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(HGC) ACNP804 Exam 5 > Trauma > Flashcards

Trauma Flashcards

1
Q

Trimodal distribution of peak incidence of trauma mortality

A

1) Prehospital: devastating head, vascular injuries
2) Minutes to hours after ED arrival: major head, chest, abdominal injuries
3) ICU: SIRS, sepsis, multi-system organ failure

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2
Q

Characteristics of Level 1 Trauma Centers

A

1) 24 hr availability of surgeons in all specialties
2) 24 hr availability of neuroradiology & hemodialysis
3) Program to establish & monitor effect of injury prevention & education efforts
4) Organized trauma research program

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3
Q

Two-person spinal stabilization technique

A

1) One provider devotes undivided attention to maintaining in-line immobilization & preventing excessive movement of c-spine
2) One provider manages the airway

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4
Q

Which trauma patients might need intubation?

A

Comatose

Agitated

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5
Q

What should we remember about nasal airways re: head trauma?

A

Don’t put a nasal airway in a suspected basilar skull fracture! Don’t put ANYTHING in the nose of a suspected basilar skull fracture! That’s gonna go in their BRAAAAAAIN!

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6
Q

5 NEXUS criteria for omitting cervical spinal imaging

A

If the patient meets ALL of the following, there is little need for c-spine imaging:

1) No posterior midline c-spine tenderness
2) No evidence of intoxication
3) Alert mental status
4) No focal neurologic deficits
5) No painful distracting injuries
* *Failure to meet any one criterion indicates need for c-spine imaging**

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7
Q

The Canadian c-spine rule:

A

1) High risk factor that mandates radiography (Age ≥ 65 or dangerous mechanism or paresthesias in extremities)? If yes, radiography. If no, move on to 2.
2) Any low-risk factor that allows safe assessment of ROM (simple rear end MVC, sitting position in the ED, ambulatory at any time, delayed onset of neck pain, absence of midline c-spine tenderness? If no, radiography. If yes, move on to 3.
3) Able to rotate neck actively? 45º L and R. If no, radiography. If yes, CONGRATS! NO RADIOGRAPHY!

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8
Q

Plain radiography may miss how many fractures?

A

Up to 15% of all c-spine fractures

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9
Q

Class I Hemmorhage

A 
Blood loss: Up to 750
Blood loss %: Up to 15%
Pulse (bpm): < 100
BP: Normal
Pulse pressure: Normal or increased
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10
Q

Class II Hemmorhage

A 
Blood loss: 750-1500
Blood loss %: 15-30%
Pulse (bpm): 100-120
BP: Normal
Pulse pressure: Decreased
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11
Q

Class III Hemmorhage

A 
Blood loss: 1500-2000
Blood loss %: 30-40%
Pulse (bpm): 120-140
BP: Decreased 
Pulse pressure: Decreased
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12
Q

Class IV Hemmorhage

A 
Blood loss: > 2000
Blood loss %: > 40%
Pulse (bpm): > 140
BP: Decreased
Pulse pressure: Decreased
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13
Q

Suspect intraperitoneal bleeding or pericardial tamponade? What exam are we gonna use?

A

FAST exam! “Focused assessment with sonography for trauma”

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14
Q

Penetrating trauma patient already in shock: rush them to OR or not?

A

Yes! “Consensus that early operative intervention in patients experiencing penetrating trauma who are in shock results in better outcomes” (Tintinalli)

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15
Q

Colloids versus crystalloids?

A

“Three decades of study have failed to demonstrate an advantage of colloid therapy over crystalloid infusion.” (Tintinalli)

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16
Q

If you need to do a subclavian stick on a trauma patient, where should you stick?

A

Most often is best to stick the same side as the injury if possible

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17
Q

Remember if you see a “Fuzzy Image” upon X-Ray…

A

…may be a hint to look for a vascular injury

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18
Q

Penetrating injuries such as a bullet often require what sort of surgery?

A

Exploratory, to track pattern of injury

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19
Q

True or false: In an adult in a blunt trauma, the degree of hematuria may not necessarily be associated with the degree of injury.

A

True

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20
Q

True or false: a Glasgow coma scale of 15 excludes the possibility of traumatic brain injury.

A

False.

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21
Q

Principal efforts in brain-injured patients should…

A

…be directed toward resuscitation to maintain normal cerebral perfusion.

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22
Q

Traumatic brain injury (TBI) is defined as…

A

…impairment in brain function as a result of mechanical force.

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23
Q

How is TBI classified?

A

Based on clinical assessment of a patient’s level of consciousness with little or no regard to the actual underlying injury.

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24
Q

What might result from the way TBI is classified?

A

Two patients might have the same TBI classification despite dramatically different pathophysiology.

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25
Q

What categories are TBI currently classified into?

A

Based on the Glasgow Coma Scale:

1) Mild: GCS of 14-15
2) Moderate: GCS of 9-13
3) Severe: GCS of 3-8

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26
Q

Three primary goals of management for patients with moderate to severe TBI

A

1) Prevent further secondary brain injury
2) Identify treatable mass lesions
3) Identify other life-threatening injuries

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27
Q

Ways to prevent secondary brain injury:

A 
Correcting or preventing:
1) hypoxemia
2) hypotension
3) anemia
4) hyperglycemia
5) hyperthermia
and
6) evacuating intracranial masses
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28
Q

Some studies have shown worse outcomes when TBI patients are intubated in the pre-hospital setting. What is one reason this might be?

A

Postintubation hyperventilation during transport.

DO NOT HYPERVENTILATE YOUR PATIENT. Their brains don’t like that.

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29
Q

When taking a history of TBI:

A

1) Reconstruct mechanism of injury to determine potential severity
2) Assess for extracranial injuries
3) Obtain details of mechanism of injury
4) Patient’s condition before & after the trauma
5) Medical history & meds (especially anticoags!)
6) Intoxication
7) Symptoms after the injury: nausea, vomiting, headache, memory impairment, visual/auditory symptoms

Symptom checklists are helpful! Acute Concussion Evaluation, ED version v 1.4 is recommended

30
Q

The goal of ED resuscitation in TBI…

A

…is to prevent secondary insult and potentially slow the expansion of the underlying injury.

31
Q

Which TBI patients require prompt airway control?

A

Severe TBI, or GCS ≤ 8

32
Q

In-line cervical spine stabilization should be maintained until…

A

…c-spine injury is definitively excluded.

33
Q

What are the recommended agents for rapid-sequence intubation in TBI cases?

A

Induction: etomidate & propofol

Neuromuscular blockers: succinylcholine & rocuronium

34
Q

What are the benefits of etomidate for intubation in TBI patients?

A

1) Rapid onset (45 seconds)
2) Short duration of action (3-5 minutes)
3) Good hemodynamic profile

May have neuroprotective properties & reduce ICP. Continuous infusions may cause adrenal suppression, but single dose does not.

35
Q

What are the benefits of propofol for intubation in TBI patients?

A

1) Rapid onset & recover
2) Strong anti-seizure properties

Boluses CAN cause hypotension & it should be used with caution in patients with labile BP or inadequate fluid resuscitation.

36
Q

What are the benefits of succinylcholine & rocuronium for intubation in TBI patients?

A

Short acting! Extended paralysis is not recommended first tier for elevated ICP (only refractory). Long-term paralysis impedes neurologic exams, limits the ability to detect changes in neuro status, and may increase risk of pneumonia.

37
Q

What is arguably the most important secondary insult in TBI patients?

A

Hypotension & subsequent ischemia of vulnerable & injured neuronal tissue can exacerbate the underlying secondary cascade & lead to expansion of injury & worse outcomes.

38
Q

Due to the importance of maintaining adequate perfusion pressure:

A

Aggressive fluid resuscitation may be required to prevent hypotension & secondary brain injury.

39
Q

But if we throw a ton of fluid at our TBI patient, aren’t we going to increase ICP?

A

No! Adequate fluid resuscitation does not increase ICP, & guidelines recommend an SBP > 90.

40
Q

What are the recommendations for MAP in a TBI patient?

A

There are no official ones, but most studies in the guidelines recommend MAP > 80.

41
Q

What is “relative hypotension”?

A

A concept often overlooked in TBI. It is normal-range BP, but still too low to adequately perfuse the injured brain.

42
Q

Hypertension is an important finding in a TBI patient. Why?

A

If it’s not because of inadequate pain control, it could be an indicator of Cushing reflex, which is increased ICP in a patient with head injury.

43
Q

The “neurologic vital sign”

A

The Glasgow Coma Scale

44
Q

The GCS interpretation can be complicated by:

A

1) intoxicants
2) sedating therapies
3) evolution of the patient’s condition

45
Q

New Orleans Head CT Clinical Decision Rules

A

GCS 15

  • Headache
  • Vomiting
  • Age >60 years
  • Intoxication
  • Persistent antegrade amnesia
  • Evidence of trauma above clavicles
  • Seizure

Presence of any one finding indicates need for CT scan

46
Q

Canadian Head CT Clinical Decision Rules

A

GCS 13-15

  • GCS < 15 at 2 hours
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture
  • > 1 episode of vomiting
  • Retrograde amnesia > 30 minutes
  • Dangerous mechanism (fall > 3 ft, pedestrian vs MV)
  • Age ≥65 years
47
Q

The New Orleans & Canadian Head CT decision rules do not apply to what groups?

A

1) People taking anticoags
2) Children

These populations were excluded from validation studies

48
Q

The New Orleans & Canadian Heat CT studies found that certain elements of the H&P have relatively more significance. What is one?

A

Nausea & vomiting have significance comparable to loss of consciousness re: a positive CT finding.

49
Q

Indications for head CT in mild TBI without loss of consciousness

A 
#GCS < 15
#Focal neurologic findings
#Vomiting > 2 times
#Moderate to severe headache
#Age > 65 years
#Physical signs of basilar skull fracture
#Coagulopathy
#Dangerous mechanism of injury (e.g. fall > 4 ft)
50
Q

Indications for head CT in mild TBI with loss of consciousness or amnesia

A 
#Intoxication (drug or ETOH)
#Physical evidence above clavicles
#Persistent amnesia
#Post-traumatic seizures
51
Q

An ICP of [what value] increases subsequent morbidity & mortality?

A

> 20

52
Q

Indicators of increased ICP

A 
#Headache
#Nausea/vomiting
#Seizure
#Lethargy
#Hypertension
#Bradycardia
#Agonal respirations
53
Q

Indicators of impending transtentorial herniation

A

DANGER, WILL ROBINSON!

#Unilateral or bilateral pupillary dilation
#Hemiparesis
#Motor posturing
#Progressive neurologic deterioration (declining GCS scores)

I am hoping you didn’t have to be told ANY of those.

54
Q

When a TBI patient does have signs/symptoms of ICP, what can be done to lower it in the ED?

A 
#Ventilation to maintain PaCO2 at 35-40 & O2 sat at > 95%
#Adequate sedation (helps with relaxation & prevention of gagging on ET tube)
#HOB at > 30 to increase CSF outflow (reverse Trendelenberg is nice)
#Stop & prevention of seizures
#Mannitol for patients who are not hypotensive
55
Q

Mannitol considerations

A 
#Osmotic diuretic that can reduce ICP, improve cerebral blood flow
#Reduces ICP in 30 minutes
#Expands plasma volume
#Initially reduces hypotension
#Some authors advocate starting at low end of range
#Net intravascular volume loss bc it's a DIURETIC, so monitor I&O.
56
Q

Scalp lacerations are important because

A

they can cause some SERIOUS blood loss!

57
Q

Anyone suspected of having a skull fracture requires…

A

…a CT of the head. BIG SURPRISE.

58
Q

Skull fractures are categorized by

A

1) Location (basilar vs. skull convexity)
2) Pattern (linear, depressed, comminuted)
3) Open or closed

59
Q

Most common CT abnormality in patients with moderate to severe TBI?

A

Traumatic subarachnoid hemorrage

60
Q

What’s the best time frame for detecting traumatic subarachnoid hemorrage on CT?

A

6-8 hours post-injury

61
Q

Epidural hematoma

A

Blood collects in the potential space between skull & dura mater

62
Q

Epidural hematoma is usually shaped like what on CT?

A

Biconvex (football shaped)

63
Q

The key to reducing morbidity/mortality from epidural hematoma is…

A

…early recognition & evacuation!

64
Q

Subdural hematoma

A

Hematoma formation between the dura mater & arachnoid

65
Q

What causes a subdural hematoma?

A

Sudden acceleration-deceleration of brain parenchyma with tearing of the bridging veins. They collect more slowly than epidural hematoma because of venous origin.

66
Q

What 3 populations are at higher risk for acute subdural hematoma because of brain atrophy?

A 
#Elderly
#Alcoholics
#Children < 2 years old
67
Q

Help! I have a subdural hematoma! Is it acute or chronic?

A

Well, if it’s < 14 days from injury, it’s acute. If it’s been more than that, it’s chronic!

68
Q

Diffuse axonal injury

A

Disruption of axonal fibers in the white matter & brainstem caused by sudden deceleration.

69
Q

What are some causes of diffuse axonal injury?

A 
#Motor vehicle crashes
#Shaken baby syndrome
#Blunt trauma
70
Q

What are some hallmarks of diffuse axonal injury?

A 
#Edema can develop rapidly
#Can result in devastating, irreversible neuro deficits
71
Q

What are some treatments for diffuse axonal injury?

A 
They're very limited but we try to prevent secondary damage by:
#Reducing cerebral edema 
#Limiting pathologic increase in ICP

(HGC) ACNP804 Exam 5 (4 decks)

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