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NUNA 692 Principles III > trauma > Flashcards

trauma Flashcards

1
Q

trauma is leading cause of _______ for those ________ years old

A

death
<40 years old

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2
Q

modern trauma system has replaced ________ leading to improved outcomes

A

“community care model”

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3
Q

_______ _______ _________ Committee on trauma developed accreditation standards

A

American College of Surgeons (ACS) Committee

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4
Q

the course developed by the ACS was:

A

Advanced Trauma Life Support (ATLS)

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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

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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

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7
Q

blunt trauma is defined as:

A

direct impact with abrupt deceleration, continuous pressure, and shearing/rotational forces

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8
Q

most common blunt trauma is from

A

MVAs and falls

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9
Q

after a blunt trauma, assume what?

A

unstable C-spine until confirmed OTW

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10
Q

Thoracic blunt trauma is usually from _______/______ _________, and 40% have _______

A

MVA/steering wheel, and 40% have a pneumothorax

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11
Q

thoracic blunt trauma PTX may not be visible on:

A

up to 50% are not visible on radiographic imaging

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12
Q

what anesthetic gas should be avoided with blunt trauma

A

N2O - until we can confirm there is no free air anywhere

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13
Q

blunt trauma thoracic associated structures:

A

lungs, airway, heart, major vessels

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14
Q

tension PTX symptoms:

A

hypotension, sub-cu emphysema, unilaterally decreased breath sounds, decreased chest wall motion, distended neck veins, tracheal shift

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15
Q

tension PTX can appear or worsen quickly with institution of ________ __________

A

mechanical ventilation

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16
Q

emergent relief of tension PTX

A
  • emergent needle aspiration at 2nd intercostal space (above the 3rd rib), MCL
  • chest tube ASAP
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17
Q

blunt/thoracic trauma can cause:

A

pericardial tamponade

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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
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19
Q

Pericardial tamponade induction

A

EXTREME caution with induction - ketamine is a good choice

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20
Q

massive hemothorax

A

(from heart and great vessels)
chest tube insertion after fluid resuscitation

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21
Q

cardiac rupture

A

rapid exsanguination

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22
Q

aortic rupture

A

complete rupture is usually fatal

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23
Q

tracheal injury

A

decrease incidence of trauma center arrival since most die at the scene - OTW, intubate, perform tracheostomy, surgical repair.

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24
Q

most airway injuries are located

A

below the carina - confirmed with bronchoscopy or CT

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25
Q

penetrating trauma - early repair is

A

necessary for life-saving measures

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26
Q

penetrating trauma - staged Damage Control Surgery (DCS)

A
  • immediate surgical control of bleeding
  • prevent the “lethal triad”: acidosis, hypothermia, coagulopathy
  • limit crystalloids, increase use of FFP, platelets, and PRBCs
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27
Q

DCS examples:

A
  • abdominal packing
  • external fixators
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28
Q

bedside technique to assess for internal bleeding

A

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

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29
Q

3 major assumption with airway

A
  1. no turning back
  2. full stomach
  3. C-spine concerns
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30
Q

airway RSI

A

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

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31
Q

breathing - 70% of chest traumas include

A

pulmonary contusions and may progress to ARDS

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32
Q

breathing dilemma: decreased ________ and need for increased __________ vs _____________ with worsening disease

A

compliance
PiPs
barotrauma

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33
Q

breathing/ventilation options

A

HFJV, oscillators, CP bypass

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34
Q

breathing/ventilation goals: (3)

A
  1. decreased Vt
  2. decreased PiP (<32 cm H2O)
  3. avoid O2 toxicity
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35
Q

Circulation - 35% of trauma deaths are d/t ________ and most are __________

A

hemorrhage
coagulopathic

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36
Q

vascular shunting from low to high metabolic areas causes ______ _________ which leads to inadequate ____________ and ___________ metabolism, causing cellular injury and toxins

A

eventual decompensation
perfusion
anaerobic

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37
Q

The “Golden Hour”

A

young male Vietnam victims survived hemorrhagic shock if perfusion was restored within 60 minutes

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38
Q

hemorrhagic shock stage 1

A

(nonprogressive or compensated)
blood volume normalized by shifting fluids

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39
Q

hemorrhagic shock stage II

A

(progressive)
CV depression d/t ischemia, thrombosis, toxins, cellular damage

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40
Q

hemorrhagic shock stage III

A

(irreversible)
ATP depleted cellular death

2 substages

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41
Q

2 substages of hemorrhagic shock stage III

A
  1. acute irreversible: massive hemorrhage leading to death
  2. sub-acute irreversible: significant shock/cellular injury leading to multi-organ failure/death over time
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42
Q

hemorrhagic shock 2008 ATLS

A

for minimal bleeding, 2 L crystalloid then blood components for greater blood loss

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43
Q

hemorrhagic shock treatment 2013 ATLS

A

1 L crystalloid with early blood products

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44
Q

increased fluids can:

A

cause worsening clinical picture

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45
Q

hypotensive resuscitation - minimize bleeding by maintaining SBP of _____-_____ mmHg, bleeding is controlled when ___________ and ____________

A

85-90
SBP>100 and HR<100

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46
Q

trauma IV access/fluids - vasoconstriction may necessitate a

A

CVL

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47
Q

CVL should be placed:

A

above the diaphragm when available

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48
Q

replace EBL with _______, ________

A

1:1 PRBCs
3:1 crystalloid

49
Q

colloids cause rapid restoration BUT they

A

increase risk of pulmonary edema and bleeding

50
Q

_____ _______ best for perfusion

A

isotonic crystalloids

51
Q

avoid ________ except in peds

A

glucose

52
Q

maintain BG < ____ mg/dL for suspected TBI/cerebral edema

A

150

53
Q

Coagulopathy - majority of survivors of initial injury are

A

coagulopathic at death

54
Q

elevated PT on admission =

A

massive hemorrhage, injury and poor perfusion state

55
Q

Trauma Induced Coagulopathy (TIC) (4 things)

A
  1. dilution
  2. hypothermia & acidosis
  3. TBI
  4. Shock
56
Q

coagulopathy - damage control resuscitation (DCR) factors

A
  • DCS
  • rewarming
  • restricted crystalloids
  • permissive hypotension
  • balanced transfusion
  • massive transfusion protocol
57
Q

Until targeted transfusion is available, empirically transfuse:

A
  • 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
Q

(TIC) most trauma patients NOT _______ on arrival

A

hypothermic

59
Q

hypothermia probably alters _______ fxn and decreases _______ formation

A

platelet fxn
fibrin formation

60
Q

1 degree C drop leads to ________________

A

5% drop in clotting reactions

61
Q

during trauma resuscitation,

A

warm EVERYTHING

62
Q

(TIC) acidosis (pH< ____) + hypothermia leads to __________

A

7.1
significant coagulopathy

63
Q

pH 7.2 decreases

A

clotting fxn to 50%

64
Q

pH of 6.8 leads to

A

clotting fxn of 20%

65
Q

NaHCO3 not effective for

A

clotting fxn

66
Q

TBI and shock lead to

A

T-T complex

67
Q

T-T complex =

A

thrombin + thrombomodulin

68
Q

T-T complex leads to ________________ which inhibits _______ and promotes ________

A

activated protein C (APC) pathway
inhibits V and VIII
promotes fibrinolysis

69
Q

result of the activated protein C pathway

A

systemic anticoagulation

70
Q

MTP assessment of blood consumption (ABC) questionnaire score:

A

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
Q

MTP is valuable but

A

expensive and labor intensive

72
Q

_____ decreases risk of death in trauma patient greater than or equal to ____ years old without an increase in _________ ______.

A

TXA
16 years old
thrombotic events

73
Q

TXA for greater than 12 years old

A

1 gm bolus followed by 1 gm over 8 hours

74
Q

TXA less than 12 years old

A

15 mg/kg bolus followed by 2 mg/kg/hr for 8 hours

75
Q

TXA must be administered at

A

less than 3 hours post-injury

76
Q

CRASH 3: TXA is safe for ________

A

TBI patients

77
Q

code red pack A

A

6U PRBCs, 4U FFP

78
Q

code red pack B

A

6U PRBCs, 4U FFP, 1U Plt, 2 cryo pools

79
Q

Disability - neuro, intubate GCS

A

< 8

80
Q

awake intubation is dangerous bc

A

increased ICPs and possible herniation

81
Q

ICP clinical targets

A

IC HTN = ICP > 10, treat if ICP > 25 mmHg

82
Q

maintain MAP at __________ to maintain CPP at __________

A

70-75 mmHg
> 50 mmHg

83
Q

PaCO2 clinical target

A

moderate hyperventilation - PaCO2 of 30-35 mmHg

84
Q

EVD for:

A

monitoring and venting

85
Q

disability - all volatiles are OK, avoid _____, ______, and ________

A

N2O (risk of air embolus)
ketamine (increase ICP)
etomidate (adrenal suppression)

86
Q

for increased ICP, consider incremental ________, moderate _________, __________, __________, head elevation

A

propofol
moderate hyperventilation
mannitol
furosemide
head elevation

87
Q

steroids are _____________ for increased ICP

A

not effective

88
Q

TREAT ALL TRAUMA PATIENTS AS ___________ INJURED UNTIL PROVEN OTHERWISE

A

C-SPINE

89
Q

succinylcholine during

A

acute phase

90
Q

fasciculations can worsen

A

SCIs

91
Q

after several days, up-regulations can cause

A

potentially lethal hyperkalemia

92
Q

spinal shock triad

A

hypotension
bradycardia
hypothermia

93
Q

______ and above leads to major CNS impairment

A

T6

94
Q

spinal shock causes loss of ____________, __________, decreased _____, heat ______, inability ________

A

cardiac accelerators
vasodilation
decreased CO
heat loss
inability to compensate

similar to “warm shock”

95
Q

_____________ is a MUST

A

arterial line is a must to guide pressor therapy

96
Q

assess spinal shock pts for

A

adequate ventilation

97
Q

anesthetic implications for SCI pts

A
  • 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
Q

autonomic hyperreflexia - massive ______ response d/t stimulus below ________

A

SNS response
below level of spinal injury (frequently related to bladder)

99
Q

most common with lesions above

A

T5

100
Q

autonomic hyperreflexia triad

A

hypertension, bradycardia, dysrhythmias

101
Q

AH seen after ______ and can occur during _______/_________ GA or regional anesthesia. (NOT seen with _________)

A

spinal shock phase
N2O/opioid
volatile agents

102
Q

HTN crisis can lead to ______, _______, __________. Treat with direct acting _______ (_________, __________)

A

seizures, IVH, MI
treat with direct acting vasodilators (nitroprusside, hydralazine)

103
Q

ortho major risks -

A

hemorrhage
shock
fat emboli
PE emboli (esp with pelvic/long bones)

104
Q

ortho procedures - hypoxic respiratory failure can happen d/t

A

continuous fat emboli and are usually repaired early

105
Q

treat ortho as

A

full stomach

106
Q

ABCDEs: E =

A

environment, exposure, examination

107
Q

junctional trauma

A

injury to areas “junctional” to the trunk (pelvis, groin, perineum, axilla, neck)

108
Q

JT is non-_______ leading to _____-______

A

non-compressible leading to life-threatening hemorrhage

109
Q

increase in JTs d/t improvised explosives

A

(non-metal)

110
Q

________ of Iraq and Afghanistan combat casualties were potentially survivable JTs

A

21%

111
Q

abdominal aortic and junctional tourniquet

A

circumferential abdominal strap with inflatable bladder that compresses the aorta at the umbilical level

112
Q

REBOA

A

resuscitative endovascular occlusion of the aorta

113
Q

the patient survived, now what?

A
  • 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
Q

despite better treatment, critically injured patients requiring emergent surgery = _______

A

50% mortality

115
Q

despite improved hemorrhage control, many die but NOT from

A

exsanguination

116
Q

most intra-op deaths d/t

A

hyperkalemia, hypocalcemia, acidosis

117
Q

later post-op death d/t multi-organ failure

A

early: CV failure
later: PIICS (persistent inflammatory immunosuppressed catabolic syndrome)*******

118
Q

research needs:

A

better understanding of trauma-specific hyperacute immune response

NUNA 692 Principles III (20 decks)

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