Trauma I Flashcards
Rapid Overview
Initial impression
Few seconds
Stable vs. unstable
Inability to oxygenate → brain injury & death w/in _____ minutes
5-10
Primary Survey
Identify & address life-threatening injuries Airway patency Breathing Circulation Disability (neuro/mental status) Exposure
What are the most common trauma causes in patients < 45yo?
MVA
Falls
Suicide
Homicide
Secondary Survey
Detailed & systematic evaluation
Head to toe assessment
Continued resuscitation as needed
GCS
Glasgow coma score - Eye opening response - Verbal response - Motor response Normal 15/15 < 8 → intubate
Airway
Keep ‘em breathing
100% oxygen
Airway Obstructions
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)
Trauma Airway Management Considerations
- 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
Basilar Skull Fracture S/S
Battle sign - bruising behind ears
Raccoon eyes
Ears and/or nose bleeding or CSF leak
When to perform ETT intubation?
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
Tracheostomy
Longer to perform as compared to cricothyroidotomy
Requires neck extension (contraindicated when neck trauma or cervical injury present)
Surgical Cricothyroidotomy
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)
Needle Cricothryoidotomy
Less effective ventilation
Smaller diameter ↑resistance
Pediatrics
RSI Indications
All traumas = full stomach
SNS response diverts blood flow away from GI tract
Cricoid pressure at C6
Trauma & Depolarizing NMBs (Succinylcholine administration)
Okay 1st 24 hours after burns or spinal cord injury
After 1st 24 hours → nAChR UPregulation
Excessive K+ release → hyperkalemia
Induction Agents
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
NMBs
Succinylcholine
Dose 1-1.5mg/kg IV Onset 30 seconds Fasciculations DOA 5-12 minutes De-fasciculating dose Rocuronium 5mg
NMBs
Rocuronium
Dose 1.2mg/kg IV
Onset 30-60 seconds
Modified RSI + mask ventilation
DOA 60-90 minutes
Cervical Spine Clearance
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
What keeps the diaphragm alive?
C4-C5
INTUBATE
C6-C7
Unable to clear secretions or cough
Intubate
Hemothorax S/S
Blood present in pleural cavity
- Hypotension
- Hypoxemia
- Tachycardia
- ↑CVP
Hemothorax Treatment
Chest tube
Possible PRBC transfusion
Single lumen ETT to secure airway → double lumen ETT
Pneumothorax
Definition/Types/Treatment
Gas present w/in pleural spaces disrupts parietal or visceral pleura
1. Simple
2. Communicating
3. Tension
Treatment = chest tube when > 20% lung collapsed
Tension Pneumothorax S/S
Occurs w/ rib fractures & barotrauma d/t mechanical ventilation
Hypotension Hypoxemia Tachycardia ↑CVP Diminished breath sounds on affected side Tracheal deviation → cardiac arrest
Tension Pneumothorax Treatment
NEEDLE DECOMPRESSION
Anterior approach 2nd/3rd ICS midclavicular line
Lateral 4th/5th intercostal space
Flail Chest
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
Flail Chest Treatment
1° supportive Pain management - Epidural - Intercostal blocks Oxygen administration - FiO2 - Incentive spirometry - CPAP/BiPAP Decompensation → intubate
What’s the most common cause traumatic hypotension & shock in trauma patients?
Hemorrhage
Active internal or external bleeding
Circulatory failure leads to _____
Inadequate vital organ perfusion & oxygen delivery
Physiological Response to Shock
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
Shock Types
Hemorrhagic*
Cardiogenic
Distributive
Neurogenic
Where do inflammatory byproducts accumulate?
LUNGS
Pulmonary capillary beds → results in ARDS
Sentinel organ to develop MODS
What patients are at increased risk to experience cardiac ischemic injury in response to shock?
Elderly
CAD
Patients w/ minimal cardiac reserve
What organ experiences the earliest effects r/t hypo-perfusion in response to shock?
Gut/intestines
Higher risk to trigger MODS
What triggers protein C?
Hypotension & tissue injury → inflammatory response → endothelial activation protein C (APC)
Protein C
Unable to form clots efficiently
Early diagnosis & treatment ROTEM/TEG
Base Deficit
Determines shock severity Oxygen debt O2 delivery changes Fluid resuscitation adequacy Multi organ dysfunction/failure likelihood
MILD Shock
Base deficit 2-5mmol/L
MODERATE Shock
Base deficit 6-14mmol/L
SEVERE Shock
Base deficit > 14mmol/L
What correlates with increased mortality r/t base deficit?
Admission base deficit 5-8mmol/L
Blood Lactate Levels
LESS specific than base deficit
Used to determine resuscitation end point
↑lactate correlate w/ hypo-perfusion
Normal Plasma Lactate
& Half-Life
0.5-1.5mmol/L
> 5mmol/L indicates significant lactic acidosis
3 hours
What correlates w/ increased mortality r/t blood lactate levels?
Failure to clear lactate w/in 24 hours after shock reversal
Systemic Perfusion Assessment
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
Shock S/S
Pale & diaphoretic Agitated or obtunded (altered neuro status) Hypotension Tachycardia Prolonged capillary refill ↓UOP Narrowed pulse pressure
IV Access Sites & Advantages
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
EARLY Resuscitation Goals
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
LATE Resuscitation Goals
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
Overall Resuscitation Goals
Oxygenate & ventilate
Restore organ perfusion
Overall Resuscitation Goals
Oxygenate & ventilate Restore organ perfusion & homeostasis Repay oxygen debt Treat coagulopathies Restore the circulating volume Continuously monitor response
Resuscitation End-Point
Serum lactate < 2mmol
Base deficit < 3mmol/L
Gastric intramucosal pH > 7.33
Hemorrhagic Shock Management
Control/STOP the bleeding
Begin fluid resuscitation - isotonic, hypertonic, colloids, PRBCs, plasma
Consider rapid infusing system 400-1,500mL/min
Isotonic Crsytalloids
NS
Lactated ringer’s
Plasmalyte
Hypertonic Saline
TBI
Osmotic agent to put fluid into the vascular space & therefore ↓ICP
Colloids
Rapid plasma volume expansion
NO oxygen carrying capacity
PRBCs
Provide adequate oxygen carrying capacity
Blood Loss Replacement
Crystalloid 3:1
PRBCs 1:1
Rh¯ blood preferable when crossmatch not complete (ABO & Rh)
*Especially in women childbearing age
FFP
Replace 2 units FFP w/ every 4 units PRBCs when massive transfusion anticipated or ongoing to replace clotting factors
Massive Transfusion Protocol
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
Goal-Direct Hemostatic Resuscitation
Utilizes POC viscoelastic monitoring TEG/ROTEM to direct therapy
Hemostatic Agents
TXA anti-fibrinolytic beneficial when instituted w/in 1 hour admission
Recombinant activated human coagulation factor VII (rFVIIa)
Rapid Infuser
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
Lethal Triad
Acidosis
Hypothermia
Coagulopathy
Acidosis & hypothermia are factors that induce coagulopathy - fluid & PRBC resuscitation w/o hemostasis properties dilute already dysfunctional platelets
Hypothermia impacts the following:
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
Trauma Patient Coagulopathy
Clotting cascade activation causes clotting factors consumption
Blood loss → clotting factors loss
Massive transfusion → hemodilution further dilutes clotting factors
Hypercoagulable state → DIC
Platelets & PTT/PT at 29°C
PTT/PT ↑50%
Platelets ↓40%
→ BLEEDING
Coagulopathy Treatment
Avoid and/or reverse the lethal triad: - Control hemorrhage - Avoid/correct hypothermia - Actively re-warm Avoid hemodilution TEG/ROTEM