Trauma ICU

Question 1

Management of traumatic hemorrhage

Answer 1

• 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

Question 2

In the setting of acute traumatic injury with severe bleed, there is evidence for benefit of tranexamic acid within ____

Answer 2

In the setting of acute traumatic injury with severe bleed, there is evidence for benefit of tranexamic acid within 3 hours of injury

Question 3

Normal pulmonary compliance

Answer 3

> 60

Less than this suggests stiff lungs of some etiology

Question 4

Inidication for tocilizumab in COVID19

Answer 4

COVID + ICU + High oxygen requirements

Question 5

Dexmedetomidine

Answer 5

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.

Question 6

Post-surgical antibiotic prophylaxis following open abdominal surgery

Answer 6

4 days of flagyl and ceftazidine

Question 7

Placing a chest tube for pneumothorax

Answer 7

“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.

Question 8

Any transfusion of pRBCs is also a transfusion of. . .

Answer 8

. . . citrate

So, these patients may become alkalotic and hypocalcemic.

Question 9

Most common vs most rare blood type

Answer 9

Most common: Type O (45%)

Most rare: Type AB (4%)

Question 10

Reading a thromboelastogram

Answer 10

Question 11

Bile peritonitis

Answer 11

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

Question 12

What is the next step if a trauma patient is found to have contrast blush in the liver or spleen on CT?

Answer 12

They are sent straight to IR prophylactically for embolization

Question 13

While bile duct injuries are often amenable to non-surgical therapy, ___ is generally a surgical abdomen

Answer 13

While bile duct injuries are often amenable to non-surgical therapy, hollow viscus injury is generally a surgical abdomen

Question 14

Urinoma

Answer 14

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.

Question 15

Pelvic hemorrhage

Answer 15

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.

Question 16

Most common thing we worry about in patients with rib fracture

Answer 16

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

Question 17

A child with blunt thoracic trauma is much more likely to have ___ than an adult with blunt thoracic trauma

Answer 17

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.

Question 18

Mechanism of pulmonary contusion in adults

Answer 18

Usually a contra-coup injury / decceleration injury with impact of the lung parenchyma against the chest wall

Question 19

Pulmonary contusions tend to ___ post-injury

Answer 19

Pulmonary contusions tend to worsen post-injury

It is a bruise on the lung! Bruises take time to develop.

Question 20

Splenic trauma: When do we take it out?

Answer 20

1. If there is any hemodynamic instability in the setting of spleen injury

2.

Question 21

Indications for intracranial pressure monitoring

Answer 21

1. CT confirmed intracranial hemorrhage
2. GCS of 8 or less
3. Receiving sedation

All three must be met.

Question 22

Triad of Death

Answer 22

Acidosis

Hypothermia

Coagulopathy

Question 23

When your blood is cold, it cannot. . .

Answer 23

. . . clot

You must be mindful of this when you are preforming a large volume resuscitation on a trauma patient

Question 24

Hemostatic resuscitation approach

Answer 24

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.

Question 25

Calcium and coagulation

Answer 25

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.

Question 26

Acidosis and coagulation

Answer 26

Acidosis directly impairs the catalysis of thrombin

Thus, any acidosis contributes to coagulopathy

Question 27

Why is coagulopathy of hypothermia never detected on Coag studies?

Answer 27

Because patient samples are rewarmed to 37^oC in order to perform a PT or PTT

Question 28

Indications for ICU

Answer 28

1. Ventilation
2. Vsaopressors/inotropes/medications that can only be received in ICU (NAC, hypertonic saline, mannitol)
3. Intensive nurse monitoring (max of 2 patients per nurse)

Question 29

Level of the cardiac accelerator fibers

Answer 29

T4

Question 30

When do you reach for the positive inotropes in CHF secondary to MI?

Answer 30

When you try fluid optimization and afterload reduction, and both of these together are insufficient