Trauma/Critical Care Flashcards
What’s the difference between a shunt vs. Dead space?
Shunt: (+) blood flow / (-) aeration
Dead space: (-) blood flow / (+) aeration
What is the PaO2 that defines failure to oxygenate?
What PaCO2 defines failure to ventilate?
PaO2 < 60
PaCO2 > 55
Mechanical ventilation safe lung strategy
Tidal volume less than what?
Plateau pressure less than?
Permissive hypercapnia up to how much?
Tidal volume <6cc/kg
Plateau pressure <30mmHg
Permissive hypercapnia up to pH7.2
What’s the difference between ALI vs. ARDS?
ALI: PaO2 to FiO2 ratio <300
ARDS: PaO2 to FiO2 ratio <200
What do NSAIDs do for renal afferent/efferent vasculature?
What does hypotension do for renal perfusion?
NSAIDs: inhibit afferent vasodilation (afferent constriction)
Hypotension: afferent constriction, efferent dilation
What’s the lifespan of RBC’s?
Lifespan of platelets?
Lifespan of wbcs?
RBC’s: 120 days
Platelets: 8-9 days
Wbcs: 1-2 days
What are the five grades of pancreatic trauma? How do you treat them?
[T/F] grade III pancreatic injury can be managed non-operatively
I: minor contusion
II: major contusion without ductal injury
- non-op
III: distal transection
- distal panc
IV: proximal transection
- drain + post-op ERCP
For grades III and IV non-op management has higher complication rate. so they need an exploration if discovered on imaging
V: massive disruption of the pancreatic head
- DRAIN DRAIN DRAIN
What’s the grading system for blunt injuries to the duodenum?
I: hematoma or laceration without perforation
II: disruption <50% circumference
III: disruption 50-75% circumference
IV: >75% circumference involving the ampulla/distal CBD
- primary repair
V: massive disruption of the duodenopancreatic complex or duodenal devascularization
Blunt trauma, rib fx non-op vs rib fixation
- narcotic requirement
- cost
- ventilator days
- pneumonia
- mortality
Who should be considered for rib fixation, when is the optimal timing?
No difference in narcotic requirement Rib fixation is more expensive Rib fixation reduces ventilator days Rib fixation reduces pneumonia rate No difference in mortality
People who can’t be weaned off of ventilator. Maximum benefit within 3-5 days
If Pringle slows down the bleeding, what does it mean? Where is the injury?
What might you consider for repair if Pringle works?
It means IVC and hepatic veins are probably fine.
Consider hepatic artery ligation
What complication may occur if you ligate the hepatic artery?
Abscess or a biloma
Surgical airway in a 13 yr old. What do you do?
Cricothyroidotomy for kids 12 or older.
For kids younger than 12 -> 12, 14, 16 gauge needle airway
Neck stab wound. Carotid artery injury found during exploration. What do you do in general?
What to do if the defect >2cm? Use prosthesis?
What about a high carotid injury- how do you expose?
Generally primary repair. Prolene
2>cm use saphenous vein graft. Prosthesis is avoided generally for long term patency
High carotid- divide the digastrics, subluxation of the mandible
Neck stab wound. Esophageal injury. How do you repair it?
What if it’s hard to locate the injury?
What if it’s been more than 24 hrs?
NG tube. Can use methylene blue to identify hole. Close in two layers, absorbable suture
> 24hrs then esophagostomy, feeding tube, tissue buttress
Neck stab wound. Tracheal injury. What do you do?
What if a tracheostomy is needed? Through the same hole?
Repair with interrupted absorbable sutures muscle buttress
Never through the same hole
Neck stab wound. Vertebral artery injury. What do you do?
IR embolize
Neck stab wound. Big vein injury. IJ. Use a graft to repair? Why or why not
Graft will thrombose. Just ligate the vein
Odontoid fx types. I, II, III
Which one tends to be painful?
Which type may have airway compromise due to swelling?
Painful: type I
Airway: type II
Cardiac tamponade pathophys.
What are the two pressures at war here? What’s the endpoint?
How many phases?
Cardiac output starts to get affected when?
Initial signs of shock becomes evident in what phase?
Intrapericardial pressure vs. ventricular DIASTOLIC filling pressure. Endpoint is when these two pressures become the same. Phase 3
3 phases
Cardiac output is maintained during phase I with tachycardia & increased SVR. Phase II cardiac output goes down.
Signs of shock at phase II
ED thoracotomy
- which intercostal space?
- how many joules to defribrillate after EDT? How many Joules to externally defib?
- to Foley or not to Foley?
5th intercostal space
15-30J to internally defib. 100-200J for external defib
Don’t Foley because it can tear the defect, make it bigger
Resuscitation goals for
Plt
INR
Fibrinogen
T
Plt > 100k
INR < 1.2
Fibrinogen > 100
T > 37 (98.6)
Define pancreatic leak
What’s considered a minor fistula vs. high output.
Drain amylase > serum x3
Minor fistula < 200cc/day
High output > 700cc/day
Boundary of posterior neck triangle
Sternocleido anteriorly
Trapezius posteriorly
Clavicle at the base
Neck stab wound. Totally stable, no crepitus, no dysphagia, no dysphonia. Small 2cm sound. Non-op management. Still do CTA? Chest XR? Barium swallow?
Yes to all. Every neck wound if non-op, get everything