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N934 Advanced Principles of Anesthesia II > Trauma I > Flashcards

Trauma I Flashcards

1
Q

what is the leading cause of death between 1-45 years in the US

A

trauma

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2
Q

how much does care at a level 1 trauma center reduce mortality?

A

25%

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3
Q

what are the three components of trauma evaluation

A
  • rapid overview
  • primary survery
  • secondary survery
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4
Q

rapid overview

A
  • initial brief impression

- takes a few seconds is patient stable or unstable

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5
Q

primary survey

A
  • look at life-threatening injuries and how to correct them

- involves rapid evaluation for functions crucial to survival and includes ABCDE

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6
Q

secondary survey

A
  • detailed and systemic evaluation of each anatomic region and continued resuscitation if needed
  • begins after critical life-saving actions have begin (like intubation, chest tube placement, and fluid resuscitation)
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7
Q

ABCDE

A
  • airway patency -is the patient talking, SOB, have an obstruction
  • breathing - high flow oxygen, trachea midline, flail chest, tension pneumo, massive hemothorax (>1500 mL)
  • circulation - skin temp, color, 2 large bore IVs
  • disability - neuro, mentation, GCS
  • exposure - take off close and examine body for injury
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8
Q

three components of glasgow coma scale

A
  • eye-opening response
  • verbal response
  • motor response
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9
Q

eye-opening response

A
  • 4 = spontaneous
  • 3 = to speech
  • 2 = to pain
  • 1 = none
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10
Q

verbal response

A
  • 5 = oriented to name
  • 4 = confused
  • 3 = inappropriate speech
  • 2 = incomprehensible sounds
  • 1 = none
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11
Q

motor response

A
  • 6 = follows commands
  • 5 = localizes to painful stimuli
  • 4 = withdraws from painful stimuli
  • 3 = abnormal flexion (decorticate posturing)
  • 2 = abnormal extension (decerebrate posturing)
  • 1 = none
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12
Q

AVPU

A

alert
voice
pain
unresponsive

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13
Q

exposure step of ABCDE

A
  • final step of the primary survey that includes the complete exposure of the patient
  • removal of clothing and turning to examine
  • includes a brief head-to-toe search for visible injuries or deformities
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14
Q

focus for the secondary survey

A
  • history of injury
  • allergies, medications, last oral intake
  • focused medical and surgical history
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15
Q

trauma airway evaluation

A
  • involves diagnosis of trauma to the airway and surrounding tissue
  • anticipate respiratory consequences of injury to airway
  • contemplate airway management maneuvers, assume patient absolutely requires an airway and cannot be re-awakened electively
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16
Q

what does airway management of trauma patients require?

A
  • assisted or controlled ventilation
  • self-inflating bag with a non-rebreathing valve is sufficient after intubation and for transport
  • 100% oxygen is necessary until ABG is complete
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17
Q

airway obstruction considerations

A
  • airway edema/direct airway injury
  • cervical deformity
  • cervical hematoma
  • foreign bodies
  • dyspnea, hoarseness, stridor, dysphonia
  • subQ emphysema and crepitation
  • hemoptysis/active oral bleeding/copious secretions
  • tracheal deviation
  • JVD
  • hemodynamic condition
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18
Q

conisderations for airway management in trauma

A
  • oxygen admin (100% oxygen)
  • chin lift and jaw thrust (usually jaw thrust to minimize further injury)
  • full stomach
  • clearing of orophrayngeal airway
  • oral and nasal airway (worry about basilar skull fracture)
  • immobilization of cervical spine
  • tracheal intubation if ventilation is inadequate
  • consider AW adjuncts to secure AW
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19
Q

nasal intubation considerations in trauma

A
  • increased blood in the airway and nasal trauma

- ensure there is not a basilar skull fracture

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20
Q

suspect basilar skull fractures

A
  • CSF dripping out of nose
  • racoon eyes
  • battle sign –> bruising behind ears
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21
Q

airway management techniques

A
  • DL
  • bougie
  • video laryngoscopy
  • AFOI
  • RSI vs MRSI
  • cricioid pressure (debated)
  • manual in line cervical stabilization
  • surgical cricothyrotomy/trach
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22
Q

indications for ETT intubation in trauma

A
  • cardiac or respiratory arrest
  • respiratory insufficiency/deteriorating condition
  • airway protection
  • need for deep sedation or analgesia (pain control)
  • GCS < 8
  • delivery of 100% FiO2 in presence of carbon monoxide poisoning
  • facilitate work-up in uncooperative or intoxicated patient
  • transient hyperventilation required
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23
Q

trachetomy

A
  • takes longer to perform

- requires neck extension which may cause extended neck trauma if cervical injury is present

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24
Q

cricothyroidotomy

A
  • surgical cricothyroidotomy
  • is contraindicated in those younger than 12 years old (<12 needs needle cric)
  • laryngeal damage precludes the ability to perform a circothyroidotomy
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25
Q

cricothyrotomy

A
  • if needed greater than 72 hours then need to replace with trach
  • massive facial trauma/hemorrhage
  • supraglottic foreign body obstruction
  • angioneurotic edema
  • inhalational thermal injury
  • epiglottitis/croup
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26
Q

airway management + full stomach

A
  • full stomach is consideration for all trauma patients and impacts AW intervention
  • time not available to allow pharmacologic intervention to decrease gastric contents and acidity
  • emphasis placed on safe technique for securing the airway
  • RSI
  • cricoid pressure
  • in-line stabilization
  • awake intubation with topical anesthesia and sedation
  • LMA use contraindicated as definitive airway
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27
Q

emergency trauma airway algorithm

A
  • need for emergent intubation
  • preoxygenate with BVM, cricoid pressure, and manual in-line cervical stabilization
  • induction, muscle relaxation
  • laryngoscopy 1
  • laryngoscopy 2
  • LMA placement
  • cricothyroidotomy
  • OR for definitive airway
  • CONFIRM - chest rise, auscultation, EtCO2
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28
Q

induction agents for trauma

A
  • etomidate 0.2-0.3 mg/kg IV
  • ketamine 2-4 mg/kg IV OR 4-10 mg/kg IM
  • propofol 2 mg/kg
  • precedex
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29
Q

NMBD for trauma

A
  • succinylcholine 1-1.5 mg/kg IV, OK in first 24 hours of burn or SCI, 30 second onset, fasciculate, 5-12 min duration
  • rocuronium 1.2 mg/kg IV, 30-60 second onset, may need gentle mask ventilation (MRSI), 60-90 min duration
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30
Q

cervical spine injuries and AW management

A
  • high suspicion for cervical injury if victim has experienced a fall, MVA, driving accidnet
  • semi-rigid collar, sandbags, and backboard provide best stabilization
  • manual inline stabilization (MIS) best for AW management
  • stabilization is maintained until cervical injury ruled out
  • orotracheal intubation is most desirable
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31
Q

when is cervical injury cleared?

A
  • full xray of C1-C7

- patient not obtunded or under influence of drugs and says there is no pain in neck

32
Q

head, open eye, major vessel injury and AW management

A
  • ensure adequate oxygenation and ventilation
  • deep anesthesia and PROFOUND relaxation prior to airway manipulation and intubation (DO NOT want to increase BP/ICP/IOP)
  • without sufficient depth of anesthesia these patients may have HTN, coughing, bucking, increased ICP/IOP
  • must consider initial assessment of airway, if difficult you cannot use muscle relaxants or IV induction agents
33
Q

maxillofacial injuries and AW management

A
  • blood and debris in orophraynx may predispose patient to complete or partial airway obstruction
  • aspiration of teeth or foreign bodies
  • serious AW compromise may present within a few hours of penetrating facial trauma
  • consider limitation of mandibular movement and trismus
  • AW management technique is based on the presenting condition
34
Q

penetrating injury

A
  • damage depends on 3 interactive factors
  • type of wounding instrument
  • velocity at time of impact
  • characteristics of tissue through which it passes
  • clinical signs includ escape of air, hemoptysis and coughing
35
Q

blunt injury

A
  • includes direct impact, deceleration, shearing, and rotary forces (laryngotracheal damage)
  • clinical signs = hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain, and tenderness, flattening of thyroid cartilage
36
Q

factors that alter respiration and interefrere with breathing

A
  • tension pneumo
  • flail chest
  • open pneumo
  • hemothorax
  • pulmonary contusion
  • diaphragmatic rupture
  • chest wall splinting
37
Q

hemothorax

A
  • presence of blood in the pleural cavity
  • hallmark symptoms = hypotension, hypoxemia, tachycardia, increased CVP
  • treatment = aim to eliminate and correct
  • anesthetic considerations = include placing a chest tube and one lung ventilation
38
Q

pneumothorax

A
  • disruption of the parietal or visceral pleura presence of gas within the pleural space
  • 3 categories = simple, communicating, tension
  • treatment = chest tub if PTX > 20% of lung collapsed
39
Q

tension pneumo

A
  • occurs with rib fractures and barotrauma due to mechanical ventilation
  • hallmark symptoms - hypotension, hypoxemia, tachycardia, increased CVP, diminished BS on the affected side
  • treatment is needle decompression
40
Q

flail chest

A
  • results from - communicated fractures of at least 3 ribs, rib fractures associated with costrochondral separation, sternal fracture
  • respiratory insufficiency and hypoxemia over several hours with deterioration of CXR and ABG
  • consider pain management (blocks, opioids, multimodal, incentive spirometry, CPAP, BiPAP) over mechanical ventilation
41
Q

circulation/shock

A
  • hemorrhage is the most common cause of traumatic hypotension and shock in trauma patients
  • circulatory failure leading to inadequate vital organ perfusion and oxygen delivery
  • resuscitation refers to the restoration of normal circulating blood volume, normal vascular tone, and normal tissue perfusion
42
Q

physiologic response to shock

A
  • initial response = mediated by neuroendocrine system
  • hypotension leads to vasoconstriction and catecholamine release
  • heart, kidney, brain, blood flow is preserved while other regional beds constricted
  • traumatic injuries –> release in hormones that set the stage for mircocirculatory response
  • ischemic cells respond to hemorrhage by taking up interstitial fluid and depleting intravascular volume and producing lactate and free radicals
  • inadequate organ perfusion interferes with aerobic metabolism –> producing lactic acid and metabolic acidosis
  • lactate and free radicals accumulate in the circulation while perfusion is diminished
  • lactate and free radicals can cause damage to cell and a toxic load that will be washed into circulation once it is re-established
  • ischemic cells also produce inflammatory factors (leukotrienes, interleukins) –> systemic inflammatory process, becomes disease process unto itself, lays foundation for MODS
43
Q

CNS response to shock

A

-responsible for maintaining blood flow to heart kidney and brain at expense of other tissue

44
Q

kidney/adrenal response to shock

A

-maintains GF during hypotension by selective vasoconstriction and concentration of blood flow in medulla and deep cortical areas

45
Q

heart response to shock

A

-preserved via increase in nutrient blood flow and cardiac function until later stages

46
Q

lung response to shock

A
  • destination of inflammatory byproducts –> accumulate in capillary beds and results in ARDS
  • sentinel organ for the development of MOSF
47
Q

gut/intestinal response to shock

A

-one of the earliest organs affected by hypo-perfusion and may be trigger for MOSF

48
Q

acute traumatic coagulopathy

A
  • begins in early presence of reduced clot strength
  • hypotension and tissue injury –> inflammatory response –> endothelial activation of protein C (APC)
  • hyperfibrinolysis due to APC formation
  • resuscitation includes early treatment of ATC
49
Q

what does base deficit reflect?

A
  • severity of shock
  • oxygen debt
  • changes in O2 delivery
  • adequacy of fluid resuscitation
  • likelihood of multi-organ failure
50
Q

mild shock

A

base deficit between 2-5 mmol/L

51
Q

moderate shock

A

base deficit between 6-14 mmol/L

52
Q

severe shock

A

base deficit between 14 mmol/L

53
Q

base deficit of 5-8 mmol/L

A

correlates with increased mortality

54
Q

blood lactate level

A
  • blood lactate level is less specific than base deficit but nonetheless important
  • elevated lactate levels correlate to hypoperfusion
  • normal plasma lactate level is 0.5-1.5 mmol/L and half life is 3 hours
  • plasma lactate level above 5 mmol/L indicate significant lactic acidosis
  • failure to clear lactate within 24 hours after reversal of shock is predictor of increased mortality
55
Q

assessment of systemic perfusion

A
  • VS
  • UOP
  • systemic acid-base status
  • lactate clearance
  • cardiac output
  • mixed venous oxygenation
  • gastric tonometry
  • tissue specific oxygenation
  • SVV
  • acoustic blood flow
56
Q

symptoms of shock

A
  • pallor
  • diaphoresis
  • agitation or obtundation
  • hypotension
  • tachycardia
  • prolonged capillary refill
  • diminished UOP
  • narrowed pulse pressure
57
Q

sites for emergency IV access

A
  • large bore IVs antecubital vein
  • other large bore IV sites
  • subclavian vein (easiest place and does not require neck manipulation in circumstance of cervical neck injury)
  • femoral vein (but infection risk, and if bleeding into abdomen could pour stuff in)
  • IJ
  • IO
58
Q

goals for early resuscitation

A
  • maintain SBP at 80-100 mmHg
  • maintain Hct at 25-30%
  • maintain PTT and PT within normal range
  • maintain plt count >50,000
  • maintain normal serum iCal
  • maintain core temp > 35 celsius
  • maintain function of pulse ox
  • prevent increase in serum lactate
  • prevent worsening acidosis
  • adequate anesthesia/analgesia
59
Q

risks of aggressive volume replacement during early resuscitation

A
  • increased blood pressure
  • decreased blood viscosity
  • decreased Hct
  • decreased clotting factor concentration
  • greater transfusion requirement
  • disruption of electrolyte balance
  • direct immune suppression
  • premature reperfusion
60
Q

anesthesia resuscitation goals

A
  • oxygenate and ventilate
  • restore organ perfusion
  • restore hemostasis/repay oxygen debt
  • treat coagulopathy
  • restore circulating volume
  • continuous monitoring of the response
61
Q

surgery resuscitation goals

A

-stop the bleeding

62
Q

goals for LATE resuscitation

A
  • maintain SBP > 100 mmHg
  • maintain Hct above individual transfusion threshold
  • normalize coagulation status
  • normalize electrolyte balance
  • normalize body temperature
  • restore UOP
  • maximize CO by invasive/noninvasive monitoring
  • reverse systemic acidosis
  • document decrease in lactate to normal range
63
Q

end point for resuscitation

A
  • serum lactate level < 2 mmol

- base deficit < 3

64
Q

management of shock

A
  • control the source of hemorrhage
  • begin fluid resuscitation - isotonic crystalloid, hyperteonic saline, colloids, PRBCs, plasma)
  • possible use rapid infusing system (RIS) (1500 cc/min)
  • early resuscitation 80-100 mmHg and late >100 mmHg
65
Q

hypertonic saline

A

-traumatic brain injury HS is used as an osmotic agent in the management of increased ICP

66
Q

colloids

A

rapid plasma volume expansion

67
Q

PRBCs

A
  • provided to adequate oxygen carrying capacity - mainstay of hemorrhagic shock
  • blood loss replacement (1:1 with RBC, 3:1 with crystallloid, Rh negative blood preferable esp for women of childbearing age)
68
Q

FFP

A

2 units of FFB with every 4 units PRBC when MTP is anticipated or ongoing

69
Q

hemostatic resuscitation damage control

A
  • administration of set protocol of blood and hemostatic products to mimic whole blood
  • MTP
  • limited crystalloid
70
Q

hemostatic resuscitation goal directed

A

-utilizes point of care viscoelastic (TEG) monitoring to direct therapy

71
Q

hemostatic agents

A
  • TXA - antifibrinolytic; benefit when instituted within 1 hour of admission
  • recombinant activated human coagulation factor VII
72
Q

lethal triad

A
  • acidosis
  • hypothermia
  • coagulopathy
  • acidosis and hypothermia are major factors in the induction of coagulopathy*
73
Q

shock and hypothermia

A
  • acid base disorders
  • coagulopathy
  • myocardial function
  • shifts oxygen-Hgb curve to the left
  • decreases the metabolism of lactate, citrate and some anesthetic drugs
74
Q

hypothermia

A
  • left shift of oxygen hgb dissociation curve - decreased tissue oxygenation (bc left loves)
  • impairs plt and clotting enzyme function
  • abnormal potassium and calcium homeostasis
  • causes vasoconstriction, can ultimately make BP appear higher than volume status actually is so BP may DROP as patient warms
75
Q

coagulopathy in trauma patient

A
  • activation of clotting cascade causes consumption of clotting factors
  • blood loss causes a loss of clotting factors
  • hemodilution further dilutes clotting factors
  • severely injured trauma patients become hypercoagulable
76
Q

29 degrees celcius

A

PT and PTT increase by 50%

plts decrease by 40%

77
Q

treatment of coagulopathy

A
  • avoidance or refersal of lethal triad
  • judicious resuscitation avoid hemodilution
  • trauma disrupts equilibrium between hemostatic and fibrinolytic processes
  • changes are complex and can either result in hypocoagulable or hypercoagulable states

N934 Advanced Principles of Anesthesia II (17 decks)

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