Trauma Flashcards
1
Q
What are the trauma statistics?
A
- 9% of total annual mortality
- 1.24 million traffic accident fatalities
- usually pedestriants, cyclists, and motorcyclists
- 1.5 million deaths d/t violence
- Most deaths d/t high energy mechanixm of injury
- 1.3 die within first 4 hours
- deaths d/t low energy impact higher after 7 days
- Leading cause of mortality is head trauma, 2nd is hemorrhagic shock
2
Q
What is the pathophysiology of hemorrhagic shock?
A
- Problem of supply vs demand: imbalance occurs between systemic O2 delivery and O2 consumption
- hemodynamic instability, coagulopathy, decreased O2 delivery, decreased tissue perfusion, and cellular hypoxia
- Initial response: macrocirculatory and mediated by neuroendocrine system
- release of: renin, antiotensin, vasopressin, ADH, GH, glucagon, cortisol, epinephrine, norepi
- renal and adrenal systems play major role in this
- this sets stage for the microcirculatory response
- release of: renin, antiotensin, vasopressin, ADH, GH, glucagon, cortisol, epinephrine, norepi
3
Q
What is the “ shock cascade?”
(flow chart)
A
- Ischemia in any part of body will trigger an inflammatory response that will affect the non-ischemic organs even after perfusion has been restored.
- individual ischemic cells respond to hemorrhage by taking up interstitial fluid, further depleting intravascular fluid
- cellular edema can block adjacent capillaries which prevents reversal of ischemia even with good macroperfusion
- Ischemic cells produce lactate–this washes back into central circulation and sets up for SIRS and Multi organ failure
4
Q
How does CNS system respond to Hemorrhagic shock?
A
- CNS is the prime trigger of the neuroendocrine response
- controls selective perfusion to heart, kidney, and brain
- reflexes and cortical electrical activity are both depressed (this is reversible in mild hypoperfusion)
5
Q
How does the cardiac system respond to hemorrhagic shock?
A
- Cardiac system is preserved from ischemia
- lactate, free radicals, and other humoral factors released by ischemic cells all act as negative inotropes
- Somebody with cardiac disease (esp fixed stroke volume) is at greater risk for decompensation d/t hypovolemia and anemia
- cardiac dysfunction is a LATE SIGN and often a terminal event
6
Q
How does the pulmonary system respond to hemorrhagic shock?
A
- The lungs are the filter for the inflammatory by-products of the ischemic cells in body.
- immunE complex and cellular factors accumulate in pulmonary capillaries and lead to neutrophil and platelet aggregation, increased capillary permeability, destruction of lung, and ARDS
7
Q
How does the renal system respond to hemorrhagic shock?
A
- Neuroendocrine response
- GFR maintained with selective vasoconstriction
- Prolonged hypotension affects the ability to concentrate urine
- also tubular epithelial necrosis and renal failure
8
Q
How does hemorrhagic shock affect the gut/intestines?
A
- One of first organs affected by hypoperfusion
- Intestinal cell death causes a breakdown in the barrier function of the gut that allows bacteria into the liver and lungs
- this potentiates ARDS
9
Q
How does the liver respond to hemorrhagic shock?
Skeletal muscles?
A
- Failure of synthetic function of the liver–cannot make things like coagulation factors
- this can be lethal
- Skeletal muscles
- tolerate ischemia better than other organs
- release lactic acid and free radicals that can potentiate the ARDS
10
Q
What are the steps for a Trauma assessment?
A
- Initial rapid assessment- is pt stable, unstable, or dead
- Primary survey: ABCDE
- ABC- airway patency, breathing, circulation
- D- disability: brief neurological examination
- E- expose: Undress and inspect for external injuries
- Must decide to proceed immediately to surery or continue on to secondary survey
- Secondary survey: detailed multi-system exam and history
- further diagnostic evaluation
11
Q
What are the details of ABCDE?
(flow chart)
A
12
Q
How is the airway managed for a trauma patient?
A
- Stabilize C-spine
- provide 100% FiO2 (until you have ABG)
- For obstruction if spontaneously breathing:
- Initial- chin lift, jaw thrust, suction, OPA (nasal ok, but avoid if any possibility pt has basilar skull fx or maxillofacial injury)
- Still inadequate- consider BMV or SGA
- Proceed to intubation
- awake vs RSI vs cricothyroidotomy
13
Q
How does the airway algorithm change when dealing with a trauma?
What is best choice?
A
- You do not have the option to awaken the patient if you cannot get the airway
- If something does not work, you MUST change something
- Best choice: RSI or awake intubation with topical anesthesia
- Steps:
- Locate cricothyroid membrane
- pre-oxygenate
- perform RSI
- look with video laryngoscopy and attempt intubation
- consider SGA but do not delay
- proceed to cricothyrotomy if no view
14
Q
What are the indications for intubation in trauma patients?
(table)
Strong indication
discretionary indication
A
15
Q
How are cervical spine injuries diagnosed or ruled out?
Gold standard?
Awake?
A
- C-spine injuries can be missed on initial trauma assessment
- CT (with < 3mm cuts) is typical diagnostic tool
- soft tissue and ligament injuries can only be detected on MRI
- MRI is gold standard
- *It is very rare to cause cervical cord injury with airway management but we still take precautions
- If pt is wake and sober, check for posterior midline neck tenderness
- if this test is negative with no other distracting injuries, there is low likelihood if c-spine injury
16
Q
How are c-spine precautions maintained during airway management?
A
- All airway maneuvers cause some s-spine movement
- Rigid collar is NOT enough
- Manual inline stabilization is preferred
- Pt may have unopposed vagal tone during airway manipulation causing severe brady
- may want to premedicate
17
Q
How is manual inline stabilization done?
A
- Ideally anesthesia provider + two people
- One perso stabilizes and aligns the head in neutral position without applying cephalad traction
- other person stabilizes both shoulders by holding them agains bed
- anterior portion of collar may be removed to improve mouth opening
- MILS can obstruct glottic view
18
Q
Blunt airway injuries:
symptoms
preferred airway management
A
- Symptoms:
- hoarseness/muffled voice
- dyspnea/stridor
- dysphagia
- odynophagia (painful swallowing)
- cervical pain and tenderness
- ecchymosis
- subQ emphysema
- flattening of adams apple
- preferred airway management:
- Fiberoptic bronch or surgical airway
- CT before intervention if stable
- 70% of blunt airway injuries also have C-spine injuries
- blunt airway injuries can be missed
19
Q
Penetrating airway injury:
symptoms
management
A
- Symptoms:
- air bubbling through wound
- hemoptysis
- coughing
- managment:
- ETT inserted in wound
- tracheostomy distal to wound
- oral intubation
20
Q
What are pulmonary complications seen in trauma?
A
- Tension pneumothorax
- no time to confirm with CT or Xray
- must do needle decompression or chest xray
- Flail chest- two or more sites of at least three adjacent ribs (costocondal separation or sternal fx)
- will decompensate over 3-6 hours
- ARDS likely if lung contusion >20%
- Open pneumothorax
- risk for vascular air entrainment
21
Q
What are symptoms of tension pneumothoras?
Where do you do needle decompression of pneumothorax?
Where does chest tube go?
A
- Symptoms:
- cyanosis
- tachypnea
- hypotension
- neck vein tistension (unless hemorrhaging)
- tracheal deviation
- diminished breath sounds on affected side
- Needle decompression:
- midclavicular line of 2nd intercostal space
- remember nerves/veins, arteries are high in intercostal space
- walk off top of third rip
- Chest tube mid-axillary 5th intercostal space
22
Q
How do you treat flail chest?
A
- Automatic intubation is NOT recommended
- focus on analgesia to maintain adequate excursion and ventilation/oxygenation
- epidural or thoracic paravertebral blocks preferred with O2 and non-invasive PPV
23
Q
What are the different classes of shock?
blood loss (ml)
blood loss (%)
pulse rate
systolic BP
pulse pressure
RR
UOP
CNS/mental state
A
24
Q
Information about shock:
difinitive treatment?
When should you expect major bleeding?
Ideal SBP?
goal Hgb?
A
- Difinitive tx- operative control of bleeding at the source
- expect major bleeding with falls >6 ft, high energy deceleration, or high velosity like GSW
- free fluid on Xray or CT warrants immediate intervention
- Ideal SBP = 100-110,
- especially in elderly (90’s ok in young/healthy)
- Goal Hgb = 7-9
30
Q
What are the two components of coagulopathy in trauma?
A
- Acute traumatic coagulopathy-occurs shortly after trauma
- hyperfibrinolysis and severe tissue injury releases tissue factor–this activates coagulation pathways
- Resuscitation-associated coagulopathy
- Caused by hypothermia, dilution with crystalloids
35
Q
How do you determin glascow coma scale?
A
