Trauma ICU Flashcards
Management of traumatic hemorrhage
- Limit use of crystalloids in favor of 1:1:1 blood products to prevent coagulopathy
- Permissive hypotension (while maintaining MBP > 65) in order to limit ongoing hemorrhage and prevent rebleeding
In the setting of acute traumatic injury with severe bleed, there is evidence for benefit of tranexamic acid within ____
In the setting of acute traumatic injury with severe bleed, there is evidence for benefit of tranexamic acid within 3 hours of injury
Normal pulmonary compliance
> 60
Less than this suggests stiff lungs of some etiology
Inidication for tocilizumab in COVID19
COVID + ICU + High oxygen requirements
Dexmedetomidine
Centrally acting alpha-2 agonist anesthetic (like clonidine)
Mild sedating effects without affecting respiratory drive. Also reduces sympathetic outflow, making patients less hyperdynamic.
Good as an adjunct to a more potent anesthetic in a patient requiring slightly more sedation without respiratory depression.
Post-surgical antibiotic prophylaxis following open abdominal surgery
4 days of flagyl and ceftazidine
Placing a chest tube for pneumothorax
“Triangle of safety”
Above the 5th or 6th rib, mid-axillary, between the pectoralis major and the latissimus dorsi
May go through the serratus anterior. Possible complication: winged scapula.
Any transfusion of pRBCs is also a transfusion of. . .
. . . citrate
So, these patients may become alkalotic and hypocalcemic.
Most common vs most rare blood type
Most common: Type O (45%)
Most rare: Type AB (4%)
Reading a thromboelastogram
Bile peritonitis
Persistent peritonitis caused by a bile leak
May be amenable to nonoperative approaches such as CT-guided drain placement or biliary decompression by ERCP and stent placement
What is the next step if a trauma patient is found to have contrast blush in the liver or spleen on CT?
They are sent straight to IR prophylactically for embolization
While bile duct injuries are often amenable to non-surgical therapy, ___ is generally a surgical abdomen
While bile duct injuries are often amenable to non-surgical therapy, hollow viscus injury is generally a surgical abdomen
Urinoma
Fluid pocket containing urine
May occur in blunt trauma to the kidney, particularly involving the renal pelvis. Often associated with sepsis due to chemical irritation.
Requires operative or percutaneous drainage.
Pelvic hemorrhage
Highly likely to occur in the setting of pelvic fracture, as there is vasculature almost all along the pelvis.
Additionally, if the pelvix is fractured its tamponade effect disappears, making it easier to exsanguinate into the pelvic space.
Tamponading effect can be restored by placing a pelvic binder, which is indicated in most cases of pelvic hemorrhage. If the binder cannot control bleeding, angiography with embolization or peritoneal packing in the OR are indicated.
Most common thing we worry about in patients with rib fracture
Poor respiratory effort as a result of pleuritic pain (“splinted breathing”)
This alone can result in atelectasis and predispose to pneumonia, especially in older patients
A child with blunt thoracic trauma is much more likely to have ___ than an adult with blunt thoracic trauma
A child with blunt thoracic trauma is much more likely to have pulmonary contusions than an adult with blunt thoracic trauma
Ribs in children are more flexible and less able to absorb force. As a result, the ribs are less likely to break. Instead, more of this force is transferred to the lungs, hence the increased risk of contusion.
Mechanism of pulmonary contusion in adults
Usually a contra-coup injury / decceleration injury with impact of the lung parenchyma against the chest wall
Pulmonary contusions tend to ___ post-injury
Pulmonary contusions tend to worsen post-injury
It is a bruise on the lung! Bruises take time to develop.
Splenic trauma: When do we take it out?
- If there is any hemodynamic instability in the setting of spleen injury
2.
Indications for intracranial pressure monitoring
- CT confirmed intracranial hemorrhage
- GCS of 8 or less
- Receiving sedation
All three must be met.
Triad of Death
Acidosis
Hypothermia
Coagulopathy
When your blood is cold, it cannot. . .
. . . clot
You must be mindful of this when you are preforming a large volume resuscitation on a trauma patient
Hemostatic resuscitation approach
The goal is to give the patient fluid that approximates what they have lost by bleeding
In other words, 1:1:1 or 1:1:2 transfusion.
Calcium and coagulation
Once a patient’s calcium drops below 0.7 mmol/L, they begin to become coagulopathic
This can become a factor in the case of massive transfusion, where citrate can sequester free calcium and calcium may be lost in whole blood and not replenished.
Acidosis and coagulation
Acidosis directly impairs the catalysis of thrombin
Thus, any acidosis contributes to coagulopathy
Why is coagulopathy of hypothermia never detected on Coag studies?
Because patient samples are rewarmed to 37oC in order to perform a PT or PTT
Indications for ICU
- Ventilation
- Vsaopressors/inotropes/medications that can only be received in ICU (NAC, hypertonic saline, mannitol)
- Intensive nurse monitoring (max of 2 patients per nurse)
Level of the cardiac accelerator fibers
T4
When do you reach for the positive inotropes in CHF secondary to MI?
When you try fluid optimization and afterload reduction, and both of these together are insufficient
