughing

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39
Q

blunt injuries causing a cervical airway injury includes

A

direct impact, deceleration, shearing, and rotary forces

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40
Q

clinical signs of blunt injury includes

A

hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain and tenderness, flattening of the thyroid cartilage

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41
Q

airway management of a cervical airway injury

A

intubation of the trachea should be with a fiberoptic scope or airway should be established surgically

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42
Q

factors that alter respiration and interfere with breathing and pulmonary gas exchange after trauma include

A

tension pneumothorax, flail chest, open pneumothorax, hemothorax, pulmonary contusion, diaphragmatic rupture, chest wall splinting

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43
Q

hemothorax hallmark symptoms

A

hypotension, hypoxemia, tachycardia, increased CVP

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44
Q

3 types of pneumothorax

A

simple, communicating, and tension

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45
Q

treatment of pneumothorax

A

chest tube is pneumothorax is >20%

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46
Q

hallmark symptoms of tension pneumothorax

A

hypotension, hypoxemia, tachycardia, increased CVP, diminished breath sounds on the affected side

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47
Q

flail chest results from

A

comminuted fractures of at least 3 ribs, rib fractures associated with costrochondral separation, sternal fracture

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48
Q

most common cause of traumatic hypotension and shock in trauma patients is

A

hemorrhage

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49
Q

shock causing circulatory failure leads to

A

inadequate vital organ perfusion and oxygen delivery

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50
Q

resuscitation refers to

A

the restoration of normal circulating blood volume, normal vascular tone, and normal tissue perfusion

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51
Q

physiologic initial response to shock

A

hypotension leads to vasoconstriction and catecholamine release, heart, kidney, and brain blood flow is preserved while other regional beds are constricted

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52
Q

ischemic cells respond to hemorrhage by

A

taking up interstitial fluid and depleting intravascular volume and producing lactate and free radicals

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53
Q

inadequate organ perfusion interferes with

A

aerobic metabolism leading to lactic acid production and metabolic acidosis

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54
Q

lactate and free radicals can cause

A

direct damage to cells, and a toxic load that will be washed into circulation once re-established

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55
Q

hormones that are released in response to pain/hemorrhage

A

renin/angiotensin, vasopressin, ADH, growth hormone, glucagon, cortisol, epi/norepi

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56
Q

CNS response to shock

A

responsible for maintaining blood flow to the heart, kidney, and brain at expense of other tissue

57
Q

Kidney/adrenal response to shock

A

maintains GF during hypotension by selective vasoconstriction and concentration of blood flow in medulla and deep cortical areas

58
Q

heart response to shock

A

preserved via an increase in nutrient blood flow and cardiac function until later stages

59
Q

lung response to shock

A

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
Q

gut/intestinal response to shock

A

one of the earliest organs affected by hypo-perfusion and may be a trigger for MOSF

61
Q

acute traumatic coagulopathy begins

A

in the early presence of reduced clot strength

62
Q

patho behind acute traumatic coagulopathy

A

hypotension and tissue injury –> inflammatory response –> endothelial activation of protein c –> hyperfibrinolysis

63
Q

base deficit reflects

A

the severity of shock, oxygen debt, changes in O2 delivery, adequacy of fluid resuscitation, likelihood of multi-organ failure

64
Q

base deficit in mild shock

A

2-5 mmol/L

65
Q

base deficit in moderate shock

A

6-14 mmol/L

66
Q

base deficit in severe shock

A

greater than 14 mmol/L

67
Q

admission base deficit of _____ mmol/L correlates with increased mortality

A

5-8

68
Q

blood lactate level is less specific than ____

A

base deficit

69
Q

elevated lactate correlates to

A

hypoperfusion

70
Q

normal plasma lactate level

A

0.5-1.5 mmol/L

71
Q

half life of plasma lactate

A

3 hours

72
Q

plasma lactate greater than ___ mmol/L indicates significant lactic acidosis

A

5

73
Q

failure to clear lactate within ___ hours after reversal of shock is predictor of _____

A

24; increased mortality

74
Q

what is an accurate marker of systemic perfusion but is difficult to obtain?

A

mixed venous oxygenation

75
Q

symptoms of shock

A

pallor, diaphoresis, agitation or obtundation, hypotension, tachycardia, prolonged capillary refill, diminished urine output, narrowed pulse pressure

76
Q

goals for early resuscitation

A

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
Q

risks of aggressive volume replacement during early resuscitation

A

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
Q

anesthesia resuscitation goals

A

oxygenate and ventilate, restore organ perfusion, restore homeostasis/repay oxygen debt, treat coagulopathy, restore the circulating volume, continuous monitoring of the response

79
Q

surgery resuscitation goals

A

stop the bleed

80
Q

goals for late resuscitation

A

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
Q

end point for resuscitation

A

serum lactate level <2 mmol/L, base deficit <3, gastric intramucosal pH > 7.33

82
Q

what fluids can be used in fluid resuscitation?

A

isotonic crystalloids, hypertonic saline, colloids, prbcs, plasma

83
Q

how much can a rapid infuser system infuse fluids?

A

1,500 mL/min

84
Q

Rh ____ blood is preferable if crossmatch is not complete especially in women of childbearing age

A

negative

85
Q

2units of FFP with every ___ units of RBCs when massive transfusion is anticipated

A

4

86
Q

TXA

A

antifibrinolytic

is of benefit when given within one hour of admission

87
Q

a fluid inflation system/rapid infuser is compatible with

A

crystalloid, colloid, prbcs, washed salvaged blood, and plasma

88
Q

lethal triad

A

acidosis, hypothermia, coagulopathy

89
Q

hypothermia worsens

A

acid base disorders, coagulopathy, myocardial function, shifts oxyhemoglobin curve to the LEFT, decreases the metabolism of lactate, citrate and some anesthetics

90
Q

hypothermia causes vaso____

A

vasoconstriction

BP may drop as patient warms

91
Q

activation of the clotting cascade in the trauma patient causes

A

consumption of clotting factors

92
Q

severely injured trauma patients become

A

hypocoagulable

93
Q

at 29 degrees C PT and PTT

A

increase 50%

94
Q

at 29 degrees C platelets

A

decrease 40%

95
Q

surgical priorities in trauma patients (most important to least)

A

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
Q

significant abnormalities on the neurological exam are an indication for

A

immediate cranial CT

97
Q

the goal of care after TBI is

A

the prevention of a secondary brain damage resulting from intracranial bleeding, edema, increased ICP, and hypoxia and shock

98
Q

mild TBI

A

GCS 13-15

short period of observation (24 hours)

99
Q

moderate TBI

A

GCS 9-12
manifested as intracranial lesions that require surgical evacuation
early CT
high potential for deterioration requires early intubation and mechanical ventilation

100
Q

severe TBI

A

GCS <8
significant rate of mortality
care is directed at perfusion of injured brain

101
Q

Severe TBI guidelines

A

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
Q

TBI airway and ventilatory management

A

hyperventilation only if herniation is imminent

hyperventilate to PaCO2 of 30 if increased ICP is not responsive to other modalities

103
Q

anesthetic management of TBI

A

early control of airway
establishing cardiovascular stability
use low concentrations of volatile anesthetics
avoid nitrous oxide

104
Q

mannitol dosing

A

0.25- 1 g/kg

105
Q

where do most spinal cord injuries occur?

A

at the low cervical spine

106
Q

outcome of the spinal cord injury patient depends on 3 factors

A

severity of the acute injury, prevention of exacerbation of the injury during rescue, transport, and hospitalization, and avoidance of hypoxia and hypotension

107
Q

autonomic hyperreflexia develops in

A

85% of spinal cord injury patients with complete injury above T5

108
Q

emergency intubation considerations for spinal cord injury

A

100% oxygen, simple chin lift with manual in line stabilization, avoid extension, flexion, and rotation

109
Q

awake fiberoptic intubation considerations for spinal cord injury

A

oral vs nasal

oral is challenging but better if the patient requires postop ventilation

110
Q

orthopedic types of injuries

A

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
Q

why does a dislocated hip need to be fixed urgently

A

can develop avascular necrosis of the femoral head

112
Q

fractured pelvis requires ____ and are at high risk of ___

A

stabilization; bleeding (T&C for 4 units)

113
Q

long bone fractures are high risk for

A

DVT

114
Q

advantages of regional anesthesia

A 
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
Q

disadvantages of regional anesthesia

A

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
Q

advantages of general anesthesia

A

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
Q

disadvantages of general anesthesia

A

impairment of neurological examination
requires airway instrumentation
hemodynamic management more complex
increased potential for barotrauma

118
Q

types of chest injuries

A

pulmonary, traumatic aortic injury, rib fractures, cardiac injury

119
Q

management of pulmonary injuries

A

chest tube, thoracotomy, double lumen tube (after initial intubation via RSI with standard ETT)

120
Q

Thoracotomy indication(s)

A
  • 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
Q

traumatic aortic injury

A

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
Q

anesthetic treatment for traumatic aortic injury

A

include partial bypass technique using inflow from the left atrium, a centrifugal pump and outflow to descending aorta

123
Q

most common area for aortic injury

A

distal to left subclavian artery (most immobile part of aorta)
happens with side impact (T bone)
chance of rupture is high

124
Q

rib fractures are

A

the most common injury from blunt chest trauma

125
Q

flail chest

A

comminuted fractures of at least 3 ribs
characterized by paradoxical respiration
consider pain management or epidural placement to maintain ventilation/perfusion

126
Q

cardiac injury

A

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
Q

management of cardiac injury

A

as ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances
get cardiology consult

128
Q

Jehovah’s witness considerations

A

deliberate hypotension
use of cell saver may be accepted by patient
early hemodynamic monitoring
postop use of erythropoietin

129
Q

elderly considerations

A

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
Q

pregnancy considerations

A

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
Q

criteria for extubation postop

A

mental status, airway anatomy and reflexes, respiratory mechanics, systemic stability

132
Q

criteria for extubation mental status considerations

A

resolution of intoxication, able to follow commands, non-combative, pain adequately controlled

133
Q

criteria for extubation airway anatomy and reflexes considerations

A

appropriate cough and gag, ability to protect airway from aspiration, no excessive airway edema or instability

134
Q

criteria for extubation respiratory mechanics considerations

A

adequate tidal volume and respiratory rate
normal motor strength
required FiO2 less than 50%

135
Q

criteria for extubation systemic stability considerations

A

adequately resuscitated
small likelihood of urgent return to the operating room
normovolemic (no signs of sepsis)

136
Q

risk factors for development of ARDS after trauma

A

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
Q

recommended vent settings in acutely injured patients

A 
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
Q

postoperative complication concerns

A

infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS

N934 Advanced Principles II - Christine (3 decks)

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