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CCP > Trauma > Flashcards

Trauma Flashcards

1
Q

Top reasons for shock in trauma patients:

A
  1. ) Hypovolemia
  2. ) Hypovolemia
  3. ) Hypovolemia
  4. ) Obstructive (PTX, tamponade, ACS)
  5. ) Distributive (neurogenic/SCI)
  6. ) Cardiogenic (pts predisposed to HF can’t compensate)
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2
Q

Shock ABCs. What three things does Dr. Hameed consider when assessing ‘C.’

A
  • Is the patient in shock?
  • What type of shock is it?
  • How do I reverse this kind of shock?
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3
Q

What is the most reliable marker for end-organ perfusion?

A

Urine output

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4
Q

ATLS classifications for blood loss:

A

Class One: 0-15%, 750mL
Class Two: 15-30%, 750-1500mL (tachypnea, tachycardia)
Class Three: 30-40%, 1500-2L (decreased UO, DLOC, Low BP)
Class Four: 40% +, 2L +

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5
Q

What percent of patients with decreased EOP shock will have normal vital signs?

A

50%

Be sure to check the lactate/base deficit off either an arterial draw or CVC. Don’t use a VBG since it can be confounded by regional ischemia.

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6
Q

Populations that hide shock particularly well:

A
  • Obstetrics
  • Pediatrics
  • Beta Blockers
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7
Q

Increasing lactate levels in a trauma patient need to be cleared somehow. If the liver is shutting down, where does it go?

A

Tachypnea isn’t just a compensatory mechanism for decreased cardiac output. It’s an early sign in shock that lactate levels are increasing and need to be blown off.

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8
Q

A base deficit of lower than ______ is often the first sign of hypovolmeic shock.

A

-3

Lactate will start to increase. Hgb won’t begin to get ‘watered down’ for 1-2 hours post insult.

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9
Q

What do hematocrit/hemoglobin levels do in a rapidly exsangunating shock patient?

A

Stay the same. It takes time for fluid to be pulled from the extravascular space and cause hemodilution.

“If you throw out half a pitcher of Kool-aid, it still tastes just as sweet.”

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10
Q

What is the target Hgb for actively bleeding trauma patients?

A

100g/l

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11
Q

Not treating anemia has certain benefits. What are some advantages of anemic blood?

A

It has increased levels of 2-3DPG which causes a right shift of the oxyhemoglobin dissociation curve. It’s also less vicious so it travels through the capillaries more easily and is also less strain and MVO2 for the heart to pump.
Another detriment of blood transfusion is that it suppresses the immune system.

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12
Q

Would you expect a high/low/normal lactate in regional true ischemia such as ischemic gut?

A

Low/Normal.

Shock does not affect the body in a homogenous manner. The gut can become ischemic in which case there is no blood going in or out. No blood coming out means no lactate.

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13
Q

The liver can be affected early in the shock process since blood is first shunted away from the skin and gut. What lab values can help support a diagnosis of early shock?

A

AST and ALT could be elevated due to shock liver.

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14
Q

Three pieces of imaging that should be ordered on every trauma patient:

A
  • CXR
  • PXR
  • EFAST
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15
Q

What is a Morel-Lavallee lesion?

A

A closed degloving injury that shears open subcutaneous bridging vessels and presents as a boggy, hemolymphatic mass. (Think motorcyclist sliding on his back across pavement. This serious hemorrhage will not be seen on an EFAST)

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16
Q

What’s the harm with a tourniquet applied too loosely?

A

It will impair venous return but still allow arterial hemorrhage, thus making blood loss worse.

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17
Q

When it comes to the trauma triad of death, what interventions can be done to prevent worsening coagulopathy?

A
  • Avoid dilutional fluid resuscitation with crystalloids
  • Replace volume with a 1:1:1 ratio
  • Allow permissive hypotension in penetrating trauma
  • Keep pt warm
  • Oxygen
  • TXA
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18
Q

What 6 factors of shock physiology contribute to worsening coagulopathy?

A
  • Consumption of clotting factors
  • Hypothermia
  • Acidosis
  • Third spacing dilution
  • Shock liver
  • Fibrinolysis
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19
Q

What three patient populations are permissive hypotension contraindicated in?

A

TBI
SCI
Obstetrics

*Keep MAP > 80 but SBP < 160

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20
Q

Land marking for chest tube insertion:

A
  • Infamammary fold to between anterior and midaxillary line
  • Cut skin/adipose through to rib
  • Choke up on scalpel to prevent going to deep, then punch through to lung just superior to 5th rib.
  • Barbarically pull tissue away
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21
Q

What electrolytes must be monitored when transfusing large volumes of RBCs?

A

Ca++ (due to citrate in RBCs)

K+ (in case of lysis during storage)

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22
Q

Fibrinogen is one of the first clotting factors consumed during ongoing massive hemorrhage. How can you replace it?

A

Cryoprecipitate

  • fibrinogen
  • factor VII (extrinsic pathway)
  • factor VIII (intrinsic pathway)
  • von Willebrand factor
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23
Q

What is the future of guiding massive blood transfusions?

A

ROTEM

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24
Q

You’re treating a trauma patient and you set some parameters. One of them is to treat if the heart rate climbs over 110. Now you’re looking at a sinus tach of 111. The patient is in obvious pain and anxious about flying. Do you let it slide?

A

No! It is easy to write something off as non-serious, but if you don’t stay on top of a trauma patient, they will deteriorate quickly and you will be left scrambling.

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25
Q

What are the three neck zones?

A
  1. Clavicles to cricoid cartilage
  2. Cricoid to angles of mandibles
  3. Lateral neck, between the mandibles and the ears
26
Q

What is the platysma?

A

A sheath of muscle that separates the superficial structures of the neck from the underlying great vessels, trachea and esophagus. A penetrating wound than involves only the platysma is much less worrisome, except an expanding hematoma can still compromise the airway.

27
Q

S and S of airway compromise:

A
  • Whispering hoarseness/dysphonia
  • Difficulty swallowing/dysphagia
  • Anxiety
  • Increased WOB
  • Bubbles in the blood
28
Q

When it comes to burn patients, what is the single, strongest predictor of worsening airway and need to intubate:

A

A Hx of being in an enclosed space fire.

29
Q

Define MIST

A

Mechanism
Injuries found
Signs and symptoms
Treatments

30
Q

What are the three hallmark features of central cord syndrome:

A
  • Arm paralysis > leg paralysis
  • Bladder dysfunction
  • Sensory loss below injury site
31
Q

When you walk into an active resuscitation, what is one principle that can guide you in bringing order to the chaos?

A

Establish a clearly defined problem list and rank each problem. Focus on one task at a time, but delegate your team to help. Perform OODA loops to figure out if your interventions are appropriate.

32
Q

What are some complications that arise from burn victims?

A
  • Inhalation injuries
  • CO and CN poisoning
  • Fluid shift
  • Heat loss
  • Infection
  • Compartment syndrome
  • Associated injuries
33
Q

How does over fluid resuscitating a burn patient a detriment?

A

It can worsen compartment syndromes and cause pulmonary edema/hypoxemia.

34
Q

How do the thermal effects of an inhalation burn affect the lung parenchyma?

A
  • Actually, most thermal energy is absorbed by the terminal bronchioles (out of the gas exchange area). Burns mostly just affect the upper airway.
  • Pulmonary edema from fluid resuscitation and circulating inflammatory mediators can later cause CXR findings.
  • However, lung compliance can still suck if the patient has circumferential burns to their thorax.
35
Q

Treatment considerations for burn patients requiring extended OOH:

A
  • Esophageal balloon (High Plats)
  • Bladder pressure monitor (ACS)
  • Calcium and cortisol replacement
  • Escharotomy
  • Monitor lactate and ABGs frequently
  • Keep UO at 30-50mL/hr
  • Keep patient warm
36
Q

ACS is diagnosed when IAP exceeds 20mm/Hg and one of the following three are present…

A
  • Oliguria
  • Mesenteric ischemia
  • Hemodynamic instability
37
Q

The six leading causes of death associated to chest trauma are:

A
  • Tension PTX
  • Massive HTX (>1500mL of blood)
  • Open PTX
  • Cardiac tamponade
  • Airway obstruction
  • Flail chest
38
Q

Explain the pressure/volume relationship in the setting of pneumothorax:

A

The intrathoracic space can handle increases in volume quite well… Until it can’t. Once a certain volume is reached, small increases in volume will exponentially increase pressure.

39
Q

How much blood is associated with a “massive” HTX?

A

1500mL (ATLS Class III)

40
Q

What’s a thoracostomy?

A

A chest tube, or finger thoracostomy.

A thoracotomy is when they crack the entire chest.

41
Q

In the setting of penetrating trauma to the heart, what is the one ironic thing keeping some of these patients alive?

A

The bleeding into the pericardial space and resulting tamponade. Often, surgeons find that the myocardium has been clotted thanks to the pressure from the tamponade.

42
Q

Describe a common injury found in patients only wearing lap belts?

A

The seatbelt acts as a fulcrum and the lumbar spine bends over it causing a separation/distraction unstable fracture. Hollow-viscous organ bleeding is also associated with seatbelt injuries.

43
Q

What is the VGH ICU fluid resuscitation formula for burn patients in the first 24 hours?

A

3mL/kg x BSA

-Run the first half of the volume in over 8 hours and the rest over the remaining 16 hours.

44
Q

Common treatments for burn patients:

A
  • FiO2 of 1 and/or hydroxocobalamin
  • Ringer’s Lactate
  • Low dose levophed
  • Calcium and cortisol
  • ABx
  • Opioids PRN > infusion
45
Q

Nexus criteria for SMR

A
  1. Midline tenderness
  2. Distracting injury
  3. DLOC
  4. Focal neurological deficits
  5. Intoxicated
46
Q

What is the risk of using a paralytic when intubating a hypothermic patient?

A

-It will stop shivering and heat production

47
Q

Describe the relationship of oxygenation and assessing the need to intubate an SCI patient:

A

-Oxygenation is the last thing to go. Instead, look for whether C-5 is affected (use of Deltoids). Other markers include accessory muscle use (traps, SCMs) and paradoxical breathing. Vital capacity and oral secretion clearance can also be checked.

48
Q

Sympathetic innervation of the heart comes from T1-T5. What neurological finding can indicate that the patient is at risk for neurogenic shock?

A

Pinky splaying is controlled by T-1.

Patient can still suffer from vasodilation if the injury is below T-5, but won’t see changes in heart rate/contractility.

49
Q

Where must an esophageal temperature probe be located in order to get accurate core readings?

A

In the lower 1/3 of the esophagus (generally about 24cm below the larynx).

50
Q

Do warm IV fluids help improve core temperature?

A

Not really. If you put in 2L of 40 degree fluid into 30 degrees of 60L of TBW, it’s not going to change much.

51
Q

What is the second dose of TXA?

A

1g over 8 hours, within the first 24 hours from injury.

52
Q

What is an abnormal cardiovascular finding in some forms of carotid trauma?

A

Damage, ischemia or swelling of the carotid sinuses can cause bradycardia.

53
Q

Neck trauma. The patient is all stitched up, but starts becoming stridorous mid-transport. What do you do?

A

Intubation or cricothyrotomy could be a fucking nightmare! Instead, cut the sutures in the tight spots and control bleeding as best you can with direct pressure.

54
Q

Benefits of hypothermia on the brain:

A

Every degree drop below 35 causes a decrease in CBrVO2 by 10-20%!

55
Q

Permissive hypotension. Does it work the same for blunt and penetrating trauma?

A

No. Penetrating trauma is more often arterial and hypotension will decrease pressures and facilitate clotting better. Blunt trauma is more often venous hemorrhage and permissive hypotension risks damaging other organs.

56
Q

What percent of circulating volume do you generally lose before there are changes to blood pressure (adult).

A

40P

57
Q

Contraindications for TXA (according to Myp):

A
  • Hematuria
  • Seizures
  • Aneurysmal SAH
58
Q

As for trauma, what is one benefit of bypassing other trauma centres like LGH, to take patients the extra distance to VGH?

A

There is always an operating room and surgeon available at VGH. You roll the dice going to other hospitals and it may actually take longer to free up an OR and find a surgeon than if you just transported to VGH instead.

59
Q

According to the Blood Consumption Assessment score, what criteria must exist to initiate an MTP?

A

At least two of the following:

  • Penetrating trauma
  • SBP < 90
  • HR > 120
  • Positive FAST
60
Q

Damage control resuscitation

A

Use 1:1:1 to:

  • Hgb > 100
  • Plt > 80
  • INR < 1.5
  • Fib < 2.0
  • Ca++ > 1.0
  • While avoiding hypothermia and acidosis.

CCP (18 decks)

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