trauma Flashcards
trauma is leading cause of _______ for those ________ years old
death
<40 years old
modern trauma system has replaced ________ leading to improved outcomes
“community care model”
_______ _______ _________ Committee on trauma developed accreditation standards
American College of Surgeons (ACS) Committee
the course developed by the ACS was:
Advanced Trauma Life Support (ATLS)
ABCDE’s of trauma care
A - airway and oxygenation
B - breathing and ventilation
C - circulation and shock management
D - disability due to neurological deterioration
E - exposure and examination
ATLS secondary survey
completed after primary survey and resuscitation and stabilization in progress
is a complete head-to-toe assessment including neurologic exam
blunt trauma is defined as:
direct impact with abrupt deceleration, continuous pressure, and shearing/rotational forces
most common blunt trauma is from
MVAs and falls
after a blunt trauma, assume what?
unstable C-spine until confirmed OTW
Thoracic blunt trauma is usually from _______/______ _________, and 40% have _______
MVA/steering wheel, and 40% have a pneumothorax
thoracic blunt trauma PTX may not be visible on:
up to 50% are not visible on radiographic imaging
what anesthetic gas should be avoided with blunt trauma
N2O - until we can confirm there is no free air anywhere
blunt trauma thoracic associated structures:
lungs, airway, heart, major vessels
tension PTX symptoms:
hypotension, sub-cu emphysema, unilaterally decreased breath sounds, decreased chest wall motion, distended neck veins, tracheal shift
tension PTX can appear or worsen quickly with institution of ________ __________
mechanical ventilation
emergent relief of tension PTX
- emergent needle aspiration at 2nd intercostal space (above the 3rd rib), MCL
- chest tube ASAP
blunt/thoracic trauma can cause:
pericardial tamponade
pericardial tamponade emergent treatment
- emergent pericardiocentesis
- needle inserted btwn the xiphoid process and L costal margin 30-45 degree angle
- aim for L mid-clavicle
- direct needle toward anterior wall of R ventricle
Pericardial tamponade induction
EXTREME caution with induction - ketamine is a good choice
massive hemothorax
(from heart and great vessels)
chest tube insertion after fluid resuscitation
cardiac rupture
rapid exsanguination
aortic rupture
complete rupture is usually fatal
tracheal injury
decrease incidence of trauma center arrival since most die at the scene - OTW, intubate, perform tracheostomy, surgical repair.
most airway injuries are located
below the carina - confirmed with bronchoscopy or CT
penetrating trauma - early repair is
necessary for life-saving measures
penetrating trauma - staged Damage Control Surgery (DCS)
- immediate surgical control of bleeding
- prevent the “lethal triad”: acidosis, hypothermia, coagulopathy
- limit crystalloids, increase use of FFP, platelets, and PRBCs
DCS examples:
- abdominal packing
- external fixators
bedside technique to assess for internal bleeding
FAST - Focused Assessment with Sonography in Trauma
- provides 4 different views (pericardiac, -hepatic, -splenic, -pelvic space)
- detects 100 mL of blood
- rapid, accurate
- cost effective
- eliminates need for unnecessary CT scans
- helps in management plan
3 major assumption with airway
- no turning back
- full stomach
- C-spine concerns
airway RSI
with paralytic
- manual in-line stabilization after front of C-collar removed
- no outcome difference between fiberoptic and direct laryngoscopy with in-line stabilization
- follow ASA algorithm (dont just go straight to cric)
have surgeon available for emergent tracheostomy
breathing - 70% of chest traumas include
pulmonary contusions and may progress to ARDS
breathing dilemma: decreased ________ and need for increased __________ vs _____________ with worsening disease
compliance
PiPs
barotrauma
breathing/ventilation options
HFJV, oscillators, CP bypass
breathing/ventilation goals: (3)
- decreased Vt
- decreased PiP (<32 cm H2O)
- avoid O2 toxicity
Circulation - 35% of trauma deaths are d/t ________ and most are __________
hemorrhage
coagulopathic
vascular shunting from low to high metabolic areas causes ______ _________ which leads to inadequate ____________ and ___________ metabolism, causing cellular injury and toxins
eventual decompensation
perfusion
anaerobic
The “Golden Hour”
young male Vietnam victims survived hemorrhagic shock if perfusion was restored within 60 minutes
hemorrhagic shock stage 1
(nonprogressive or compensated)
blood volume normalized by shifting fluids
hemorrhagic shock stage II
(progressive)
CV depression d/t ischemia, thrombosis, toxins, cellular damage
hemorrhagic shock stage III
(irreversible)
ATP depleted cellular death
2 substages
2 substages of hemorrhagic shock stage III
- acute irreversible: massive hemorrhage leading to death
- sub-acute irreversible: significant shock/cellular injury leading to multi-organ failure/death over time
hemorrhagic shock 2008 ATLS
for minimal bleeding, 2 L crystalloid then blood components for greater blood loss
hemorrhagic shock treatment 2013 ATLS
1 L crystalloid with early blood products
increased fluids can:
cause worsening clinical picture
hypotensive resuscitation - minimize bleeding by maintaining SBP of _____-_____ mmHg, bleeding is controlled when ___________ and ____________
85-90
SBP>100 and HR<100
trauma IV access/fluids - vasoconstriction may necessitate a
CVL
CVL should be placed:
above the diaphragm when available
replace EBL with _______, ________
1:1 PRBCs
3:1 crystalloid
colloids cause rapid restoration BUT they
increase risk of pulmonary edema and bleeding
_____ _______ best for perfusion
isotonic crystalloids
avoid ________ except in peds
glucose
maintain BG < ____ mg/dL for suspected TBI/cerebral edema
150
Coagulopathy - majority of survivors of initial injury are
coagulopathic at death
elevated PT on admission =
massive hemorrhage, injury and poor perfusion state
Trauma Induced Coagulopathy (TIC) (4 things)
- dilution
- hypothermia & acidosis
- TBI
- Shock
coagulopathy - damage control resuscitation (DCR) factors
- DCS
- rewarming
- restricted crystalloids
- permissive hypotension
- balanced transfusion
- massive transfusion protocol
Until targeted transfusion is available, empirically transfuse:
- PRBCs/plasma/platelets at a 1:1:1 unit infusion
- transfuse according to labs if possible
- ASA rec: maintain INR less than or equal to 1.5 and PLT count greater than 50,000
- TEG
(TIC) most trauma patients NOT _______ on arrival
hypothermic
hypothermia probably alters _______ fxn and decreases _______ formation
platelet fxn
fibrin formation
1 degree C drop leads to ________________
5% drop in clotting reactions
during trauma resuscitation,
warm EVERYTHING
(TIC) acidosis (pH< ____) + hypothermia leads to __________
7.1
significant coagulopathy
pH 7.2 decreases
clotting fxn to 50%
pH of 6.8 leads to
clotting fxn of 20%
NaHCO3 not effective for
clotting fxn
TBI and shock lead to
T-T complex
T-T complex =
thrombin + thrombomodulin
T-T complex leads to ________________ which inhibits _______ and promotes ________
activated protein C (APC) pathway
inhibits V and VIII
promotes fibrinolysis
result of the activated protein C pathway
systemic anticoagulation
MTP assessment of blood consumption (ABC) questionnaire score:
yes/no
- penetrating injury?
- SBP < 90?
- HR > 120?
- positive FAST?
a score greater than or equal to 2 means there is an increased risk of needing massive transfusion
MTP is valuable but
expensive and labor intensive
_____ decreases risk of death in trauma patient greater than or equal to ____ years old without an increase in _________ ______.
TXA
16 years old
thrombotic events
TXA for greater than 12 years old
1 gm bolus followed by 1 gm over 8 hours
TXA less than 12 years old
15 mg/kg bolus followed by 2 mg/kg/hr for 8 hours
TXA must be administered at
less than 3 hours post-injury
CRASH 3: TXA is safe for ________
TBI patients
code red pack A
6U PRBCs, 4U FFP
code red pack B
6U PRBCs, 4U FFP, 1U Plt, 2 cryo pools
Disability - neuro, intubate GCS
< 8
awake intubation is dangerous bc
increased ICPs and possible herniation
ICP clinical targets
IC HTN = ICP > 10, treat if ICP > 25 mmHg
maintain MAP at __________ to maintain CPP at __________
70-75 mmHg
> 50 mmHg
PaCO2 clinical target
moderate hyperventilation - PaCO2 of 30-35 mmHg
EVD for:
monitoring and venting
disability - all volatiles are OK, avoid _____, ______, and ________
N2O (risk of air embolus)
ketamine (increase ICP)
etomidate (adrenal suppression)
for increased ICP, consider incremental ________, moderate _________, __________, __________, head elevation
propofol
moderate hyperventilation
mannitol
furosemide
head elevation
steroids are _____________ for increased ICP
not effective
TREAT ALL TRAUMA PATIENTS AS ___________ INJURED UNTIL PROVEN OTHERWISE
C-SPINE
succinylcholine during
acute phase
fasciculations can worsen
SCIs
after several days, up-regulations can cause
potentially lethal hyperkalemia
spinal shock triad
hypotension
bradycardia
hypothermia
______ and above leads to major CNS impairment
T6
spinal shock causes loss of ____________, __________, decreased _____, heat ______, inability ________
cardiac accelerators
vasodilation
decreased CO
heat loss
inability to compensate
similar to “warm shock”
_____________ is a MUST
arterial line is a must to guide pressor therapy
assess spinal shock pts for
adequate ventilation
anesthetic implications for SCI pts
- prepare for difficult intubations
- awake FO, VL, DL with straight blade
- document all pre-op deficits
- prepare for heavy blood loss
- avoid sux for life (and N2O)
- consider ketamine, dexmedetomidine
autonomic hyperreflexia - massive ______ response d/t stimulus below ________
SNS response
below level of spinal injury (frequently related to bladder)
most common with lesions above
T5
autonomic hyperreflexia triad
hypertension, bradycardia, dysrhythmias
AH seen after ______ and can occur during _______/_________ GA or regional anesthesia. (NOT seen with _________)
spinal shock phase
N2O/opioid
volatile agents
HTN crisis can lead to ______, _______, __________. Treat with direct acting _______ (_________, __________)
seizures, IVH, MI
treat with direct acting vasodilators (nitroprusside, hydralazine)
ortho major risks -
hemorrhage
shock
fat emboli
PE emboli (esp with pelvic/long bones)
ortho procedures - hypoxic respiratory failure can happen d/t
continuous fat emboli and are usually repaired early
treat ortho as
full stomach
ABCDEs: E =
environment, exposure, examination
junctional trauma
injury to areas “junctional” to the trunk (pelvis, groin, perineum, axilla, neck)
JT is non-_______ leading to _____-______
non-compressible leading to life-threatening hemorrhage
increase in JTs d/t improvised explosives
(non-metal)
________ of Iraq and Afghanistan combat casualties were potentially survivable JTs
21%
abdominal aortic and junctional tourniquet
circumferential abdominal strap with inflatable bladder that compresses the aorta at the umbilical level
REBOA
resuscitative endovascular occlusion of the aorta
the patient survived, now what?
- multi-organ failure, ARDS, DIC, mechanical ventilation, sepsis
- may have repeated procedures and anesthetics
- transporting with ETTs, lines, infusions
- maintain continuum of care from the ICU to anesthesia care and then back to ICU as much as possible
despite better treatment, critically injured patients requiring emergent surgery = _______
50% mortality
despite improved hemorrhage control, many die but NOT from
exsanguination
most intra-op deaths d/t
hyperkalemia, hypocalcemia, acidosis
later post-op death d/t multi-organ failure
early: CV failure
later: PIICS (persistent inflammatory immunosuppressed catabolic syndrome)*******
research needs:
better understanding of trauma-specific hyperacute immune response
