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Mar: Sem 6 - Principles B > Trauma Anesthesia > Flashcards

Trauma Anesthesia Flashcards

1
Q

Trauma is the leading cause of death between these ages?

A

1-46 years (young people)

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2
Q

What percentage of pre-hospital deaths were potentially survivable?

A

24%

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3
Q

What are the three main causes of preventable deaths?

A
  • Hemorrhages
  • Airway Obstruction
  • Tension Pneumothorax
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4
Q

What is the leading cause of preventable death in all types of traumatic injuries

A

Bleeding

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5
Q

What components make up the “Lethal Triad”

A
  • Coagulopathy
  • Hypothermia
  • Metabolic Acidosis
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6
Q

What are the effects of crystalloid resuscitation on blood loss?

A
  • Increases blood loss
  • Increase transfusion requirements

  • Balanced blood product resuscitation decreases blood loss, transfusion requirements and improves survival
  • Must have dried/thawed/liquid plasma to really do this well
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7
Q

What is the primary survey for Advance Trauma Life Support (ATLS)?

A

ID life-threatening injuries and simultaneously treat it

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8
Q

ATLS Framework for Airway (A)

A
  • Stabilize cervical spine
  • Assess Airway (vocal response, chin-lift, apnea)
  • Intervene (suction, bag, intubate)
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9
Q

ATLS Framework for Breathing (B)(Inaqeduate Ventilation)

A
  • Assess chest: inspection, palpation, percussion, auscultation
  • Manage: obstruction, tension pneumo, massive, hemothorax, open pneumothorax, flail chest, tamponade
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10
Q

Causes of diminished respiration

A
  • TBI
  • Shock
  • Intoxication
  • Hypothermia
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11
Q

What type of trauma may cause inadequate ventilation?

A
  • Direct injury to the trachea or bronchi
  • Pneumothorax or hemothorax
  • Aspiration
  • Pulmonary contusion
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12
Q

What type of trauma may cause circulatory issues?

A
  • Cardiac tamponade
  • Aortic injury/dissection
  • Penetrating trauma
  • Femur/pelvic fractures
  • Occult abdominal trauma (spleen, liver)
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13
Q

Class I Hypovolemic Shock (Hemorrhage)

A
  • 15% blood loss
  • Normal vital signs
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14
Q

Class II Hypovolemic Shock (Hemorrhage)

A
  • 15-30% blood loss
  • Tachycardia
  • Normal SBP
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15
Q

Class III Hypovolemic Shock (Hemorrhage)

A
  • 30-40% blood loss
  • Significant ↓BP and Mentation
  • HR > 120
  • Cap refill delayed
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16
Q

Class IV Hypovolemic Shock (Hemorrhage)

A
  • > 40% blood loss
  • Hypotensive with narrowed pulse pressure
  • UO absent
  • Significantly altered mentation
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17
Q

Presume shock is a result of ___________
until proven otherwise

A

Hemorrhage

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18
Q

ATLS Framework for Circulation (C)

A
  • Assess: VSV, cap refill, CBC, coags, crossmatch, peritoneal lavage, US/ films
  • Manage: 2 large bore IV’s with crystalloid/O neg whole blood, direct pressure
  • Surgical: thoracotomy, laparotomy
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19
Q

What can cause disabilities in trauma patients?

A
  • Closed or open head injuries: until proven otherwise
  • Hypoxia
  • Drug/alcohol ingestion
  • Hypoglycemia
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20
Q

ATLS Framework for Disability (D)

A
  • Assess: pupil size, spinal cord injury level, GCS score
  • Manage: CT, steroid drips
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21
Q

Glasgow Coma Scale: Eye-Opening Response Scores

A
  • 4: Spontaneous
  • 3: To Speech
  • 2: To Pain
  • 1: None

Spincy SPinach

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22
Q

Glasgow Coma Scale: Verbal Response Scores

A
  • 5: Oriented to name
  • 4: Confused
  • 3: Inappropriate Words
  • 2: incomprehensible Sound
  • 1: None

ORIENTED CoWS

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23
Q

Glasgow Coma Scale: Motor Response Scores

A
  • 6: Obeys commands
  • 5: Localized to painful stimuli
  • 4: Withdraw from painful stimulus
  • 3: Abnormal Flexion (decorticate posturing)
  • 2: Abnormal Extension (decerebrate posturing)
  • 1: None

OLd WiFE

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24
Q

What is the purpose of Exposure (E)?

A
  • Secondary survey
  • Additional lab and xrays
  • Detailed H & P
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25
Q

What are the principles of Damage Control Resuscitation (DCR)?

A
  • Early control of hemorrhage
  • Rapid transport to definitive care
  • Limited crystalloid infusion
  • Early and liberal use of blood products in appx of whole blood (1:1:1, PRBC:FFP:Platelets)
  • Permissive hypotension (excluding TBI/SCI patients)
  • Judicious and early use of tourniquets, pelvic binders, splints, compressive dressings/direct pressure
  • Quick peripheral large bore IV
  • Focusing on and addressing ABC’s using available adjuncts (FAST, CXR, Pelvic X-ray)
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26
Q

What are the two biggest complications of resuscitation?

A
  • Abdominal Compartment Syndrome
  • Hemodilution
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27
Q

What fluids should be used in resuscitation in DCR (rank them).

A
  • Plasmalyte (most pH balanced)
  • LR
  • NS
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28
Q

Albumin (5% or 25%) provides effective and more physiologic volume expansion than other colloids, but given alone contributes to ______________.

A

Hemodilution

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29
Q

When should Hypertonic Saline be used?

A
  • Traumatic Brain Injury (TBI)
  • Evidence of raised ICP
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30
Q

Blood Product Resuscitation = __________________

A

Improved Survival

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31
Q

What are the components of operative damage control?

A
  • Control hemorrhage
  • Control contamination
  • Temporary closure
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32
Q

Hemorrhage and injury cause acute _________ or ____________ (leading to the “lethal triad”).

A
  • blood failure
  • hemovascular dysfunction
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33
Q

DCR treats drivers of blood failure simultaneously with ____________

A
  • Blood
  • Blood products
  • TXA
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34
Q

What is LTOWB?

A
  • Low Titer O Whole Blood
  • Contains red cells, platelets, and plasma; an ‘all in one’ transfusion therapy to treat bleeding patients.
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35
Q

What situations will lead to increased potassium during a trauma?

A
  • Crush injuries
  • Rhabdomylosis
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36
Q

Why is succinylcholine contraindicated in open-globe injuries?

A

The muscle fasciculations caused by succinylcholine can lead to a transient increase in intraocular pressure.

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37
Q

What is the best paralytic to use for trauma intubation?

Dose:
Duration of action:

A
  • Rocuronium
  • 1.2 mg/kg
  • 1-2 hours
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38
Q

What is the delay time of Sugammadex?

A

3 minutes

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39
Q

C-spine protection during intubation

A
  • C-spine instability presumed until cleared
  • 3 providers ideal
  • Collar should not be removed
  • Use glide scope
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40
Q

Most trauma patients are young and healthy. Hypotension is most likely related to what factor?

A
  • Interruption of sympathetic compensation
  • > 40% blood loss
  • Onset of PPV
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41
Q

What induction drug will cause trauma patients the most hemodynamic instability?

A
  • Propofol
  • Rarely used in “field”
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42
Q

Etomidate is often used in the field as an RSI anesthetic. What is the concern with this drug?

A
  • Inhibits immune response
  • Adrenal Suppression
  • Myoclonus
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43
Q

Ketamine can provide analgesia and sedation in a trauma patient. What is the concern with this drug?

A

Myocardial depressant if catecholamines are depleted.

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44
Q

When will nasal intubation be contraindicated?

A
  • Basilar skull fracture
  • Cribiform plate fracture
  • Sinusitis
  • Suctioning/ bronchoscopy
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45
Q

Pathophysiology of Hemorrhagic Shock

A
  • Decrease volume → Decrease BP
  • Vasoconstrictions of the vessels
  • Release of catecholamines to preserve blood flow to heart, kidney, and brain
  • Peripheral vasoconstriction and decreased blood flow
  • Release of hormones and inflammatory mediators for compensation
  • Microcirculatory response where ischemic cells uptake interstitial fluid, leading to further depletion of intravascular space
  • Lactate and free radicals are produced → Direct damage to cells
  • Inflammatory factors are released
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46
Q

CNS response to shock

A
  • Decrease glucose uptake
  • Decrease cortical activity and reflexes
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47
Q

Kidney/adrenal response to shock

A
  • Early response: maintains GFR
  • Late response: inability to concentrate urine, ATN
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48
Q

Heart response to shock

A
  • Cardiac dysfunction d/t negative inotropes (lactate) → Troponin elevation
  • Tachycardia
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49
Q

Lung response to shock

A
  • ↑ Inflammatory byproducts in capillaries
  • ↑ Capillary permeability → Pulmonary Edema
  • ARDS
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50
Q

Intestine response to shock

A
  • ↑ Bacteria load
  • Trigger of MSOF
  • Earliest organs affected d/t blood been shunted away
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51
Q

Liver response to shock

A
  • Reperfusion injury during recovery
  • Unstable blood glucose
52
Q

What organ is the main source of citrate metabolism?

A

Liver

53
Q

What is Tranexamic Acid derived from?

A

Lysine

54
Q

What is the function of TXA?

A

Inhibits fibrinolysis by blocking the lysine binding sites on plasminogen → contributes to clotting

55
Q

Data shows TXA administered within _______ is associated with the largest reduction in deaths caused by bleeding.

A

< 1 hour

56
Q

TXA treatment given __________ hours after injury was associated with an increased risk of death from bleeding.

A

> 3 hours

57
Q

Significance of Calcium in the body

A
  • Plays a significant role in coagulation
  • Platelet adhesion
  • Contractility of myocardial and smooth muscles
58
Q

Which clotting factors require calcium?

A
  • Factor II
  • Factor VII
  • Factor IX
  • Factor X

S.N.0.T. (7,9,10,2) makes your K+/Ca+ CLOT

59
Q

What substance in PRBC drops the calcium level?

A

Citrate

60
Q

Why is citrate in PRBC?

A

Packed red blood cells (PRBCs) contain citrate, which is used as an anticoagulant to prevent the blood from clotting.

61
Q

What factors lead to a decrease in Citrate Metabolism? What does this lead to?

A
  • Hemorrhage → Hypothermia and Liver Injury
  • Hypocalcemia
62
Q

If calcium chloride is not available to treat hypocalcemia in trauma patients, what is an alternative?

A

Calcium Gluconate (needs 3x more)

63
Q

Aggressive fluid resuscitation with crystalloid to achieve BP >100mm Hg or massive RBC replacement with random FFP/platelet addition will result in:

A
  • Dilution of red cell mass
  • Hypothermia
  • Coagulopathy
  • Increased hemorrhage d/t increased blood pressure
64
Q

Effects of Coagulopathy with worsened acidosis and hypothermia

A
  • Impaired coagulation factors
  • Drop in fibrinogen levels
  • Drop in platelet levels
  • ↑ risk factors for death
65
Q

Hematocrit comparison b/w Components vs. Whole Blood.

A

Components: Hct 29%
Whole Blood: Hct 38-50%

66
Q

Coag factor comparison b/w Components vs. Whole Blood.

A

Components: 65% normal coag factors
Whole Blood: 100% normal coag factors

67
Q

Plt comparison b/w Components vs. Whole Blood.

A

Components: 80K
Whole Blood: Normal plt range

68
Q

Fibrinogen comparison b/w Components vs. Whole Blood.

A

Components: 1 G
Whole Blood: 1 G

69
Q

Citrate comparison b/w Components vs. Whole Blood.

A

Components: Significant amount
Whole Blood: Lower

70
Q

Calcium needed comparison b/w Components vs. Whole Blood.

A

Components: Need IV Calcium
Whole Blood: Calcium is not needed

71
Q

What is the most common type of tourniquet?

A

C.A.T.
Meow

Combat Action Tourniquet

72
Q

How long can tourniquets safely stay on?

A

Less than 2 hours

73
Q

What is REBOA?

A
  • Resuscitative Endovascular Balloon Occlusion (of the) Aorta
  • REBOA is a technique used in trauma for patients who are rapidly bleeding to death from injuries to their chest, abdomen, or pelvis.
74
Q

What would be indications for a REBOA?

A

Torso Hemorrhage

75
Q

What would be contraindicated for a REBOA?

A
  • Pericardial Tamponade
  • Aortic Dissection
76
Q

How much does REBOA increase cardio-cerebral perfusion?

A

150-200%

77
Q

Do not leave REBOA in for more than _________ minutes

A

no more than 30 minutes

78
Q

GCS for Mild TBI

A
  • 13-15
  • Postconcussive effects
  • Half the patients will have functional limitations
79
Q

GCS for Moderate TBI

A
  • 9-12
  • Early CT…may be surgical
  • Early intubation/ventilation
  • Low mortality
  • Long-term morbidity significant
80
Q

GCS for Severe TBI

A
  • 8 or less
  • High risk of mortality
81
Q

An epidural hematoma usually occurs due to a tear in which artery?

A

Middle meningeal artery

Surgical Emergency

82
Q

Presentation of an epidural hematoma

A
  • In and out of LOC
  • Lucid intervals
83
Q

What are the symptoms of brain herniation

A
  • Cushing’s Reflex
  • Irregular Breathing
  • Hypertension
  • Bradycardia
  • Mydriasis
84
Q

A subdural hematoma is due to a tear in which vessel?

A

Sagittal Sinus veins

85
Q

What are the presentations of a Subdural Hematoma?

A
  • HA
  • Progressive drowsiness
  • Visual disturbances
  • Gait disturbances
86
Q

How do you ventilate patients with/ TBI?

A
  • Keep PaCO2 30-35 mmHg
  • Intermittent hyperventilation if ICP elevates despite treatment
87
Q

What is the mortality rate of a TBI patient with one hypoxic episode?

A

2x Mortality rate

88
Q

What is the mortality rate of a TBI patient with a hypoxic episode with hypotension

A

3x Mortality rate

89
Q

Why would the patient need to stay intubated with an injury above C4?

A

Diaphragm weakness

90
Q

Why would the patient need to stay intubated with an injury above C6-7?

A

Increased secretion and pneumonia

91
Q

What is the benefit of early stabilization of long bone fractures?

A

Reduces pulmonary complications and length of stay

92
Q

Advantages of Regional Anesthesia for Orthopedics

A
  • Allows continued assessment of mental status
  • Increased vascular flow
  • Improved postoperative mental status (Especially in geriatrics)
  • Decreased incidence of deep venous thrombosis
93
Q

Disadvantages of Regional Anesthesia for Orthopedics

A
  • Peripheral nerve function difficult to assess
  • Not suitable for multiple body regions
  • May wear off before procedure(s) conclude
94
Q

Advantages of General Anesthesia for Orthopedics

A
  • Speed of onset
  • Duration
  • Allows multiple procedures for multiple injuries
  • Greater patient acceptance
  • Allows positive-pressure ventilation
95
Q

Disadvantages of General Anesthesia for Orthopedics

A
  • Impairment of global neurologic examination
  • Requirement for airway instrumentation
  • Hemodynamic management is more complex
  • Increased potential for barotrauma
96
Q

Complications of Orthopedic Trauma

A
  • Pulmonary Embolism
  • Acute Compartment syndrome
  • Crush Syndrome
97
Q

Pulmonary Embolism presentation

A
  • Hypoxia
  • Tachycardia
  • Petechial rash on upper chest
  • PAP elevates with decrease CI
98
Q

What are the 5 P’s of Acute Compartment Syndrome

A
  • Pallor
  • Paralysis
  • Paresthesia
  • Pain
  • Pulselessness

Edema d/t muscle injury

99
Q

Most common site for Acute Compartment Syndrome

A

Distal Tibia

100
Q

What procedure is likely for penetrating trauma between the mandible and clavicle?

A
  • Emergency Exploration
  • May suture the ETT in place
101
Q

What is the purpose of a tube thoracostomy (chest tube)?

A
  • Relieves tension
  • Drains accumulated blood
  • Keep suction on until the leak resolves
102
Q

What is a Thoracotomy?

A

A procedure that allows a surgeon to look into your chest cavity to diagnose or treat illnesses. A thoracostomy (chest tube) may be inserted after to facilitate drainage.

103
Q

When will a Thoracotomy be necessary?

A
  • Mediastinal injury
  • Chest tube output exceeds 1500 ml in first hours
  • Tracheal or bronchial injury with massive air leak
  • Hemodynamically unstable with obvious chest trauma
104
Q

Complications of Blunt Chest Trauma

A
  • Bilateral pulmonary contusions (require ↑ FiO2/PEEP)
  • Subcutaneous Emphysema
  • Pneumomediastinum
  • Pneumopericardium
105
Q

Where do traumatic aortic injuries most commonly occur?

A

Distal to the takeoff of the left subclavian tethered by the ligamentum arteriosum

106
Q

What is used to diagnose traumatic aortic injuries?

A
  • CXR (wide mediastinum)
  • CT
  • Angiography
107
Q

What is the most common injury from blunt chest trauma?

A

Rib Fractures

Fractures heal over several weeks

108
Q

What is the main concern w/ Rib Fractures?

A
  • Pulmonary Complications (w/ multi rib fx)
  • Flail Chest (prone to go into ARDS)
109
Q

What type of ventilation will be necessary for Flail Chest?

A

PPV

110
Q

From an anesthesia standpoint, what type of block will be beneficial for rib fracture patients?

A

Erector Spinae to mitigate pain and avoid pulmonary complications

111
Q

Anesthesia Management of Blunt Cardiac Trauma

A
  • Control of fluid
  • Coronary vasodilators (nitrate infusion)
  • Treatment of rhythm disturbance
  • Possible ASA/heparin
  • If new hypotension or dysrhythmia develops….TTE/TEE
112
Q

Hallmark signs of pericardial tamponade

A
  • Beck’s Triad
  • Hypotension
  • Muffled Heart Tones
  • Distended neck veins
113
Q

What does FAST stand for?

A

Focused Assessment (by) Sonography (for) Trauma

114
Q

What is the SBP goal if bleeding is non-compressible (chest, abdomen injury)?

A

90 mmHg

115
Q

Where are the four areas in the body where non-compressible bleeding can occur?

A
  • Chest (Thoracic Cavity)
  • Abdomen (Abdominal Cavity)
  • Pelvis
  • Retroperitoneal Space
116
Q

What three areas of the body are semi-compressible or difficult to compress?

A
  • Neck
  • Groin
  • Axillia
117
Q

What a ”well resuscitated” trauma looks like.

SBP:
O2 Sat:
Temp:
U/O:
Hb:
Base Deficit:
Lactate:
INR:

A

SBP: 100mmHg (if no TBI)
O2 Sat: >92%
Temp: > 95 (35)
U/O: > 30 (0.5 ml/kg/h)
Hb: > 8.0
Base Deficit > -0.4
Lactate < 2.5
INR < 1.5

118
Q

What risks are involved with Trauma and Pregnancy?

A
  • Spontaneous Abortion
  • Preterm labor
  • Premature delivery
119
Q

Considerations for 1st-trimester trauma patients?

A
  • HCG in female trauma
  • Birth defects/miscarriage d/t radiation and medications
120
Q

Considerations for 2nd/3rd-trimester trauma patients?

A
  • US exam
  • B-agonists/magnesium for preterm labor
  • Emergency CS for uterine hemorrhage or gravid uterus in the way
  • Left lateral displacement
  • Long spine board
121
Q

Anesthesia Considerations for Jehovah’s Witness and Trauma.

A
  • Early ID and control of hemorrhage
  • Deliberate hypotension
  • Limited preoperative phlebotomy
  • Some patients may accept cell saver, albumin
  • Factor VII
122
Q

Criteria for Extubating Trauma Patient (Mental Status standpoint)

A
  • Resolution of intoxication
  • Able to follow commands
  • Non-combative
  • Pain adequately controlled
123
Q

Criteria for Extubating Trauma Patient (Airway Anatomy and Reflexes standpoint)

A
  • Appropriate cough and gag
  • Ability to protect the airway from aspiration
  • No excessive airway edema or instability
124
Q

Criteria for Extubating Trauma Patient (Respiratory Mechanics standpoint)

A
  • Adequate Vt and respiratory rate
  • Normal motor strength
  • Required FiO2 less than 0.50
  • Systemic Stability
125
Q

Criteria for Extubating Trauma Patient (Systemic standpoint)

A
  • Aqeduately resuscitated
  • Normothermic w/o signs of sepsis

Mar: Sem 6 - Principles B (14 decks)

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