trauma anes, burns Flashcards by zarieh Novela

T/F: avoid ventilation between administration of medication and intubation

True

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Indication for endo tracheal intubation

CRAFTeDD
Cardiac or respiratory arrest
Respiratory insuff
Airway protection
Facilitation for diagnostic work up (uncoop, intoxicated)
Transient hyperventilation (increase ICP)
Deep sedation or analgesia
Delivery of 100% O2 (CO poisoning)

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T/f: administer particulate antacid prior to induction

False. Nonparticulate

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Maneuver to be applied during airway management

Cricoid pressure or sellick maneuver

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T/f: do mri of cervical spine if have neck pain or have cervical tenderness to palpations

True

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High risk factors mandating c-spine radiography

> 65y/o
Dangerous mechanism
Paresthesia on extremities

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Low risk factors allowing neck range of motion

Simple rear-end MVA
No immediate neck pain
No midline c-spine tenderness
Ability to sit or ambulate in ER

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Unable to rotate neck (how many degrees) left and right for c-spine radiography

45 degrees

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T/f: direct laryngoscopy cause cervical motion and the potential to exacerbate sc injury

True

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Uncleared cervical spine mandates..

In-line stabilization (no traction)

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T or F: the front of cervical collar cannot be removed for greater mouth opening and jaw displacement

False. Can be removed.

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Minutes of hypoxia before permanent brain injury and death

5-10 min hypoxia

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Airway/breathing, which is the most immediate threat to life?

Hypoxia

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Protection of cervical spine.

T or F: Emergency awake fiber optic intubation requires less manipulation of the neck

True

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Emergency awake fiber optic intubation is generally difficult becoz…

Hemorrhage
Airway secretions
Rapid desaturation
Lack of PTS coop

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Vasodilator
(-) inotropic effect

Propofol

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Potentiate hypotension or cardiac arrest

Propofol

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Increased cvs stability

Etomidate

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Direct myocardial depressant

Ketamine

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Catecholamine release

Ketamine

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Hypertension or tachycardia

Ketamine

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Reduced awareness

Midazolam

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Hypotension

Propofol

Midazolam

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone:
Inhibits memory formation

Scopolamine

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Propofol/ etomidate/ ketamine/ midazolam/ scopolamine/ ms relaxant alone: Recall of intubation / recall of emergency procedures

Ms relaxant alone

Neuromuscular blocking drug

Succinylcholine

Onset of action of succinylcholine

Fastest onset | <1 min

Duration of succinylcholine

Shortest duration | 5-10min

What are increased in succinylcholine?

Increase potassium level (0.5-1mEq/L) (5mEq/L after 24hr) Increased IOP Increased ICP

Consequence of hemorrhage

Shock

T or F: cancel airway management when difficulty arise

False. It is not an option.

When difficult arise in intubation, do...

Awake intubation

Of unsuccessful ventilation after gen anes

Standard: awake is always an option Trauma: seldom an option

If surgical airway decision

Standard: only if awake intubation failed/ failed ventilation Trauma: first and best choice

If management of recognized diff airway

Standard: awake ventilation Trauma: only if uncoop, stable and spont. ventilating

If failed awake ventilation

Standard: cancel is an option Trauma: requires gen anes with or without spont. ventilation

T or F: due to urgency, there is NO time for pharma to decrease gastric volume and acidity

True

MRI of cspine can not be done in (hours)

First 24 hrs

MRI Cspine contraindication

Metallic skeletal fixators

T or F: airway maneuver can cause Cspine movement

True

T or F: pressure in tongue during airway manipulation affects Cspine.

True. Indirectly

Standard care for Cspine injury

MILS, manual in-line immobilization

Consist of primary cellular injury due to hypoperfusion and the secondary inflammation response that follows.

Shock

Deaths in trauma is due to

Shock -50% Hemorrhage -40% MOSF -10%

Patho physio of lost airway/ pulmonary injury on shock

O2 does not reach circulation

Patho physio of tension pneumothorax

Decrease blood return to heart

Patho physio of cardiac tamponade

Decrease blood return to the heart

Patho physio of hemorrhage

Decrease O2 carrying capacity | Decrease intravascular vol

Patho physio of cardiac injury

Decrease pump action

Patho physio of spinal cord injury

Decrease pump action | Decrease vasodilation

Patho physio of poisoning

Decrease vasodilation | Direct failure of cellular

Patho physio of sepsis

Decrease vasodilation | Direct failure of cellular

Cns response to ischemia

Mod: anxiety Severe: coma

Cvs response to ischemia

Mod: vasoC, increase CO Severe: vasoD, MI, dysthymia

Pulmonary response to ischemia

Mod: increase RR Severe: V/Q mismatch, ARDS

Renal response to ischemia

Mod: hybernation Severe: ATN

GI response to ischemia

Mod: ileus Severe: infarct, loss of barrier function

Hepatic response to ischemia

Mod: increase glucose release Severe: no reflow, re perfusion injury

Hematologic response to ischemia

Mod: none Severe: decrease cell production, impaired immune function

It begins as soon as Shock is identified

Fluid resuscitation

T or F: resu and primary therapy overlaps

True

Risk of aggressive fluid resuscitation

``` BBHC GEDP Increase bp Decrease blood viscosity Decrease hct Decrease clothing factors Greater transfusion reqr Electrolyte imbalance Direct immune suppression Premature reperfusion "pop the clot" ```

Fluid resu goal of maintaining Lower than normal Bp (___mnHg) until definitive control of hemorrhage

90mmhg

Responder/ transient responder/ non responder and implication Increased and sustained improvement of bp

Responder- | Not actively bleeding, unlikely to require transfusion

Responder/ transient responder/ non responder and implication Increased bp Ff by recurrent hypotension

Transient responder- | Actively bleeding, consider early transfusion

Responder/ transient responder/ non responder and implication No improvement

Non-responder- | Must R/o other causes, active bleeding

Fluid which causes dilution of blood composition

0.9% Saline LR Plasmalyte Starch

Fluid which cause rapid volume expansion

``` Starch Hypertonic saline RBC Plasma FWB ```

Fluid which is cheap and compatible with blood

0.9 saline

Fluid which cause hyperchloremic metab acidosis

0.9 saline

Fluid in which Ca clots the blood

Fluid with physiologic electrolyte mix

Plasmalyte

Fluid which cause coagulopqthy with 1st generation

Starch

Fluid which cause rapid increase of bp

Hypertonic saline

Fluid which cause increase O2 delivery

RBC

Fluid which have clotting factors

Plasma

Fluid which have O2, clotting factors and is ideal but Unavailable

FWB

Fluid which are expensive, limited resource, requires cross matching, viral transmission, TRALI

RBC | Plasma

Vicious cycle of rapid crystalloids infusion in pts with Active hemorrhage

Vigorous fluid resu Hemodilution, increased bleeding Recurrent hypotension

In deep shock, one can use ____ to rapidly restore coagulation

Bicarbonate Cryoprecipitate FActore VIIa

1 blood loss vol in 24hr is equivalent to

10units of whole blood

Indications for massive transfusion

``` 4 units in 1hr 50 units in 48hrs 20 units in 24hrs 50% blood loss in 3hrs >150ml/min blood loss ```

Bloody vicious cycle or lethal triad

``` Acidosis Hypothermia Coagulopathy (due to large vol of crystalloids, colloid, PRBC without hemo static component) ```

Warm all IV fluids and blood to avoid hypothermia. Room temp?

>28C | Humidify inspired gas

For decreased ionized calcium, how many CaCl to give?

Calcium chloride 20mg/kg

Resu end points within 1st 24hr after trauma: | Mixed venous oxygen tension

>35mmHg

Resu end points within 1st 24hr after trauma: | Mixed venous oxygen saturation (CVP, PA)

>65mmHg

Resu end points within 1st 24hr after trauma: | Base deficit

<3mmol/L

Resu end points within 1st 24hr after trauma: | Lactate

<2.5mmol/L

Pulse oximetry information

O2 sat HR Plethysmographic tracing of pulse Tissue perfusion

Interferes with reading in pulse oximetry

``` IV dyes Movement Dark fingernails Highly pigmented skin COHgb metHgb ```

High sat but truly with low oxyhemoglobin

Poisoning/inhalational injury

Trauma pts suffers from low perfusion state thus oximetry reading not reliable. Which is a more sensitive measure?

ABG

Efficacy of ventilation or ute elimination of CO2 can be assessed by both PETCO2 values and Capnogran analysis

End tidal CO2 analysis

High CO2 | Increased production

Hyperthermia/malignant hyperthermia Cancer Burn Sepsis

High CO2 | Decreased elimination

Asthma COPD Inadequate ventilation (drugs, fatigue, sweating)

Low CO2 | Increased elimination

Hyperventilation | Anxiety/vent strategy

Low CO2 | Decreased production

Coma Hypothermia Anesthesia Paralysis

``` Ventilator setting (low pressure/high pressure alarms): Machine leak or disconnection of breathing circuit ```

Low pressure alarm

``` Ventilator setting (low pressure/high pressure alarms): Due to patient condition such ass reduced lung compliance, secretions in ET tubes, dyssynchronous ventilation ```

High pressure alarms

Pulse electrical activity 5H

``` Hypovolemia Hypothermia Hyper/hypokalemia H ion acidosis Hypoxemia ```

Pulseless electrical activity 5T

``` Tension pneumothorax Tamponade Thrombosis (pulmonary embolism) Thrombosis (coronary artery embolus) Tablets (drug overdose) ```

CVP level

8-12mmHg

T or F: CVP has no predictable relationship between pressure and volume preload indices and cardiac performance variables

True

T or F: CVP is used as guide to fluid therapy

True

PA catheter information

CO CVP PAP PAWP

Urine production

0.5ml/kg/hr

Surrogate measure of organ perfusion

Urine output

Indicator of hemolysis, sk ms destruction and UT integrity

Urine output

T or f: urine output reliability is increased in prolonged shock prior to surgery and use of osmotic dieresis

False. Decreased reliability

Accurate site for temp

Distal esophagus Tympanic mem PA catheter sensor Nasopharynx

Intermediate accurate site of temp

Bladder Rectum Mouth Axilla

Inaccurate site of temp

Skin

Conseq of patient expo

``` Coagulation disturbance Arrhythmias Inappro diuresis Delay in metab of drugs Risk of infection ```

T or F: avoid anesthetics and ms relaxants before securing the airway

True

Hemorrhagic shock (increase/decrease) the MAC by approx __

Decrease Mac by 25%

T or f: anesthetic drugs are direct CV depressant and inhibit compensatory hemodynamics mechanism

True

Expulsion of eye contents and loss of vision

``` LEt BuCKS Laryngoscopy ET intubation Bucking Coughing Ketamine Succinylcholine ```

T or F: aspiration of stomach contents may cause lung injury and pneumonia

True

Induction agents

Thiopental Propofol Midazolam

Crystalloids/colloid: what to give during early phase of burn

Crystalloids

Crystalloids/colloid: what to give 24hrs after burn injury

Colloid

When to avoid succinylcholine in burn injury

If >24hrs and for at least 18mos after injury

Burn injury, rapid sequence induction of ____ if >24hrs after burn injury

Rocuronium

IV anesthetics in early phase burn injury

Decrease dose requirements

IV anesthetics in during hyper dynamic phase burn injury

Increase dose reqr | Consider multimodal therapy (opioid, Propofol, ketamine, benzodiazepines)

Inhalation agents in early phase burn injury

Decrease MAC during early phase

Inhalation Agnets in during hyper dynamic phase burn injury

Increase MAC

T or F: beta blocker attenuated hyperdynamic phase of burn injury

True

Succinylcholine increase K if __%TBSA

10%

Causes of persistent hypotension

Bleeding Tension pneumothorax Neurogenic shock Cardiac injury

LR/NS in persistent hypotension

LR cause no acidosis but tissue edema due to..

Hypotonicity

The higher the molar substitution, the ___ retention, the ___ chance of coagulopqthy

The higher the molar substitution, the higher retention, the higher chance of coagulopqthy

Causes of hypothermia

``` SAAFE Shock Alcohol intoxication Abnormal Thermoregulatory mech Fluid resu Expo to cold ```

Coagulation abnormalities causes

``` DATHH Dilution of coag factors Acidosis Tissue hypoperfusion Hypoxia Hypothermia ```

Indication for FFP

>10 units PRBC within 6hrs >1.5x the normal PTT and PT Reversal of coag in pts in Vit.K antagonist

Platelet indication

<50 x 10^9/L | Higher in pts with DIC, hyperfibrinolysis, head injury and massive bleeding

One unit of whole blood contains platelet concentrates of

7.5 x 10^10/L

Fibrinogen indications

<1.5g/L

Replace fibrinogen conc and cryoprecipitate

3-4g fibrinogen | 50mg/kg cryoprecipitate

Antifibrinolytic agents and dose

Tranexamic acid - 10-15mg/kg then 1-5mg/kg/hr | Aminocaproic acid - 100-150mg/kg then 15mg/kg/hr

T or F: anti fibrinolytic agents are effective in cardiac and elective surgery

True

Why is antifibrinolytic agents not included in massive transfusion protocol?

Be do it contains all endogenous antifibrinolytic elements

Conditions to justify the use of factor 7a

Controlled bleeding Corrected severe acidosis, hypothermia and hypocalcemia Using antifibrinolytic agents

Caution for the use of factor 7a

Arterial and venous TE

Dose for factor 7a

100-140 mg/kg repeat after 1-3hrs later

Electrolyte and acid base disturbance

Hyperkalemia | Metab acidosis

Early post-op considerations

Acute renal failure Abdominal compartment syndrome TE

Creatinine and free water clearance on ARF

Creatinine <25ml/min | Free water >15ml/hr

Myoglobinuria/hemoglobinuria: clear supernatant (crush syndrome)

Myoglobinuria

Myoglobinuria/hemoglobinuria: rose color

Hemoglobinuria

Management for ARF

Fluids only. | DONT Give mannitol and HCO3

Intra abdominal hypertension with organ dysfunction

Abdominal compartment syndrome

Most important factor in abdominal compartment syndrome

Limit crystalloids infusion

Management for TE

``` PPV FiO2 of 1 Intubation Fluids and inotropes Arterial CVP monitoring TEE ```

TE prophylaxis

Compressin devices LMW heparin Vena cava filter Thrombolytic agents

Superficial burn

First degree burn

Partial thickness burn

Second degree burn (superficial and deep dermal burn)

Full thickness burn

Third and fourth degree burn

Erythema of skin Microscopic destruction of superficial layers of epidermis Heals spontaneously

First degree burn

Burn from epidermis to upper Dermis | Heals spontaneously

Superficial derma burn

Burn from epidermis to deep Dermis | Requires excision and grafting

Deep dermal burn

Burn of epidermis and dermis | Excision and grafting with limitation of function and scar formation

Third degree burn

Burn of ms, fascia and bone | Complete excision with limited function

4th degree burn

Full thickness burn TBSA

>10% TBSA

Partial thickness TBSA

>25% TBSA in adults | 20% TBSA in extremes of age

Surface area of head and neck in children is larger than 9%, and that of lower extremities are smaller, thus can't use rules of 9, instead use...

Lund and Browder chart | -takes into aact the changing prop of body from infancy to adulthood

CO increase/decrease immediately after burn injury due to ...

Decrease CO due to circulating myocardial depressant factors

CO increase/decrease after 24hrs resu due to ...

Increase CO due to hypemetabolic state (tachycardia, hypertension)

Patho physio changes in burn injury in upper airway

Glottis and preglottic edema = obstruction

Patho physio changes in burn injury in lower airway

Decrease surfactant and mucociliary func Mucosal necrosis and ulceration Edema Leads to obs, air trapping, broncho spasm, ARDS, PE

Patho physio changes in burn injury in GI

``` Adynamia ileus (>20%tbsa) Curlings ulcer (stomach and duo) ```

Life threatening complication of burn injury in GI

Curlings ulcer

Patho physio changes in burn injury in renal

Decrease RBF and GFR = RAAS activation and ADH release = Na and water retention = exag K, Ca, Mg losses

T or F: Renal changes in burn injury improves with adequate resu

True

Patho physio changes in burn injury in endocrine

ADH, renin, aldosterone, angiotensin, glucagon and catecholamine release = inc serum glucose

Patho physio changes in burn injury in metab and thermoreg

Increase metab rate Increase skin and core temp Ineffective water vapor barrier = loss of ion-free water

Leading cause of hypoxia in burn injury

Carbon monoxide poisoning.

Produced by incomplete combustion of C-containing cmpds (wood, coal, gasoline)

Carbon monoxide

Carbon monoxide is ___x greater affinity for ____

200x greater affinity to Hgb than O2

Carbon monoxide (competitive/noncompetitive; irrev/rev) reaction

Competitive reversible reaction

T or F: fluid resu is essential in the early burn injury period

True

Parkland formula

4ml/kg/% TBSA 1st 8hrs - 1/2 Nxt 8hrs - 1/4 Nxt 8hrs - 1/4

What to give in 1st 24 hr in burn injury

LR | Parkland formula

What to give in second 24hr in burn injury

``` Glucose in water (replace water loss and maintain Na level) Colloid soln (albumin) ```

Dose of colloid soln with TBSA 30-50%

0.3ml/kg/%

Dose of colloid soln with TBSA 50-70%

0.4ml/kg/%

Dose of colloid soln with TBSA >70%

0.5ml/kg/%

What to give in children <20kg burn injury

Crystalloids (2-3ml/kg/%) same hr Crystalloids with 5% dextrose (maintenance) for 24 hrs 1st 10kg = 100ml/kg 2nd 10kg = 50ml/kg

Fluid resu clinical ends

Uo 0.5-1ml/kg/hr PR 80-140bpm SBP 60mmHg infants; 70-90mmHg + (age x 2) children Basale deficit <2

If difficult mask ventilation and intubation, consider

Awake intubation

Ms relaxant of choice in burn injury

Non depolarizing | Esp with minimal histamine release

T or F: burn patient have RELATIVE RESISTANCE To nondepolarizing relaxants

True

How many fold increase in dose requirement of ms relaxant in burn injury

3-fold

In pts with burns >30% TBSA, manifesting approx 10 day postinjury, peak is ____ and declines after ____

Peak -40d | Decline -60d

T or F: succinylcholine is contraindication in burn patients

True, 24hrs postinjury up to 2yrs

Reason behind an increase serum K in succinylcholine

Due to presence of extra junctional Ach receptors

T or F : avoid NSAID in burn injury

True