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AS - N934 Advanced Principles II > Trauma I > Flashcards

Trauma I Flashcards

1
Q

Rapid Overview

A

Initial impression
Few seconds
Stable vs. unstable

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2
Q

Inability to oxygenate → brain injury & death w/in _____ minutes

A

5-10

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3
Q

Primary Survey

A 
Identify & address life-threatening injuries
Airway patency
Breathing
Circulation
Disability (neuro/mental status)
Exposure
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4
Q

What are the most common trauma causes in patients < 45yo?

A

MVA
Falls
Suicide
Homicide

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5
Q

Secondary Survey

A

Detailed & systematic evaluation
Head to toe assessment
Continued resuscitation as needed

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6
Q

GCS

A 
Glasgow coma score
- Eye opening response
- Verbal response
- Motor response
Normal 15/15
< 8 → intubate
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7
Q

Airway

A

Keep ‘em breathing

100% oxygen

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8
Q

Airway Obstructions

A 
Edema or direct injury
Cervical deformity or hematoma
Foreign body
Dyspnea, hoarseness, stridor, dysphonia
Subcutaneous emphysema & crepitus
Hemoptysis and/or oral bleeding
Copious secretions
Tracheal deviation = tension pneumothorax EMERGENCY ↓CO → cardio-respiratory arrest
Jugular venous distension
Hemodynamic condition (internal bleeding)
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9
Q

Trauma Airway Management Considerations

A
  • 100% oxygen admin
  • Jaw thrust > chin lift (avoid neck manipulation)
  • Full stomach d/t SNS response
  • Oral and/or nasal airway
  • Cervical spine immobilization
  • Ventilation inadequate → tracheal intubation
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10
Q

Basilar Skull Fracture S/S

A

Battle sign - bruising behind ears
Raccoon eyes
Ears and/or nose bleeding or CSF leak

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11
Q

When to perform ETT intubation?

A

Cardiac or respiratory arrest
Respiratory insufficiency or deteriorating condition
Airway protection
Pain control - deep sedation or analgesia
GCS < 8
Carbon monoxide treatment 100% FiO2 delivery
Facilitate work-up in uncooperative (anoxic) or intoxicated patient
Transient hyperventilation TBI required

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12
Q

Tracheostomy

A

Longer to perform as compared to cricothyroidotomy

Requires neck extension (contraindicated when neck trauma or cervical injury present)

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13
Q

Surgical Cricothyroidotomy

A 
Emergency placement up to 72 hours
Vertical incision to prevent RLN injury
Complications:
1. Esophageal perforation
2. SQ emphysema
3. Bleeding or hemorrhage
Contraindicated in patients < 12yo (potential laryngeal damage)
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14
Q

Needle Cricothryoidotomy

A

Less effective ventilation
Smaller diameter ↑resistance
Pediatrics

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15
Q

RSI Indications

A

All traumas = full stomach
SNS response diverts blood flow away from GI tract
Cricoid pressure at C6

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16
Q

Trauma & Depolarizing NMBs (Succinylcholine administration)

A

Okay 1st 24 hours after burns or spinal cord injury
After 1st 24 hours → nAChR UPregulation
Excessive K+ release → hyperkalemia

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17
Q

Induction Agents

A

Etomidate 0.2-0.3mg/kg IV (cardiac stable)

Ketamine 2-4mg/kg IV or 4-10mg/kg IM (direct myocardial depression typically masked by SNS stimulation)

Propofol 2mg/kg IV

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18
Q

NMBs

Succinylcholine

A 
Dose 1-1.5mg/kg IV
Onset 30 seconds
Fasciculations
DOA 5-12 minutes
De-fasciculating dose Rocuronium 5mg
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19
Q

NMBs

Rocuronium

A

Dose 1.2mg/kg IV
Onset 30-60 seconds
Modified RSI + mask ventilation
DOA 60-90 minutes

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20
Q

Cervical Spine Clearance

A

Maintain stabilization until x-ray clearance C1-C7
Ensure patient not obtunded, sedated, or ETOH intoxication
Patient needs to be able to communicate any pain or paresthesias present

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21
Q

What keeps the diaphragm alive?

A

C4-C5

INTUBATE

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22
Q

C6-C7

A

Unable to clear secretions or cough

Intubate

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23
Q

Hemothorax S/S

A

Blood present in pleural cavity

  • Hypotension
  • Hypoxemia
  • Tachycardia
  • ↑CVP
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24
Q

Hemothorax Treatment

A

Chest tube
Possible PRBC transfusion
Single lumen ETT to secure airway → double lumen ETT

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25
Q

Pneumothorax

Definition/Types/Treatment

A

Gas present w/in pleural spaces disrupts parietal or visceral pleura
1. Simple
2. Communicating
3. Tension
Treatment = chest tube when > 20% lung collapsed

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26
Q

Tension Pneumothorax S/S

A

Occurs w/ rib fractures & barotrauma d/t mechanical ventilation

Hypotension
Hypoxemia
Tachycardia 
↑CVP
Diminished breath sounds on affected side
Tracheal deviation
→ cardiac arrest
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27
Q

Tension Pneumothorax Treatment

A

NEEDLE DECOMPRESSION
Anterior approach 2nd/3rd ICS midclavicular line
Lateral 4th/5th intercostal space

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28
Q

Flail Chest

A

At least 2 ribs fractured
Costochondral separation
Sternal fracture
Paradoxical rib/chest wall movement retract on inhalation & outward on exhalation
Respiratory insufficiency & hypoxemia over several hours w/ deterioration on CXR & ABG

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29
Q

Flail Chest Treatment

A 
1° supportive 
Pain management
- Epidural
- Intercostal blocks
Oxygen administration
- FiO2
- Incentive spirometry
- CPAP/BiPAP
Decompensation → intubate
30
Q

What’s the most common cause traumatic hypotension & shock in trauma patients?

A

Hemorrhage

Active internal or external bleeding

31
Q

Circulatory failure leads to _____

A

Inadequate vital organ perfusion & oxygen delivery

32
Q

Physiological Response to Shock

A

Vasoconstriction & catecholamine release
Preserve cardiac, brain, & renal blood flow
Inadequate organ perfusion → lactic acid & metabolic acidosis
Ischemic cells produce inflammatory factors - leukotrienes, interleukins, etc.
Multiple organ dysfunction/failure

33
Q

Shock Types

A

Hemorrhagic*
Cardiogenic
Distributive
Neurogenic

34
Q

Where do inflammatory byproducts accumulate?

A

LUNGS
Pulmonary capillary beds → results in ARDS
Sentinel organ to develop MODS

35
Q

What patients are at increased risk to experience cardiac ischemic injury in response to shock?

A

Elderly
CAD
Patients w/ minimal cardiac reserve

36
Q

What organ experiences the earliest effects r/t hypo-perfusion in response to shock?

A

Gut/intestines

Higher risk to trigger MODS

37
Q

What triggers protein C?

A

Hypotension & tissue injury → inflammatory response → endothelial activation protein C (APC)

38
Q

Protein C

A

Unable to form clots efficiently

Early diagnosis & treatment ROTEM/TEG

39
Q

Base Deficit

A 
Determines shock severity
Oxygen debt
O2 delivery changes
Fluid resuscitation adequacy
Multi organ dysfunction/failure likelihood
40
Q

MILD Shock

A

Base deficit 2-5mmol/L

41
Q

MODERATE Shock

A

Base deficit 6-14mmol/L

42
Q

SEVERE Shock

A

Base deficit > 14mmol/L

43
Q

What correlates with increased mortality r/t base deficit?

A

Admission base deficit 5-8mmol/L

44
Q

Blood Lactate Levels

A

LESS specific than base deficit
Used to determine resuscitation end point
↑lactate correlate w/ hypo-perfusion

45
Q

Normal Plasma Lactate

& Half-Life

A

0.5-1.5mmol/L
> 5mmol/L indicates significant lactic acidosis

3 hours

46
Q

What correlates w/ increased mortality r/t blood lactate levels?

A

Failure to clear lactate w/in 24 hours after shock reversal

47
Q

Systemic Perfusion Assessment

A 
Vital signs
UOP - potentially inaccurate d/t diuretic therapy, intoxication, or renal injury
Acid-base status
Lactate clearance
CO
Mixed-venous oxygenation

Gastric tonometry
Tissue specific oxygenation
SVV (stroke volume variation)
Acoustic blood flow

48
Q

Shock S/S

A 
Pale & diaphoretic
Agitated or obtunded (altered neuro status)
Hypotension
Tachycardia
Prolonged capillary refill
↓UOP
Narrowed pulse pressure
49
Q

IV Access Sites & Advantages

A

AC PIV
Subclavian - easiest to place & does not require neck manipulation (cervical neck injuries)
Femoral - access above the diaphragm ideal especially w/ abdominal injuries
Internal jugular
IO only 2-3 days

50
Q

EARLY Resuscitation Goals

A 
Maintain SBP 80-100mmHg
Hct 25-30%
PTT/PT w/in normal range
Platelet count > 50,000
Normal serum iCal
Core temperature > 35°C
Maintain Pox function - consider alternative site (ear lobe or nose)
Prevent ↑serum lactate & worsening acidosis
Adequate anesthesia/analgesia
51
Q

LATE Resuscitation Goals

A

Maintain SBP > 100mmHg
Individualized Hct goals (CAD ↑Hct oxygen-carrying capacity)
Normalize coagulation status, electrolyte balance, & body temperature (warming)
Restore UOP
Maximize CO w/ invasive or non-invasive monitoring
Reverse systemic acidosis
Document serial lactates

52
Q

Overall Resuscitation Goals

A

Oxygenate & ventilate

Restore organ perfusion

53
Q

Overall Resuscitation Goals

A 
Oxygenate & ventilate
Restore organ perfusion & homeostasis 
Repay oxygen debt
Treat coagulopathies
Restore the circulating volume
Continuously monitor response
54
Q

Resuscitation End-Point

A

Serum lactate < 2mmol
Base deficit < 3mmol/L
Gastric intramucosal pH > 7.33

55
Q

Hemorrhagic Shock Management

A

Control/STOP the bleeding
Begin fluid resuscitation - isotonic, hypertonic, colloids, PRBCs, plasma

Consider rapid infusing system 400-1,500mL/min

56
Q

Isotonic Crsytalloids

A

NS
Lactated ringer’s
Plasmalyte

57
Q

Hypertonic Saline

A

TBI

Osmotic agent to put fluid into the vascular space & therefore ↓ICP

58
Q

Colloids

A

Rapid plasma volume expansion

NO oxygen carrying capacity

59
Q

PRBCs

A

Provide adequate oxygen carrying capacity

60
Q

Blood Loss Replacement

A

Crystalloid 3:1
PRBCs 1:1

Rh¯ blood preferable when crossmatch not complete (ABO & Rh)
*Especially in women childbearing age

61
Q

FFP

A

Replace 2 units FFP w/ every 4 units PRBCs when massive transfusion anticipated or ongoing to replace clotting factors

62
Q

Massive Transfusion Protocol

A

Damage control
Set blood & hemostatic products to mimic whole blood
Limit crystalloid
Prevent over-resuscitation early on as too much fluid will potentially dislodge clots & lead to ↑bleeding

63
Q

Goal-Direct Hemostatic Resuscitation

A

Utilizes POC viscoelastic monitoring TEG/ROTEM to direct therapy

64
Q

Hemostatic Agents

A

TXA anti-fibrinolytic beneficial when instituted w/in 1 hour admission
Recombinant activated human coagulation factor VII (rFVIIa)

65
Q

Rapid Infuser

A

Fluid administration rates up to 1,500mL/min
Crystalloid, colloid, PRBCs, washed blood, & plasma compatible
Reserve allows product mixing to prepare for rapid blood loss
Controlled temperature 38-40°C
Able to pump simultaneously through multiple IV lines
Accurately records fluid volume administration
Portable & able to travel w/ patient b/w units

66
Q

Lethal Triad

A

Acidosis
Hypothermia
Coagulopathy

Acidosis & hypothermia are factors that induce coagulopathy - fluid & PRBC resuscitation w/o hemostasis properties dilute already dysfunctional platelets

67
Q

Hypothermia impacts the following:

A

Acid-base disorders
Coagulopathy - impairs platelet & clotting enzyme function
Myocardial function
Shifts oxy-hemoglobin curve to the left ↓tissue oxygenation
↓lactate, citrate, & anesthetic drug metabolism
Vasoconstriction ↑BP

68
Q

Trauma Patient Coagulopathy

A

Clotting cascade activation causes clotting factors consumption
Blood loss → clotting factors loss
Massive transfusion → hemodilution further dilutes clotting factors
Hypercoagulable state → DIC

69
Q

Platelets & PTT/PT at 29°C

A

PTT/PT ↑50%
Platelets ↓40%

→ BLEEDING

70
Q

Coagulopathy Treatment

A 
Avoid and/or reverse the lethal triad:
- Control hemorrhage
- Avoid/correct hypothermia
- Actively re-warm
Avoid hemodilution
TEG/ROTEM

AS - N934 Advanced Principles II (18 decks)

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