Trauma and Burns Exam 1 Flashcards
Phases used to evaluate the trauma patient? (3)
rapid overview - stable, unstable, and dead or dying.
primary survey - airway, breathing, circulation, neurologic function, examination of undressed patient. (essential laboratory and radiologic examination)
secondary survey - detailed and systematic evaluation of injury to each anatomic region and resuscitation at any time, if necessary.
signs and symptoms of airway obstruction?
Signs of upper and lower airway obstruction include dyspnea, cyanosis, hoarseness, stridor, dysphonia, subcutaneous emphysema and hemoptysis
what symptoms may present FIRST when someone has airway obstruction?
Cervical deformity, edema, crepitation, tracheal tug and/or deviation, or jugular venous distention may be present first.
In a patient with eye obit injury who IS HEMODYNAMICALLY STABLE, preferred anesthetic sequence to achieve depth you want is?
preoxygenation and opioid loading followed by large doses of intravenous anesthetic and muscle relaxant
Why is ketamine advantageous for head and open eye injuries?
How could it be bad?
it maintains the systemic blood pressure and does not cause an appreciable increase in ICP and IOP.
By increasing systemic blood pressure it can, however, cause dislodgement of a hemostatic plug, initiating bleeding in vascular injuries.
Which C spine evaluation is more reliable in diagnosing C spine injury in a responsive patient?
Canadian rule
What are the high risk factors mandating radiography according to the Canadian C spine rule? (3)
age equal to or greater than 65
dangerous mechanism
paresthesia in extremities
What are the low risk factors allowing neck range of motion according to the Canadian C spine rule? (4)
simple rear end MVA
ability to sit or ambulate in ED
No immediate-onset neck pain
No midline C spine tenderness
What is the final evaluation to rule out C spine injury in the Canadian C spine rule?
able to rotate neck 45 degrees left to right?
If unable then need CT
The probable reason for the lower reliability of the NEXUS criteria?
difficulty of evaluating distracting injuries
What would rule a person out from having FOB awake sedated patient intubation performed?
full stomach
time constraints
uncooperative patient
If a person is in a rigid collar or neck stabilizing device, what complications can occur?
pressure ulceration, increased ICP, compromised central venous access.
Most common cause of traumatic hypotension and shock - and is, after head injury, the second most common cause of mortality after trauma?
Hemorrhage
Why might tachycardia not always present in the hypovolemic trauma patient?
(up to 30% of patients)
activated Bezold–Jarisch reflex,
increased vagal tone,
chronic cocaine use, or other reasons.
If a patient is hypovolemic and unable to elevate their heart rate in order to compensate for the blood/fluid lost, what does that indicate/show?
considered a predictor of increased mortality independent of severity of injury, systemic blood pressure, or presence of a head injury.
What age group is more likely to have normal blood pressure but have significant tissue hypo-perfusion.
age greater than 65 (elderly)
Assessment of Blood Consumption (ABC) score, which asks four yes/no questions are?
penetrating mechanism of injury
SBP of 90 mmHg or less
heart rate of 120/min or greater
and a positive FAST finding.
Shock index (SI), a value derived by WHAT CALCULATION appears to be another accurate indicator of early hemorrhagic shock and a predictor of mortality.
dividing the heart rate by the SBP
Transient or no blood pressure response to this maneuver suggested major hemorrhage and dictates administration of blood products, explain the maneuver?
Classic crystalloid resuscitation.
The response to initial fluid resuscitation with lactated Ringer’s (LR) or normal saline solution of about 2 L, or 20 mL/kg in children, over a period of 15 to 30 minutes allowed estimation of the severity of hemorrhage.
Explain damage control resuscitation?
brief permissive hypotension;
rapid control of any bleeding source;
minimal crystalloid infusion; early administration of plasma and other blood products in a balanced ratio (preferably 1:1:1) of packed red blood cells (PRBCs), plasma, and platelets by activation of the MTP;
and tranexamic acid.
If indicated, damage control surgery may be required to control bleeding and sources of contamination.
Definitive surgery is deferred until after normalization of the patient’s physiologic condition.
purpose of damage control resuscitation is?
prevent the pulmonary edema,
ARDS,
coagulopathy, multiple organ failure (MOF),
and abdominal compartment syndrome attributed to administration of large volumes of resuscitative crystalloids
Over infusing fluids before control of the hemorrhage may lead to further bleeding how?
increasing arterial and venous pressures,
displacing a hemostatic plug,
diluting clotting factors and platelets,
reducing body temperature,
and decreasing blood viscosity.
Markers for organ perfusion, you have base deficit and blood lactate levels, which one is a better indicator?
base deficit
The base deficit reflects the severity of shock, the oxygen debt, changes in O2 delivery, the adequacy of fluid resuscitation, and the likelihood of MOF (multi organ failure) and survival with reasonable accuracy in previously HEALTHY adult and pediatric trauma patients.
recommended target Hgb concentration in all phases of trauma management?
7-9 g/dL
What type of un-crossmatched blood can be available for patients with sever hemorrhage? (satisfactory in most situations)
O Rh- positive PRBCs and AB negative FFP
For children the term massive hemorrhage is relatively new and is considered if transfusion volume exceeds ?
40mL/kg
The 1:1:1 ratio that is often applied to adults translates to what ratio for children?
20 mL/kg of PRBCs, 20 mL/kg of FFP, and 10 mL/kg of platelets in children.
If a patient has sever injuries you should place venous access with large-bore cannulae where?
peripheral veins that drain both above and below the diaphragm is essential for adequate fluid resuscitation in the patient who is severely injured.
If a patient has isolated facial injuries do they require emergent tracheal intubation?
No, Surgery may be delayed for as long as a week with no adverse effect on the repair.
nasogastric or nasotracheal intubation should be avoided when what types of fractures are suspected?
why?
basilar skull or maxillary fractures
possibility of the tube entering the cranium or the orbit.
If you have an increase in Hct the first day after a burn what does that suggest?
inadequate fluid resuscitation because hemolysis and sequestration are actually expected to cause a decrease in this parameter.
What are the Hct % limits for burn victims before they need blood replacement?
Blood replacement is usually not initiated until the Hct is decreased to 20% to 24% in healthy patients requiring limited operations.
approximately 25% in those who are healthy but need extensive procedures
30% or more when there is a history of pre-existing cardiovascular disease
thermal trauma caused by flames in a closed space is likely to be associated with?
airway damage
The presence of a lung injury markedly increases the fluid requirements and the mortality rate from thermal injuries, what is the increase % of fluid?
30-50%
If a patient is moderately to severely burned what decides if you apply 02 by face mask or immediate tracheal intubation?
02 by facemask at the highest possible concentration if they have a patent airway.
if the patient has stridor, respiratory distress, hypoxemia, hypercarbia, loss of consciousness, or altered mentation, immediate tracheal intubation is indicated.
in an adult with moderate or greater amounts of burns what is probably the safest way to intubate?
awake fiberoptic intubation under adequate topical anesthesia.
what sedative for intubation preserves pharyngeal tone?
ketamine
What % TBSA burned requires fluid resuscitation early in care (essential)?
over 15%
The addition of glucose to resuscitation fluid is not needed except for what patient population?
children, especially those weighing less than 20kg.
maintenance fluid for surgery?
4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the second 10 kg, and 1mL/kg/hr for additional weight thereafter.
The most important therapeutic maneuvers in patients with head injury is? (3)
normalizing ICP, CPP and oxygen delivery.
current recommendations for glucose control in head injury patient?
110-180 g/dL
Nearly 75% of severely brain-injured patients who die expire within the how many days following the initial trauma?
3 days
Normalization of the WHAT has been shown to reduce mortality in head injury patients?
ICP
Bleeding where is more common in the pediatric patient vs the adult patient?
bleeding into the retroperitoneal space and in the brain
The 1:1:1 ratio is of what components?
PRBC, Plasma (FFP), Platelets
The purpose of damage control resuscitation is to prevent what events from occurring? (dz processes)
pulmonary edema, ARDS, coagulopathy, multiple organ failure (MOF), and abdominal compartment syndrome attributed to administration of large volumes of resuscitative crystalloids
If MTP goals are met and the patient remains hypotensive then what may be the issue (rare)?
hypocalcemia
head injury accounts for approximately what % of deaths in truama?
40%
Is hypotension a result of brain injury in adults?
No, brain injury by itself does not cause hypotension in adults.
Mental impairment after trauma can be for many reasons, however what must always be considered?
hypoxia and shock
If consciousness remains depressed despite ventilation and fluid replacement what is to be assumed?
head injury is assumed to be present.
what is neurogenic shock/spinal shock comprised of?
hypotension and bradycardia caused by the loss of vasomotor tone and sympathetic innervation of the heart as a result of functional depression of the descending sympathetic pathways of the spinal cord.
It is usually present after high thoracic and cervical spine injuries and improves within 3 to 5 days.
Injuries to the spinal cord C5 or lower vs C4 and above?
Injuries at C5 or lower are usually associated with normal tidal volumes because the function of the diaphragm is intact, whereas patients with injuries at C4 or above may require permanent ventilatory assistance.
How does CO produce tissue hypoxia?
impairing 02 unloading
CO has a 200-300 x greater affinity for hemoglobin than oxygen, which way does it shift the oxy hemoglobin dissociation curve?
to the left
clinical presentation of cyanide toxicity
unexplained metabolic acidosis in the absence of cyanosis
what is the parkland formula for burns?
4ml/kg x TBSA% burned. Give ½ over 8hrs. Give remaining ½ over 16 hrs
Lethal Triad “Bloody Vicious Cycle”
Acidosis, Hypothermia, Coagulopathy
adult front and back of head % for burn?
9% (4.5% for front and 4.5%for back)
adult front of torso and back of torso burns %?
18% front, 18% back
adult front and back of each leg burn %?
front of each leg is 9% and back of each leg is 9% thus the entire left leg is 18% and the entire right leg is 18%
adult % of burns for front of left arm?
front of left arm only is 4.5% (front and back of each arm is 9%)
Burns to over 40% of TBSA will cause the person to be in a state of catabolism and weight loss for how long?
may last up to a year
If fluid resuscitation after a burn is successful then edema formation does what?
stops within 18-24 hours
Newtons 3 laws are?
- an object at rest will remain at rest, and an object in motion will remain in motion unless acted upon by an external force.
- the force acting on an object is equal to the mass of that object times its acceleration.
- for ever action, there is an equal and opposite reaction.
When should chest wall instability be a reason for intubation?
only when gas exchange abnormalities are present with the chest wall instability.
what position aggravates a quadriplegic patients paradoxical respirations during inspirations and why?
upright position, partial chest wall collapse is happening. The diaphragm cannot maintain its domed shape when upright, best to be supine.
What anesthetic technique is satisfactory for the spinal cord injured patient?
ANY anesthetic technique that is compatible with the patients general condition is satisfactory.
Maintain a MAP of what in the quadriplegic patient?
above 85
fluid replacement in the quadriplegic patient to a PCWP of?
18
In most pediatric patients, awake intubation is not possible. An inhalation induction with what is typically done?
02 and sevo, followed by intubation using FOB or conventional laryngoscope is appropriate.
Of the several causes that may alter respiration after trauma WHAT three issues are immediate threats to the patient’s life and therefore require rapid diagnosis and treatment.
tension pneumo
flail chest
open pneumo
classic signs of tension pneumo?
cyanosis,
tachypnea,
hypotension,
neck vein distention, tracheal deviation,
and diminished breath sounds on the affected side
definitive diagnosis of tension pneumothorax would be?
CT scanning
If your patient is hypoxemic and hypotensive what would you do immediately for suspected tension pneumo?
immediate insertion of a 14-gauge angiocatheter through the fourth or fifth intercostal space in the midaxillary line or, at times, through the second intercostal space at the midclavicular line is essential. There is no time for radiologic confirmation in this setting.
what provides the best opportunity for detection of pneumo?
upright plain chest radiograph
What is TXA?
competitive inhibitors of plasmin and plasminogen
What is plasmin?
clot buster
What is Plasminogen
tPA
TXA and trauma, when to give?
given within 3 hours of injury (1 g in a 10-minute bolus and then 1 g infused over the next 8 hours) decreased mortality from hemorrhage
If TXA is given beyond 3 hours of injury?
increased bleeding-related mortality
The usual dose of TXA is?
10-15 mg/kg followed by 1-5 mg/kg/hr
Burns and Succs?
The response to depolarizing and nondepolarizing muscle relaxants remains unaltered during the first 24 hours after burn injury. After this period, succinylcholine should be avoided for at least 1 year because it can result in a potentially lethal increase of serum K+ when the burn size exceeds 10% of TBSA
What has the greatest detrimental impact on a person with brain injury?
decreased oxygen delivery as a result of hypotension and hypoxia
what vasopressor does not constrict cerebral vessels?
phenylephrine
if a patient has a head injury where do you want to maintain their blood pressure MAP, Pa02, ICP, and CPP?
Primary therapy includes normalization of the systemic blood pressure (mean blood pressure >80 mmHg) PaO2 over 95, the ICP below 20 to 25 mmHg, and the CPP at 50 to 70 mmHg.
What is Mannitol?
osmotic diuretic
