trauma & cric care Flashcards
Crash 3 trial
TXA is safe in patients with traumatic brain injury and that treatment within 3 hours of injury reduces head injury–related death.
TXA dosing?
1g within 3 hours then
1g given over 8 hours
PROMMTT study
early administration of balanced blood products leads to a decreased 6-hour mortality rate
1:1:1 red blood cells:platelets:plasma is recommended
LD50 fall from height
4 stories
indication for hemostatic resucitation?
4+ U RBC in 1 hour
or 10+U in 24 hours
timing of acute traumatic coagulopathy?
immediate, happens before ED arrival.
FAST locations?
perihepatic (MC to see blood), perisplenic, pelvis, pericardium (START WITH PERICARDIUM)
when to use low v high frequency FAST US?
low: good for tissue penetration
high: good for resolution
FAST cannot detect fluid < ?
<80 cc.
FAST scan misses what?
hollow viscus injury, rp bleeding
when is local wound exploration OK in penetrating abdominal trauma?
if no fascial violation (after ruled out peritonitis/evisceration)
bladder pressure in abdominal compartment syndrome?
25-30 mm Hg.
ED thoracotomy
4th or 5th IC space
open pericardium ant to phrenic
cross clamp aorta; watch anterior esophagus
ED thoracotomy indication (Fiser)
- penetrating 15 min chest
- penetrating 5 min non-chest
- penetrating with signs of life on way to hospital
- blunt 5 min
epidural (lenticular) or subdural (crescent) hematoma OR indication?
midline shift > 5 mm
epidural > 15mm
sundural >10mm
MC bleed in head trauma?
Intraparenchymal hemorrhage.
normal cerebral perfusion pressure
60+ mm Hg
Cerebral perfusion pressure calculation?
CPP = MAP - ICP
Main regulator of CPP?
PaCO2 (this autoregulation is lost in TBI)
normal ICP?
10 mm Hg (keep <20 mm Hg)
Co2 and Na goals in increased ICP?
CO2 (relative hyperventilation) 30-35 pCO2
Na goal 140-150
mannitol in increased ICP? Side effect?
1 g/kg; give 0.25 mg/kg q4h after that
Side effect: HYPOTENSION
ICP monitor indication and types?
GCS < 8 with abnormal CT.
Ventriculostomy into ventricle.
BOLT into parenchyma. (cannot drain CSF)
Golden rule of Head Trauma?
Avoid HYPOtension and HYPOxia (to avoid secondary brain injury and HYPER&HYPOglycemia
Cushing’s in increased ICP
bradycardia (intermittent = impending herniation)
hypertension
low respiratory rate = Cheyne Stokes breathing
How to quickly treat increased ICP?
HOB 30 elevation, ventilate to CO2 35, mannitol, HTS, sedate, paralyze.
when is peak ICP due to swelling?
48-72 hours
raccoon eyes
peri orbital ecchymosis (anterior fossa fracture = basal skull fx)
battle sign
mastoid ecchymosis (middle fossa fx = basal skull fx)
look for facial nerve injury
Adjuncts to give in head trauma?
- Keppra x 1 wk BID for EARLY Sz ppx
- EARLY feeding 24-48hr
- Correct COAGULOPATHY
Avoid steroid unless worsening deficit
CM site of facial injury in temporal skull fx?
geniculate ganglion
nerves affected in temporal skull fx?
VII > VIII.
coagulopathy with TBI?
release of tissue thromboplastin
Jefferson fracture = C1 BURST FX
caused by axial loading
tx: rigid collar
tx burst fx = spinal fusions (bc usually anterior and middle columns (1+ column = fixation indicated)
Hangmans fx = C2 fx
caused by distraction/extension
tx: traction and halo
dens
odontoid process
C2 odontoid fracture
type I: above base, stable
type II: at base, unstable (need fusion or halo)
type III: extends into vertebral body (nee fusion or halo)
thoracolumbar spine columns
anterior: ALL to ante 1/2 vert body
middle: post 1/2 to PLL
posterior: facets, lamina, spinous processes, interspinous ligaments
compression = wedge fx (spine)
typically anterior column
tx: TLSO
upright fall injuries
calcaneus, lumbar, wrist/forearm injuries
lefort I
max fracture straight across
tx: reduction, stabilization, possible wires
lefort II
lateral to nasal bone, diagnoal toward maxilla
tx: reduction, stabilization, possible wires
lefort III
lateral orbital walls
tx: suspension wiring to frontal bone +/- ex fix
nasoethmoidal orbital fx
70% have CSF leak (tau protein)… try to wait it out 2 wks then may need epidural catheter or surgical dura closure
orbital blowout fx
impaired upward gaze or diplopia with UPWARD vision need repair
(use bone frag or bone graft to restore floor)
mgmt posterior nose bleed (INTERNAL MAXILLARY ARTERY>ethmoidal)
angioembolization or foley catheter
neck zone I
clavicle to cricoid
neck zone II
cricoid to angle of mandible
neck zone III
angle of mandible to base of skull
mandibular injury dx
fine cut face CT
mandibular fx tx
IMF x 6-8 wks or ORIF
which zone MUST YOU ALWAYS OR?
zone 2.
traumatic esophageal or hypopharyngeal repair leak rate?
20%; leave drains next to all
traumatic thyroid injury?
suture bleeders and DRAIN. don’t resect.h
where can you reimplant the RLN if injured traumatically?
into cricoarytenoid muscle
what % of common carotid ligation leads to stroke?
20%
Thoracotomy indication after CTb?
1.5L initial, 200cc/hr x 4 hours
mgmt of sucking PTX
(>2/3 diameter of trachea); cover with gauze taped on 3 sides
Flail chest dx
3+ consec ribs broken at 2+ sites
can have 48 hours of good before resp decomp
Treatment flail chest?
Supportive
Consider epidural
Consider PPV (contusions cause respiratory compromise)
Consider plating if not improving
traumatic diaphragmatic hernia repair appraoch?
acute < 1 wk: transabdominal
chronic >1wk: chest to bring down adhesions
strangulation can occur at any time.
consider PTFE mesh
what % of aortic tears will show on XR?
5%. need CTA.
distal R SCA injury approach?
midclavicular incision with resection of medial clavicle
cause of death after myocardial contusion?
Vtach and Vfib, esp in first 24 hours.
MC arrhythmia overall in myocardial contusion?
SVT.
MC finding is ST or PVCs
consider aortic transection with which rib fx?
1st and 2nd.
pelvic fx type I
unstable (CRUSH)
20-30% mortality; 10+U EBL, high complication risk
pelvic fx type II
unstable (noncrush)
8-12% mortality, 2-10U EBL, med complication
pelvic fx type III
stable <5% mortality, 1-4U EBL, 10-20% complications
anterior pelvic fx manifestation?
venous bleeding mostly from pelvic venous plexus
tx: just tamponade
posterior pelvic fx manifestation?
more likely arterial….
MC associated injury with pelvic fx in trauma?
head injury
pelvic fx open book mgmt
stable: angiography
unstable: preperitoneal packing in OR
MC traumatic injury to duo?
D2 > LoT
intraop duodenal hematoma?
mostly at D3 (overlying spine); need to open if 2+cm any mechanism.
CT scan finding on old paraduodenal hematoma?
stacked coin or coiled spring; presents as SBO
tx: NGT TPN until hematoma resorbed.
traumatic duodenal injury?
try to primarily repair.
consider pyloric exclusion and GJ, consider J tube, place many drains.
if D2 and can’t primarily repair?
jejunal serosal patch until Whipple
need pyloric eclusion and GJ, J tube
trauma whipple
don’t do it.
MC organ injured in penetrating abdominal trauma?
small bowel > liver
what circumference and lumen diameter to consider bowel resection and anastomosis in traumatic injury?
50% circumference and 1/3 lumen diameter.
hematomas to explore in OR?
2cm+ (mesenteric, duodenal, etc.) and ALL COLONIC HEMATOMAS
R and T colon injuries?
primarily repair if <50% circumference injured and without devascularization. no diversion.
L colon injury and intraabdominal rectum mgmt?
primary without diversion < 50% and no devascularization.
if COLON colectomy/LAR required, DLI if gross contamination, 6 hrs to repair, 6+U RBC given.
if RECTAL injury, needs DLI regardless.
extraperitoneal rectal injury
high rectum: primary repair (if LAR needed, always DLI)
midde rectum: end colostomy only without APR (rly hard to reach)
low rectum: primarily with transanal approach & end colostomy only without APR if cannot access it or too hard to primarily repairx
MC organ injured in blunt abdominal trauma?
liver > spleen.
portal triad hematoma?
explore all.
retrohepatic IVC Injury? how to perfuse while repairing?
can place an atriocaval shunt.
traumatic CBD injuyr?
<50%: repair over stent.
>50%: choledochojejunostomy
consider IOC
portal vein injury
repair with lateral venorrhaphy
may need to perform distal panc to get to portal vein
mortality with ligation of portal vein
50%.
PV injury can’t get to?
transect pancreatic duct (will then need distal pancreatectomy)
pringle maneuver clamp time?
15-20 min.
indication to OR or IR for stable blunt liver injury?
4+U RBC or becomes unstable.
bed rest in liver or splenic injury, blunt?
5 days.
postsplenectomy sepsis highest risk after splenectomy?
2 yrs
timing of vax postsplenectomy?
pneumococcus
meningococcus
H. flu
within 30 days after splenectomy (best if before discharge)
indication to OR or IR for stable splenic injury?
2+U RBC or becomes unstable
pancreatic injury mgmt?
only operative if duct is involved.
any hematoma needs to be explored.
pancreatic duct injury managment?
if close to SMV, need to placed drains and Whipple later
if far from SMV, distal panc
major signs of vascular injury?
- active hemorrhage
- pulse deficit
- expanding/pulsatile hematoma
- distal ischemia
- bruit or thrill
minor signs of vascular injury?
- hx hemorhage
- large stable/nonpulsatile hematoma
- ABI < 0.9
- unequal pulses …
they all need CTA.
when GSV graft needed for arterial injury?
2+cm defect in vessel.
use contralateral if leg injury
single calf artery transection tx?
just ligate.
indication for fasciotomy?
ishcemia > 4-6 hrs
compartment syndrome dx?
20+mm Hg in compartment
6 P’s
pulselessness
pain
paresthesia
paralysis
poikilothermia
pallorh
how to repair IVC injury
if <50% residual stenosis, primary
if >50%, GSV or synthetic patch
proximal/distal control with pRESSURE NOT CLAMPS
how to access posterior wall injury to IVC?
cut into anterior wall and repair through anterior approach.
all knee dislocations need what vascular study?
formal angiogram unless pulse absent.. then just go to OR
anterior shoulder dislocation associated injury?
ax nerve
prox humerus fx injury?
ax nerve
posterior shoulder dislocation injury?
ax artery
midshaft humerus fx or spiral humerus fx injury?
radial nerve.
distal supracondylar humerus fx
brachial artery
elbow dislocation injury?
brachial artery
distal radius fx
median nerve
anterior hip dislocation injury?
femoral artery & fem fx
posterior hip dislocation injury?
sciatic nerve, peroneal nerve/injury
distal supracondylar femur fx
pop artery
posterior knee dislocation injury?
pop artery
fibula neck fx
peroneal nerve
hematuria in trauma
all need CT scan.
L renal vein ligation?
near IVC is fine.. has adrenal and gonadal collaterals unlike R RV.
Ant to post renal hilum?
vein, artery, pelvis. VAP.
meatal or scrotal hematoma/bleeding?
need CT cystogram
extraperitoneal: starbursts. (just need FOLEY x 7-14 days)
intraperitoneal: leak seen (need OR and FOLEY)b
bladder injury… mostly blunt or pen?
mostly blunt. (pelvic fx lacerates)
ureteral trauma… mostly blunt or pen?
mostly penetrating.
how to dx ureteral trauma?
IVP (multishot) or retrograde pyelogram.
traumatic upper or middle third ureteral injury > 2cm?
perc nephrostomy, tie off both ends of defect
later: ileal conduit or tran UUostomy
traumatic lower third ureteral injury > 2cm?
reimplant +/- hitch.
<2cm upper and middle ureteral injury?
primary over stent
<2cm lower third ureteral injury?
reimplant into bladder
blood supply location to ureter?
upper 2/3: medial
lower 1/3: lateral
drainage after ureteral injury repair?
all need DRAINS.
<2cm ureteral injury
upper/middle third: mobilize, spatulate primary repair over double J STNET with fine absorbable suture
lower: reimplant
how to check for leaks in ureteral trauma/repair
IV indigo carmine or IV methylene blue
blood supply location to ureter
upper/middle: medial
lower: lateral
urethral injury suspected over bladder? (free floatig prostate, scrotal hematoma, pelvic fx, meatal blood)
need RUG.
which portion of urethra most susceptible for transection
MEMBRANOUS
mgmt urethral trauma: anterior vs posterior, small vs large
Anterior, small: explore, debride, primary closure over foley catheter
Posterior: perc suprapubic catheter drainage and repair in 2-3 mos
genital trauma
erectaile body fx… may need to repair tunica albuginea or Buck’s fascia
testicular rupture dx
US: tunica albuginea violation
pediatric trauma vital sign considerations?
increased risk of hypothermia, increased risk head injury, BP is not good indicator of shock (last thing to go)
respiratory changes in pregnant mom
CHRONIC COMPENSATED RESP ALKALOSIS
increased Tv, decreased FRC, increased O2 consumption
blood loss permitted in pregnant lady before sx seen?
1/3 total loss without signs!
Rhogam in pregnant trauma?
RhoGAM if mother Rh- (in case baby +)
look for fetal blood cells in mom blood. “Kleihauer Betke test” = preterm labor associated with placenta abruption
fetal maturity dx?
lecithin:sphingomyelin LS ratio > 2:1
positive phosphatyidylcholine in amniotic fluid
Fetal monitoring at what week gestation?
24 weeks+
MC cause placental abruption in trauma setting? 50% will die.
shock > mechanical forces
location of uterine rupture
POSTERIOR fundus
tx uterine rupture AFTER Delivery
just aggressively resuscitate until uterus begins to clamp down
zone 2 hematoma penetrating vs blunt?
explore all PEN, explore if BLUNT expanding
zone 1 hematoma
explore all (PEN AND BLUNT)
zone 3 hematoma
blunt just angioembolize (pelvic)
penetrating: OPEN > 2cm
black widow bite
n/v, cramps
treat: IV calcium gluconate, muscle relaxants, morphine if no cramp
brown recluse spider bite
skin ulcer with necrotic center and surrounding erythema
treat: dapsone, wait a few weeks to demarcate before skin graft NO ANTIVENIN LIKE BLACK WIDOW OR CORAL SNAKE
human bite ppx?
yes. Augmentin
viperidae snake bite presentation
hematologic effects
thrombocytopenia, coagulopathy, and DIC
Rhabdomyolysis and compartment syndrome
elapidae snake bite
toxic neurologic effects
irreversible binding at the acetylcholine receptors
generalized weakness and fasciculations
respiratory paralysis and death
every bite needs?
tetanus
cat bite
needs 3-5 days of ppx abx and irrigation
EF ejection fraction equation?
SV/LVEDV
atrial kick percentage of LVEDV?
20%
anrep effect
automatic increase in contractility secondary to increased afterload
bowditch effect
automatic increase in contractility secondary to increased HR
normal O2 delivery to consumption ratio
4:1
right shift (decreased affinity) on oxygen-hemoglobin dissociation curve.
increase CO2 (bohr effect)
increase temp
increase ATP
increase 2 3 DPG
decrease pH
where to place swan ganz catheter
zone III; lower lung (less resp influence)
swan ganz hemoptysis
pulmonary artery bleed…
1. mainstem opposite (can increase PEEP before this to tamponade PA)
2. fogarty affected side or thoracotomy/lobectomy
only absolute contraindication to swan ganz?
mechanical heart valve on RIGHT side
relative CI to swan
LBBB, hx pneumonectomy, recent PPM, right sided endocarditis
distance to wedge. RSV R IJ, LSVC L IJ
R SCV: 45 cm
R IJ 50 cm
L SCV 55 cm
L IJ 60 cm
when to calculate the wedge pressure
at end expiration.
determinant for myocardial oxygen consumption
- ventricular wall tension»_space;» heart rate
normal alveolar-arterial gradient?
10-15 mm Hg
VEINS with highest and lower oxygen saturation
coronary sinus blood LOWEST
renal veins HIGHEST
Classes of hemorrhagic shock?
I: 0-15% (no signs)
II: 15-30% (tachycardic, narrow PP)
III: 30-40% (hypotension)
IV: >40%
hemorrhagic shock
effect on wedge, CO, SVR?
decrease wedge, decrease CO, increase SVR
septic shock
effect on wedge, CO, SVR?
decrease wedge, increase CO, decrease SVR
cardiac shock
effect on wedge, CO, SVR?
wedge increase, decrease CO, increase SVR
neurogenic shock
effect on wedge, CO, SVR?
wedge decrease, decrease CO, decrease SVR
adrenal insufficiency
effect on wedge, CO, SVR?
wedge decrease, decrease CO, decrease SVR
Becks triad
hypotension, muffled heart sounds. jugular venous distension
ECho finding in cardiac tamponade
impaired diastolic filling of right atrium initially (1st sign)
pulsus paradoxus
in cardiac tamponade;
decrease 10mm+ SBP with inspiration
early sepsis triad?
hyperventilation, confusion, hypotension
sudan red stain for fat embolism
can light up fat in sputum and urine
Fat embolism sx?
- Petechial rash
- AMS
- Resp distress
2 criteria for fat emboli dx?
Gurd & Wilson’s (2 major, or 1 maj+4min)
Schoenfeld (5+ = dx)
mgmt fat emboli?
supportive only
positioning for air embolus?
left lateral decubitus; keep air in the R heart
iABP placement
tip distal to L SCA 1-2 cm below top of arch; infaltes on T wave (diastole), deflates on P wave (systole)
absolute CI to IABP
aortic dissection
severe aortoiliac disease
aortic regurgitation
relative CI to IABP
aortic aneurysm
vascular grafts
dobutamine receiptors?
B-1 (increase contractility)
insulin in sepsis
early gram negative sepsis: decrease insulin, increase glucose
late gn sepsis: increase insulin and increase glucose (insulin resistance)
dopamine receptors?
DA (renal), B-adrenergic (increase contractility), a-adrenergic (increase BP)
milrinone receptors?
phosphodiesterase inhibitro (increase cAMP)
increase Ca and contractility… cause vascular smooth muslce relaxation and pulm vasodilation
neo MOA
a-1 vaoconstriction
levo MOA
a1 and a2»_space; B1
epi MOA
B1 and B2 –> a1 and a2 (high doses)
isoproterenol MOA
B1 and B2
very arrhythmiogenic
nipride MOA
arterial vasodilator…
check thiocyanate levels for toxicity
nipride toxicity mgmt
amyl nitrite then sodium nitrite
weaning parameters for extubation?
NIF > 20
FiO2 < 40%
PO2 > 60
PCO2 < 50
7.3507.45
can follow commands
total lung capacity
FVC + RV
FVC forced vital capacity
maximal exhalation after maximal inhalation
RV
lung volume after maximal expiration (20% TLC)
functional residual capacity FRC
lung volume after normal exhalation ERV + RV
increase by increasing PEEP!
also increases in aging
ERV vs IRV
additional inspired or expired after normal tidal volume
restrictive lung disease FEV1
can be normal with decrease FVC
obstructive lung disease FEV1
decreases, with normal FVC
dead space vs shunt
dead space is ventilated and not perfused
high V/Q dead space increase PCO2
shunt is perfused. decreased PO2 low V/Q
ARDS criteria
acute onset
bilateral pulmonary infiltrates
PaO2/FiO2 < 300
absence of heart failure; wedge < 18 mm Hg
phases of ARDS
- EXUDATIVE: proteinaceous fluid into alveolar space (WBC in, oxygen can’t get in)
- FIBROPROLIFERATIVE: fibrosis and collagen formation = noncompliant
this is REVERSIBLE - RESOLUTION: remodeling and clearing the edema
mendelsons syndrome in aspiration?
chemical pneumonitis from aspiration of gastric secretions
MC site of aspiration?
sup seg RLL
how much renal destruction before renal dysfunction occurs?
70%
best to diagnose and find etiology for azotemia
fena
urine Na/Cr / plasma Na/Cr
>3% parenchymal
<1% prerenal
MC cause of renal ATN and postop low UOP?
intraop hypotension
renin released why?
decrease BP (JG apparatus) and hypernatremia (macula densa), hyperkalemia, B-adrenergic stimulation
where does aldosterone act after stim in cortex by ace II
DCT to reabsorb water by upregulating NaK ATPase on membrane
ang II autoregulation
vasoconstricts and inhibits renin release
ANP atrial naturetic peptide
released from atrial wall when distended
inhibits na and water resorption in the collecting ducts and is a vasodilator
what stimulates posterior pituitary gland to release ADH?
high osmolality; increase water resorption at CDs
also to V1 (vasoconstrictor)
afferent vs efferent limb on GFR
EFFERENT limb controls GFR
NSAIDs on kidneys
decrease prostaglandins - results in renal ARTERIOLE constriction
aminoglycosides nephrotoxic
direct tubular injury
7myoglobin and DYES nephrotoxic
direct tubular injury
SIRS
- temp <36, ,>38
- HR > 90
- RR > 20 or PAcO2 < 32
WBC > 12 or <4
brain death exam requirements
unresponsive to pain, absent cold caloric oculovestibular reflexes, absent oculocephalic reflex (no tracing), no spontaneous respirations, no corneal reflx, no gag reflex, fixed and dilated pupiles, positive apnea
DTR in brain death
can still be present
apnea test
CO 2 > 60 mm Hg or increase by 20 mm Hg after 10 min disconnection
SCORE: “repeat ABG 8 min showing the above^”
CO affinity for Hgb compared to o2
250 stronger
CO affect on Hgb dissociation curve
left shift
abnl carboxyHgb in smokers vs normal
20% vs 10%
methemoglobinemia cause
nitrites (hurricaine spray, fertilizer)
mgmt methemoglobinemia
methylene blue
methemoglobinemia sat O2?
85%
mgmt cyanide toxicity
amyl nitrite then Na nitrite, or hydroxycobalamin
TRICC trial
Transfusion Requirements in Critical Care (TRICC) trial
only transfuse > 7 g/dL
UTI dx on UA; LE and nitrites?
Leukocyte esterase is directly related to #WBC; may be negative in patients with recent Foley catheter insertion.
Nitrites are a by-product of nitrate metabolism by Enterobacteriaceae and do not accurately account for Staphylococcus, Enterococcus, or Candida spp.
Decrease CAUTI?
48 hours max.
STOPIT trial
antibiotic treatment for 4 days = 10 days of therapy
primary endpoint of the study:
surgical site infection
recurrent intra-abdominal infection
deaths
how much Ca to infuse with transfusion?
If 10% calcium gluconate is used, 10 to 20 mL should be infused per 500 mL of blood transfused.
If 10% calcium chloride is used, only 2 to 4 mL should be infused per 500 mL of blood transfused.
how to minimize tracheal stenosis after prolonged intubation
maintain trach cuff pressures < 30 mm Hg
small ETT size
femoral vein localization/identification on US
use GSV
medially/distally: GSV find. trace up to femoral vein can be a useful confirmatory maneuver.
best pacing mode for intraop
‘OO’ - asynchronous
delirium after OR; risk factor
MMSE mild dementia < 25 score
amanita mushroom causing acute liver failurew
Cerebral edema and intracranial hypertension are unique to acute liver failure (ALF) – neurologic exams
The coagulopathy should not be corrected unless the patient is spontaneously bleeding, which is very rare. Unless going to OR for CNS.
dpl op note
open cut down vs Seldinger
10 cc of blood/bile/food is +
1L of warm saline in adult
10 cc/kg in children
drain to gravity
if 100K RBC or 500 WBC or bacteria, bile/food.. POSTIIVE DPL.
dpl contraindication
pregnancy, unstable, previous abdominal operations, pelvic ring fracture** though last two are relative conrtraindications
damage control operation indication
<34C
>12L or 10U x 24 hours
Base Def > 15
pH < 7.2
Cricothyroidotomy landmarks?
Triangle with cricothyroid muscle “V” below and cricoid cartilage below.
Superiorly thyroid cartilage.
Pupillary exam abnormalities and their meanings?
Fixed and dilated unilaterally: IPSILATERAL blood compressing CN III.
Bilateral pinpoint pupils: PONTINE hemorrhage.
Rapid warfarin reversal?
PCC.
Can give FFP and Vit K.
Central cord syndrome?
CAPE/GLOVE weakness (UE)
2/2 spinal stenosis.
Brown Sequard syndrome?
IPSILATERAL motor, CONTRALATERAL pain/temperature.
Hemisection 2/2 SW
Anterior cord syndrome?
MOTOR deficit alone.
2/2 vascular injury to anterior spinal artery
SCIWORA?
Spinal cord injury without radiographic abnormality.
in peds.
Spinal shock vs neurogenic shock?
Spinal: SENSORY/MOTOR (not hemodynamics)
- absent bulbocavernosus and cremasteric reflex
- functions can return with spinal shock so if reflexes are GONE, then all deficits are permanent.
Neurogenic: HEMODYNAMIX (brady/hypo)
What to consider with sternal fx?
Blunt cardiac injury (get EKG)
Echo if instability or new arrhythmia
MC abnormalities: sinus tachycardia and PVCs
Traumatic aortic injury (MC: lig arteriosum) sx?
Hypotension, upper extremity hypertension, unequal blood pressures
CXR findings in aortic injury?
- Widened mediastinum >8cm
- Depressed mainstem bronchus
- Deviated NGT to right
- Apical cap, disruption of calcium ring “broken halo” …
Get CTA CHEST!
Aortic injury grading
Type I: intimal tear
Type II: intramural hematoma
Type III: pseudoaneurysm
Type IV: rupture
Anterior stab wound management - what to look for on local exploration?
Anterior rectus sheath violation
If violated anterior rectus sheath, WTD?
Observe if HDS and good exam.
Dx lap if unexaminable or concerning exam/vitals.
What injury in FLANK stab wound?
RP structure (get CT IV/PR/PO contrast)
What injury in THORACOABDOMINAL stab wound?
Diaphragm injury (get dx lap even if imaging/exam good)
Bowel injury in trauma?
<50% primary repair if palp pulses
>50% resect and anastomosis unless damage control.
Penetrating colon injury management?
Primary repair if non-destructive
Resect if destructive.
Bucket handle injury repair?
Resect
Pancreatic HEAD injury (+/- duct injury)
Drain only.
Pancreatic distal injury with duct injury?
Distal panc +/- splenectomy depending on HDStability
Pancreatic distal injury without duct injury?
Drainage only
Zones of RP?
I: central (aorta, cava)
II: lateral (renals)
III: pelvic (iliacs)
Penetrating injury to all RP zones?
EXPLORE ALL.
Blunt RP injuries based on zones
I: explore
II: explore if expanding
III: pack and angio
Triad of death?
Hypothermia, coagulopathy, acidosis
Abdominal compartment syndrome first signs?
Increased peak pressures on vent and decreased UOP
Diagnostic abdominal compartment syndrome?
Absolute bladder pressure > 20
Treatment of ACS? In burn patient?
Decompressive laparotomy
In burn, HIGH mortality. Consider drain placement for ascites instead.
Factor VII in trauma
DO not give.
TEG: thromboelastrography
vs
ROTEM rotational thromboelastometry
TEG manual pipetting
ROTEM automated pipetting
ROTEM interpretation
clotting time low - give FFP or PCC
MCF (max clot firmness) low - get FIBTEM
FIBTEM MCF low - fibrinogen
FIBTEM MCF nl - plt
LI30 - give TXA
TEG interpretation
R time to make clot - give FFP
K time to make 20mm clot - give cryo
A angle to make strong clot - cryo
Max amp size of clot - plt
LY30 to lyse - TXA if high
Bladder injury?
Esp in PELVIC fx.
dx = CT cystogram or retrograde cystopgraphy
Intra: OR
Extra: Foley if uncomplicated
How to suture bladder injuries
2 layers, watertight absorbable suture with Foley x 10-14 days prior to removal
Ureteral injury management?
Mid-ureteral: if <2cm spatulate, primary anastomosis with double J stent with FINE ABSORBABLE suture. if> 2cm tie off +PCNT, later can do UU or ileal conduit
Distal: re-implant +/- psoas hitch If tension.
Urethral injury signs?
Scrotal/perineal hematoma, high riding prostate, blood at meatus. Can’t pass a foley
Urethral injury suspected? Diagnostic of choice?
RUG. RETROGRADE URETHROGRAM.
Hard signs of vascular injury?
Pulsatile bleeding.
Expanding hematoma.
Absent pulses.
Bruit/thrill.
Soft signs of vascular injury
Nonexpanding hematoma.
Decreased pulses ABI < 0.9.
Proximity to nv structures.
vascular/ortho order?
VASCULAR BEFORE ORTHO
if ABI <0.9, fix then recheck ABI.
Popliteal artery/vein injury
Consider fasciotomy after repair.
Cuffed vs uncuffed ETT pediatrics?
CUFFED tube (except in infants)
ETT size peds?
Pinky nail bed width or
Age/4 + 4 = ET tube size
intubation considerations for peds
narrow, short, anterior airway
use a straight blade with upward angulation
Pediatric resuscitative fluid dosing?
20 cc/kg bolus for crystalloid
10 cc/kg bolus for blood
Handlebar injury ass’d injury?
Duodenal hematoma
if able, just NGT decompression bowel rest & parenteral nutrition, repeat contrast study in 5-7 days
OR in 10-14 days if no improvement
When to suspect popliteal artery injury?
Posterior knee dislocation
Large differential between peak and plateau (insp pause) pressure?
Large airway obstruction
or Bronchospasm
inspiratory pause?
alveolar pressure - plateau pressure
expiratory pause
total PEE (pressure in airways when there is no airflow)
Berlin criteria for ARDS
Mild P:F 200-300
Mod 100-200
Severe <100
Indications for diverting colostomy in trauma?
Complex perineal wound
Big rectal wall hematoma on rigid proctoscopy (GSW)
If both peak and plateau pressures are high?
Alveolar lung disease (ARDS)
SIMV vs ACVC
Both RR and Tv are set.
In SIMV: Spontaneous breaths ABOVE set rate are not fully supported but delivered breaths are synchronized (typically more comfortable)
Extubation criteria
50% or less
PEEP < 10
RSBI (Rapid shallow RR/TV) < 100 (BEST PREDICTOR)
NIF > 20 (good predictor to fail if < 20)
Acuity of ARDS?
1 wk from insult
ARDSNET
Vt 4-6 cc/kg
Permissive hypercapnia in ARDS?
pH > 7.20 as long as good oxygenation
ARDS tx plateau pressure
keep it low < 30 cm H2O
APRV mode?
Airway pressure release ventilation
Long inhalation, short exhalation
Set Phigh and Plow, Thigh, Tlow (time) … want long Thigh and short Tlow
Spontaneous breaths
Prospective RCTs proved what benefits ARDS?
Proning and paralysis.
Severe sepsis definition
SIRS + source + EOD*
Sepsis based on SOFA
If SOFA increases by 2+ or a score of 2+
SOFA score based on:
GCS
MAP
P:F
PO tolerance
Cr
plt
BG
What lab to send for fungal infection?
1,3 beta D glucan assay
What lab to send for invasive candidiasis?
Mannan antigen
+
Anti-mannan antibody
Timing in sepsis management?
3 hrs - Cx, Abx, fluids
6 hrs - pressors
Dopamine receptors
kidney, squeeze, press.
LOW:
DA (kidneys)
MEDIUM:
B1
HIGH:
alpha
Norepinephrine receptors
alpha > B1
Epinephrine receptors
alpha, B1
Phenylephrine receptors
alpha ONLY
Vasopressin receptors
V1-R
V2-R kidney (ADH) and endothelium (8 and vWF release)
Dobutamine receptors
B1, B2
(cardiac output and some vasodilatory…)
Milrinone receptors
Phosophodiesterase inhibitor
Increase CO, cAMP… inotrope, vasodilatory
Uncommon PE EKG Finding
S1Q3T3
Cardiac output calculation?
CO = HR X SV
Cardiac index calculation?
CI = CO/BSA (body surface area)
Swan reading in HEMORRHAGIC SHOCK
Low CO, high SVR, LOW** filling pressures (CVP, PWP)
Swan reading in SEPTIC SHOCK
HIGH* CO (may be low in late severe), LOW* SVR, low/normal CVP and PWP (filling pressures)
Swan reading in CARDIOGENIC SHOCK
Low CO, high SVR, HIGH** filling pressures
Oxygen delivery calculation
Oxygen delivery = CO x [Hgb x O2 sat x 1.34 + (PaO2 x 0.003)]
Oxygen consumption calculation
Consumption = CO x (Arterial - venous O2 differences)
Extraction ratio calculation
O2 consumption / O2 delivery
AMPLE secondary survey questiosn?
Allergies
Medications
Past illnesses/preg
Last meal
Events leading up to injury
lumbar vessels orientation to renals?
Lumbar veins enter posterior L renal vein
Right gonadal into IVC?
Anteriorly
Right adrenal into IVC?
Laterally
Exposure to unk status? Needle stick
- wait for results of blood.
- if HBV titer high, good.
- if unvax/unk, give PEP HBV: HBIG and vaccination
- give PEP HIV: 3 drug
Traumatic bronchus injury?
If blunt:
MC distal trachea within 2 cm of carina >
Right main bronch
Chest CT confirms with pneumomediastinum.
Vent has continuous air leak.
cauda equina syndrome injury?
compression of lumbar plexus:
spinal roots (L3-S1) = motor loss, flaccid, loss DTR
spinal roots (S2-S4) = perineal sensory loss and bowel/bladder/sexual dysfunction, no rectal tone
IVC injury - ligation indication?
attempt anastomosis
4-0 / 5-0 prolene transverseley
better than time consuming patch or graft or shunt.
if ligating, wrap legs after and elevate
forearm compartment fasciotomy?
3 compartments: superficial flexor compartment, deep flexor compartment, and extensor compartment.
fasciotomy: dorsal incision + volar incision
when to repair facial N injury
if lateral to lateral canthus, need to surgically repaired within 72 hours…
reapproximate epineural layer or use interposition graft.
if medial, can fix nonop
direct defibrillation energy?
15 to 30 J only (as compared to 200J biphasic, 350J monophasic)
blunt solid organ injury return to work?
grade of injury + 2 wks
frostnip
frostnip: brief exposure - ice crystals on surface of skin only, with pain and the numbness/pallor
tx with rewarming - no long term damage
frostbite: 4 degrees
- first degree.
superficial. numbness, edema with firm plaque
- heals spontaneously 1-4 wks - second degree.
partial thickness with milky-white blister, healing skin is atrophic
2-4 wks to heal - third degree.
full thickness hemorrhagic blister. eschar resulting in limb/tissue loss
1-3 mos to heal - fourth degree.
all the way to bone
mummified. black.
tx frostbite
- core temp normothermic first
- remove jewelry
- rapid rewarming fo tissue in 37-39 water until tissue pliable to touch
- assess for drainage/debridement
- remove blisters (harmful prostaglandins) via needle aspiration
but leave hemorrhagic blisters intact
- no abx warranted
external landmarks for subclavian line
junction between medial and middle thirds of clavicle
and
the lateral edge of the SCM where it inserts into clavicle
where does the SCV originate?
medial border of the anterior scalene muscle
HF subsets
HFrEF <40%
HFmrEF (midrange/borderline) 41-49%
HFpEF 50+%
highest mortality rate for sepsis?
- respiratory
- abdomial
- UTI
VAP empiric coverage?
IV Vanc/Zosyn
IM epi for anaphylaxis, positioning?
lay flat to prevent empty heart syndrome
MC CAP and VAP?
CAP: S. pneumo
VAP: Pseudomonas
or after ctb?
1500 initial
or 200 x 4 hrs
shock index suggestive of shock
HR/SBP > 1
think hemorrhagic
eastern vs western trauma for resuscitative thoracotomy
WESTERN; <10min blunt, pulseless, no signs || <15min penetrating
EASTERN: penetrating thoracic: RT if signs of life; conditional without
penetrating extrathoracic RT conditional pulseless
blunt extrathoracic RT conditional pulseless with signs ONLY
esophageal injjury repair goals
control
debride
drain widely
abx
buttress
distal feeding
thoracentesis landmark
1-2 IC spaces above highest extent of the effusion if seated upright
auscultatory triangle
thinnest portion of musclular chest wall; 5-6th midaxillary line
what temp to stop CPR as you rewarm?
90F
what to explore if anterior stomach injury
posterior stomach
what to explore if posterior stomach injury
pancreas
aast stomach injury grades
I: contusion/hematoma
II: lac <2cm in GEJ or pylorus, <5cm proximal 1/3, <10cm distal 2/3
III: >
IV: tissue loss/devasc < 2/3 stomach
V: >
aast duo injury grades
I: hematoma x 1 or partial thickness lac
II: hematoma x 2, or lac < 50% circumf
III: lac D2 50-75%, D1/3/4 50+%
IV: lac >75% D2 involving ampulla
V: devasc of duodenopancreatic complex
tx duo injury with GOO
NGT x 5-7 days
CT with PO contrast prior to PO intake
+/- TPN
tx duo injury
grade I-III: Heinecke Mikulicz
IV/V: DD or RNY DJ
aast small bowel injury
I; hematoma, partial lac
II: lac < 50%
III: 50+%
IV: transection
V: transection with tissue loss or devascularized segment
bucket handle injury tx
resection
rectal injury tx
intra: resection
extra: fecal diversion with colostomy (loop or end)
do not irrigate/presacral drainage as definitive mgmt)
repewat scan post splnic angioembolization?
consider for psa or delayed bleed
mc opsi
s. pneumo
MC location for blunt liver injury?
posterior right lobe
presentation of hepatic arterial to biliary fistula
days to weeks after initial injury… hematemesis
dx with CTA and embolize
intraop kidney hematoma seen
penetrating: explore
blunt: leave unless expanding
hepatic necrosis mgmt
only necrosectomy/resection if causing pain or PO intolerance
aast renal injury grading
I: subcap hematoma w/o lac or contusion
II: nonexpanding hematoma perirenal, lac <1cm deep
III: lac > 1 cm deep without CD injury
IV: lac involving CD or hilar vascular injury with contained hemorrhage
V: shattered kidney OR avulsion with devascularizatino
aast liver grading
I: hematoma subcap < 10%, lac <1cm deep
II: hematoma subcap 10-50% or parench <10 cm, lac 1-3 cm deep, < 10 cm long
III: hematoma subcap >50% or parench >10 cm (can all be expanding), lac > 3 cm deep
IV: laceration disrupting 25-75% lobe of 1-3 segments within 1 lobe
V: >75% lobe or >3 segments within 1 lobe or juxtahepatic venous injury - retrohepatic cava or central hepatic veins
VI: hepatic avulsion
geriatric trauma inpatient (ICU) admission criteria? EAST
major trauma to any system with ISS >3
base deficit <-6av
avoid succinylcholine in who?
burn
hyperK
crush injuries
Muscular dystrophy
significant spinal cord trauma
malignant hyperthermia
MVC with lumbar chance fracture and seat belt sign?
high suspicion for HOLLOW viscus injury
maybe pancreatic injury
mortality sepsis
10%
mortality septic shock
40-50%
sepsis guidelines timing
1hr Abx after Cx
3 hr fluid 30cc/kg if lactate > 4
6 hr start pressor PRN
sepsis steroid use
IV hydrocorti 200 mg/day
respiratory failure types
1: hypoxemic
2: hypercapnic
oxygenation affected by (mech vent)
FiO2, PEEP, mean airway pressure
ventilation affected by
RR and Vt
PE tx heparin
bolus = 60-70 U/kg (max 5000)
+ gtt for PTT 60-80
PE tx
- AC
- thrombolytics (systemic) if HD instability, RH strain on TTE
- IR embolectomy/catheter directed thrombolysis
- Trendelenberg procedure if thrombolysis contraindication
coag goals before IR perc chole tube
INR 1.5
plt 50 K
mangled extremity score to amputate?
greater than 7
superficial peroneal (fibular) N injury in fasciotomy?
N trvels in lateral compartment, exits fascia 10-12 cm superior to lateral malleolus
superifical peroneal N injury sx
difficult foot eversion
tingling to dorsal foot
hounsfield units to consider blood
> 35
pedicle flap to aorta/ivc repair
patch omentum
see bleeding lac after pringle
suture ligation of vessels and omental packing
total spinal anesthesia
excessive cephalad spread of local anesthetic… large volume into intrathecal space (direct for Cr/S) or in dural puncture after epidural….
recommended fluid mIVF postop
<24 hr - LR
>24 hr - D51/2NS + 20KCl for 150Cal/day
how to gauge postop fluid resuscitation?
UOP
fluid loss in open abdomen operations?
.5cc/kg/hr
how much intraop loss to leave alone?
500 cc
insensible daily fluid losses
10 cc/kg/day mainly 75% thru skin
predictor of survival after FALL
age and body orientation
permissive hypotension in hypovolemic shock (CI IN TBI THo!)
SBP > 80
what may zone III neck injury require resection of to access carotid injuries?
digastric, SCM, jaw subluxation, mastoid sinus resection
a1 vs a2 receptors
a1 vascular smooth muscle
a2 venous smooth muscle
b1 vs b2 receptors
B1 myocardiac contraction/rate
b2: relax bronchial smooth muscle, relax vascular smooth muscle, increase renin
