trauma Flashcards
1
Q
trauma is leading cause of _______ for those ________ years old
A
death
<40 years old
2
Q
modern trauma system has replaced ________ leading to improved outcomes
A
“community care model”
3
Q
_______ _______ _________ Committee on trauma developed accreditation standards
A
American College of Surgeons (ACS) Committee
4
Q
the course developed by the ACS was:
A
Advanced Trauma Life Support (ATLS)
5
Q
ABCDE’s of trauma care
A
A - airway and oxygenation
B - breathing and ventilation
C - circulation and shock management
D - disability due to neurological deterioration
E - exposure and examination
6
Q
ATLS secondary survey
A
completed after primary survey and resuscitation and stabilization in progress
is a complete head-to-toe assessment including neurologic exam
7
Q
blunt trauma is defined as:
A
direct impact with abrupt deceleration, continuous pressure, and shearing/rotational forces
8
Q
most common blunt trauma is from
A
MVAs and falls
9
Q
after a blunt trauma, assume what?
A
unstable C-spine until confirmed OTW
10
Q
Thoracic blunt trauma is usually from _______/______ _________, and 40% have _______
A
MVA/steering wheel, and 40% have a pneumothorax
11
Q
thoracic blunt trauma PTX may not be visible on:
A
up to 50% are not visible on radiographic imaging
12
Q
what anesthetic gas should be avoided with blunt trauma
A
N2O - until we can confirm there is no free air anywhere
13
Q
blunt trauma thoracic associated structures:
A
lungs, airway, heart, major vessels
14
Q
tension PTX symptoms:
A
hypotension, sub-cu emphysema, unilaterally decreased breath sounds, decreased chest wall motion, distended neck veins, tracheal shift
15
Q
tension PTX can appear or worsen quickly with institution of ________ __________
A
mechanical ventilation
16
Q
emergent relief of tension PTX
A
- emergent needle aspiration at 2nd intercostal space (above the 3rd rib), MCL
- chest tube ASAP
17
Q
blunt/thoracic trauma can cause:
A
pericardial tamponade
18
Q
pericardial tamponade emergent treatment
A
- 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
19
Q
Pericardial tamponade induction
A
EXTREME caution with induction - ketamine is a good choice
20
Q
massive hemothorax
A
(from heart and great vessels)
chest tube insertion after fluid resuscitation
21
Q
cardiac rupture
A
rapid exsanguination
22
Q
aortic rupture
A
complete rupture is usually fatal
23
Q
tracheal injury
A
decrease incidence of trauma center arrival since most die at the scene - OTW, intubate, perform tracheostomy, surgical repair.
24
Q
most airway injuries are located
A
below the carina - confirmed with bronchoscopy or CT
25
penetrating trauma - early repair is
necessary for life-saving measures
26
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
27
DCS examples:
- abdominal packing
- external fixators
28
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
29
3 major assumption with airway
1. no turning back
2. full stomach
3. C-spine concerns
30
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
31
breathing - 70% of chest traumas include
pulmonary contusions and may progress to ARDS
32
breathing dilemma: decreased ________ and need for increased __________ vs _____________ with worsening disease
compliance
PiPs
barotrauma
33
breathing/ventilation options
HFJV, oscillators, CP bypass
34
breathing/ventilation goals: (3)
1. decreased Vt
2. decreased PiP (<32 cm H2O)
3. avoid O2 toxicity
35
Circulation - 35% of trauma deaths are d/t ________ and most are __________
hemorrhage
coagulopathic
36
vascular shunting from low to high metabolic areas causes ______ _________ which leads to inadequate ____________ and ___________ metabolism, causing cellular injury and toxins
eventual decompensation
perfusion
anaerobic
37
The "Golden Hour"
young male Vietnam victims survived hemorrhagic shock if perfusion was restored within 60 minutes
38
hemorrhagic shock stage 1
(nonprogressive or compensated)
blood volume normalized by shifting fluids
39
hemorrhagic shock stage II
(progressive)
CV depression d/t ischemia, thrombosis, toxins, cellular damage
40
hemorrhagic shock stage III
(irreversible)
ATP depleted cellular death
2 substages
41
2 substages of hemorrhagic shock stage III
1. acute irreversible: massive hemorrhage leading to death
2. sub-acute irreversible: significant shock/cellular injury leading to multi-organ failure/death over time
42
hemorrhagic shock 2008 ATLS
for minimal bleeding, 2 L crystalloid then blood components for greater blood loss
43
hemorrhagic shock treatment 2013 ATLS
1 L crystalloid with early blood products
44
increased fluids can:
cause worsening clinical picture
45
hypotensive resuscitation - minimize bleeding by maintaining SBP of _____-_____ mmHg, bleeding is controlled when ___________ and ____________
85-90
SBP>100 and HR<100
46
trauma IV access/fluids - vasoconstriction may necessitate a
CVL
47
CVL should be placed:
above the diaphragm when available
48
replace EBL with _______, ________
1:1 PRBCs
3:1 crystalloid
49
colloids cause rapid restoration BUT they
increase risk of pulmonary edema and bleeding
50
_____ _______ best for perfusion
isotonic crystalloids
51
avoid ________ except in peds
glucose
52
maintain BG < ____ mg/dL for suspected TBI/cerebral edema
150
53
Coagulopathy - majority of survivors of initial injury are
coagulopathic at death
54
elevated PT on admission =
massive hemorrhage, injury and poor perfusion state
55
Trauma Induced Coagulopathy (TIC) (4 things)
1. dilution
2. hypothermia & acidosis
3. TBI
4. Shock
56
coagulopathy - damage control resuscitation (DCR) factors
- DCS
- rewarming
- restricted crystalloids
- permissive hypotension
- balanced transfusion
- massive transfusion protocol
57
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
58
(TIC) most trauma patients NOT _______ on arrival
hypothermic
59
hypothermia probably alters _______ fxn and decreases _______ formation
platelet fxn
fibrin formation
60
1 degree C drop leads to ________________
5% drop in clotting reactions
61
during trauma resuscitation,
warm EVERYTHING
62
(TIC) acidosis (pH< ____) + hypothermia leads to __________
7.1
significant coagulopathy
63
pH 7.2 decreases
clotting fxn to 50%
64
pH of 6.8 leads to
clotting fxn of 20%
65
NaHCO3 not effective for
clotting fxn
66
TBI and shock lead to
T-T complex
67
T-T complex =
thrombin + thrombomodulin
68
T-T complex leads to ________________ which inhibits _______ and promotes ________
activated protein C (APC) pathway
inhibits V and VIII
promotes fibrinolysis
69
result of the activated protein C pathway
systemic anticoagulation
70
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
71
MTP is valuable but
expensive and labor intensive
72
_____ decreases risk of death in trauma patient greater than or equal to ____ years old without an increase in _________ ______.
TXA
16 years old
thrombotic events
73
TXA for greater than 12 years old
1 gm bolus followed by 1 gm over 8 hours
74
TXA less than 12 years old
15 mg/kg bolus followed by 2 mg/kg/hr for 8 hours
75
TXA must be administered at
less than 3 hours post-injury
76
CRASH 3: TXA is safe for ________
TBI patients
77
code red pack A
6U PRBCs, 4U FFP
78
code red pack B
6U PRBCs, 4U FFP, 1U Plt, 2 cryo pools
79
Disability - neuro, intubate GCS
< 8
80
awake intubation is dangerous bc
increased ICPs and possible herniation
81
ICP clinical targets
IC HTN = ICP > 10, treat if ICP > 25 mmHg
82
maintain MAP at __________ to maintain CPP at __________
70-75 mmHg
> 50 mmHg
83
PaCO2 clinical target
moderate hyperventilation - PaCO2 of 30-35 mmHg
84
EVD for:
monitoring and venting
85
disability - all volatiles are OK, avoid _____, ______, and ________
N2O (risk of air embolus)
ketamine (increase ICP)
etomidate (adrenal suppression)
86
for increased ICP, consider incremental ________, moderate _________, __________, __________, head elevation
propofol
moderate hyperventilation
mannitol
furosemide
head elevation
87
steroids are _____________ for increased ICP
not effective
88
TREAT ALL TRAUMA PATIENTS AS ___________ INJURED UNTIL PROVEN OTHERWISE
C-SPINE
89
succinylcholine during
acute phase
90
fasciculations can worsen
SCIs
91
after several days, up-regulations can cause
potentially lethal hyperkalemia
92
spinal shock triad
hypotension
bradycardia
hypothermia
93
______ and above leads to major CNS impairment
T6
94
spinal shock causes loss of ____________, __________, decreased _____, heat ______, inability ________
cardiac accelerators
vasodilation
decreased CO
heat loss
inability to compensate
similar to "warm shock"
95
_____________ is a MUST
arterial line is a must to guide pressor therapy
96
assess spinal shock pts for
adequate ventilation
97
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
98
autonomic hyperreflexia - massive ______ response d/t stimulus below ________
SNS response
below level of spinal injury (frequently related to bladder)
99
most common with lesions above
T5
100
autonomic hyperreflexia triad
hypertension, bradycardia, dysrhythmias
101
AH seen after ______ and can occur during _______/_________ GA or regional anesthesia. (NOT seen with _________)
spinal shock phase
N2O/opioid
volatile agents
102
HTN crisis can lead to ______, _______, __________. Treat with direct acting _______ (_________, __________)
seizures, IVH, MI
treat with direct acting vasodilators (nitroprusside, hydralazine)
103
ortho major risks -
hemorrhage
shock
fat emboli
PE emboli (esp with pelvic/long bones)
104
ortho procedures - hypoxic respiratory failure can happen d/t
continuous fat emboli and are usually repaired early
105
treat ortho as
full stomach
106
ABCDEs: E =
environment, exposure, examination
107
junctional trauma
injury to areas "junctional" to the trunk (pelvis, groin, perineum, axilla, neck)
108
JT is non-_______ leading to _____-______
non-compressible leading to life-threatening hemorrhage
109
increase in JTs d/t improvised explosives
(non-metal)
110
________ of Iraq and Afghanistan combat casualties were potentially survivable JTs
21%
111
abdominal aortic and junctional tourniquet
circumferential abdominal strap with inflatable bladder that compresses the aorta at the umbilical level
112
REBOA
resuscitative endovascular occlusion of the aorta
113
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
114
despite better treatment, critically injured patients requiring emergent surgery = _______
50% mortality
115
despite improved hemorrhage control, many die but NOT from
exsanguination
116
most intra-op deaths d/t
hyperkalemia, hypocalcemia, acidosis
117
later post-op death d/t multi-organ failure
early: CV failure
later: PIICS (persistent inflammatory immunosuppressed catabolic syndrome)*********
118
research needs:
better understanding of trauma-specific hyperacute immune response
