Trauma/ABCs

Question 1

Indications for Intubation

Answer 1

5Ps - protect airway, positive pressure ventilation (failure to ventilate/oxygenate), pulmonary toileting, anticipatory (trauma, OD, inhalation, COPD, CHF), patency

Question 2

Difficult to ventilate

Answer 2

“BOOTS” - beard, obese, no teeth, older, snores

Question 3

Difficult to intubate

Answer 3

LEMON- look for signs, evaluate 3-3-2 rule, mallampati, obstruction/obesity, neck mobility (ankylosing spondylitis, RA)

Question 4

Measures to improve airway

Answer 4

chin-lift jaw thrust, BVM, suctioning, nasal airway, oral airway, LMA

Question 5

Definitive airway

Answer 5

endotracheal tube (orotracheal or nasotracheal), surgical airway

Question 6

Airway methods

Answer 6

RSI, blind nasotracheal intubation, oral intubation without agents “crash airway”

Question 7

Rapid Sequence Intubation

Answer 7

6Ps: preparation, preoxygenation (100% O2 x 3 mins or pt taking deep breaths on 100% O2), Pretreatment (optional - lidocaine 1.5 mg/kg for reactive, fentanyl 3 mcg/kg for CVD or increased ICP), paralysis (sedative followed by muscle relaxant if indicated, place tube with proof, post-intubation (CXR, ongoing analgesia and sedation, resuscitation)

Question 8

Definition of Acute Respiratory Failure

Answer 8

pO2 < 50 mmHg or pCO2 > 45 mmHg

Question 9

Types of Respiratory Failure

Answer 9

Type 1 (respiratory failure without hypercapnia), Type 2a (respiratory failure with hypercapnia normal lungs), Type 2b (respiratory failure with hypercapnia abnormal lungs)

Question 10

Type 1 Respiratory Failure

Answer 10

no hypercapnia (< 45 mmHg): diffusion problem (pneumonia, ARDs), V/Q mismatch (PE), shunting, low FiO2 (high altitudes), alveolar hypoventilation

Question 11

Type 2a Respiratory Failure

Answer 11

hypercapnia and normal lungs: disorder of respiratory control - OD, brainstem lesion, CNS, disease, NM disorder (muscular dystrophy, GBS, MG, ALS), trauma, AnkSp

Question 12

Type 2b Respiratory Failure

Answer 12

hypercapnia abnormal lungs: COPDae, Asthma exacerbation, scarring, IPF

Question 13

Assessment of Breathing

Answer 13

Look: mental status, colour, chest wall movement, accessory muscle use; Listen: auscultate for breath sounds, signs of obstruction, air entering or escaping, Feel: tracheal devation, crepitus, flail segments, chest wounds

Question 14

MGMT of breathing

Answer 14

Spontaneous: NP, face mask, non-rebreather face mask; Inadequate Ventilation: BVM, nasal airway, high-flow nasal oxygenation, CPAP/BiPAP (CHF, COPD, asthma)

Question 15

Causes of Shock

Answer 15

Hypovolemic shock (bleeding, GI losses, third spacing), Obstructive shock (PE, cardiac tamponade, TPTX, valvular dysfunction, air embolism), Distributive shock (Septic, anaphylactic, neurogenic, drug overdose, adrenal), Cardiogenic shock (ACS, cardiomyopathy, cardiac structural damage, dysrhythmia)

Question 16

Rosen’s Empirical Criteria for Circulatory Shock

Answer 16

Ill appearance or altered LOC, RR > 20 or PaCO2 < 32, UO < 0.5 ml?kg/hr, HR > 100 BMP, base deficit < -4 or lactate > 4, arterial hypotension > 30 mins continuous treatment

Question 17

Initial Investigations for Shock

Answer 17

CBC, lytes, BUN, Cr, LFT, coag, VBG, lactate

Question 18

Hemorrhagic hypovolemic shock MGMT

Answer 18

control hemorrhage, aggressive fluids, blood productions (1:1:1 - pRBC platelets, FFP)

Question 19

Obstructive shock MGMT

Answer 19

TPTX: needle decompression, chest tube; Cardiac Tamponade: IV crystalloids, pericardiocentesis, PE: IV crystalloids, inotropes, thrombolysis

Question 20

Anaphylaxis Shock MGMT

Answer 20

epi IM, IV crystalloids, antihistamines, corticosteroids

Question 21

Septic Shock

Answer 21

broad-spec Abx, IV crystalloids, norepi; Goals: UO > 0.5, CVP 8 - 12 mmHgs, MAP > 65 mmHg, ScvO2 > 70%, lactate clearance

Question 22

Cardiogenic Shock MGMT

Answer 22

MAP > 65 with fluid bolus to optimize preload, norepi 5 mcg/min, dobutamine 2.5 mcg/kg/min, treat underlying cause (Cath lab, ECMO)

Question 23

PRIMARY SURVEY

Answer 23

Airway (patency, obstruction, C-spine, RSI), Breathing (expose chest, assess breathing, auscultate for breath sounds, r/o TPTX), Circulation (assess LOC, signs of shock, degree of hemorrhagic shock), Disability (GCS assessment, neurological evaluation), Exposure (expose patient, logroll to inspect for injuries, spine tenderness, rectal exam for high-riding prostate and tone), Keep patient warm and dry to prevent hypothermia

Question 24

Secondary Survey

Answer 24

full physical exam (Head and neck, chest, abdomen, MSK, neuro, SAMPLE, collateral), FAST exam (pericardial window, perisplenic, hepatorenal, pelvic)

Question 25

Investigations for Trauma

Answer 25

CBC, lytes, BUN, Cr, glucose, lactate, INR/PTT, firbinogen, BHCG, tox screening, UA; CXR, pelvis XR spine XR, CT if stable

Question 26

Deadly Triad

Answer 26

coagulopathy, hypothermia, acidosis

Question 27

MGMT of Trauma patient

Answer 27

1. Resuscitation: blood products, Transexamic acid (1g IV q 10 mins, then 1g q8 hours)

Question 28

MGMT of head trauma

Answer 28

seizure MGMT, treat suspected cause of raised ICP, neurosurgical intervention for severe head injury or bleed

Question 29

spinal cord trauma MGMT

Answer 29

immobilize, treat neurogenic shock, consult spine service

Question 30

chest trauma MGMT

Answer 30

airway MGMT, thoracotomy for blunt vs. penetrating trauma, surgical intervention for life threatening injuries

Question 31

abdominal trauma MGMt

Answer 31

laparatomy for hemodynamically unstable and hollow organ injuries

Question 32

orthopedic injury MGMT

Answer 32

reduce, immobilize when possible, analgesia, consult ortho