Trauma II Flashcards
TBI Goals
Traumatic brain injury
Prevent 2° brain damage resulting from intracranial bleeding, edema, ↑ICP, hypoxia, & shock
TBI Classifications
Mild GCS 13-15 - Resolves w/ minimal deficits - Observation 24hrs Moderate GCS 9-12 - Early CT - High deterioration potential requires early intubation & mechanical ventilation - Manifested as intracranial lesions that require surgical evacuation Severe GCS < 8 - Intubate - Carries significant mortality rate - Direct care at cerebral perfusion
What ideal CPP should be maintained in patients w/ severe TBI?
CPP 60-70mmHg
CPP Formula
MAP - ICP
What inhalational anesthetics should be avoided in TBI anesthetic management?
Nitrous oxide → pneumoencephalogram
SCI
Spinal cord injury
Most often occurs at lower cervical spine level C4-7
SCI Deficits
Sensory
Motor
Sensory & motor
What 3 factors do SCI patient outcomes depend on?
- Acute injury severity
- Exacerbation prevention during rescue, transport, & hospitalization
- Avoid hypoxia & hypotension*
Early SCI Treatment Focus
Adequate perfusion to prevent 2° injury
What complication develops in 85% SCI patients w/ complete injury above T5?
Autonomic hyperreflexia
SCI Goal MAPs
> 85mmHg
Neurogenic Shock
Unopposed PSNS tone
Loss cardioaccelerator fibers → bradycardia
C-Spine Evaluation
Requires all 7 cervical vertebrae to clear
Patients need to be awake - no sedation, ETOH, drug intoxication, or CNS impairment
SCI Intubation
Simple chin lift w/ manual in-line stabilization
Avoid extension, flexion, & rotation w/ direct laryngoscopy
Consider video laryngoscopy
Gold standard = awake fiberoptic intubation*
*Requires cooperative patient
What fractures are at high risk for DVT?
Long bone fractures
Fix or reduce w/in 1st 24hrs ↓pneumonia, ARDS, or fat emboli risk
Dislocated Hip Considerations
Femoral head avascular necrosis = EMERGENCY
Requires paralysis → GETA
Fractured Pelvis Considerations
Pelvic binder
Expect high blood loss
- Type & cross 4 units
- Notify blood bank to remain at least 2 units ahead
Crush Injury Considerations
Muscle damage → myoglobinurea
Administer fluids to flush myoglobin through kidneys & prevent renal tubal clogging
Consider Mannitol & Bicarbonate to treat
Open Fracture Considerations
OR w/in 1st 12hrs to debride
Compartment Syndrome Considerations
Check pulses distal to the fracture
Treatment = fasciotomy
Orthopedic Trauma
Anesthetic Management
Emergency trauma = full stomach → general anesthesia
Controlled hypotension MAP < 20mmHg baseline to prevent bleeding or w/in 20%
Administering inotropes before bleeding controlled → excessive blood loss
Traumatic Aortic Injury
Diagnosis
CXR
Angiography
CT scan
TEE
Requires surgery to repair d/t rupture risk in hours to days
The most common injury resulting from blunt chest trauma: _____ ______
Flail chest
Flail Chest
Comminuted fractures at least 3 ribs
Characterized by paradoxical respirations
Consider pain management - epidural placement to maintain ventilation/perfusion or regional techniques (intercostal or TAP blocks)
CPAP or BiPap support
Beck’s Triad
Hypotension
Jugular venous distension
Muffled heart sounds
Cardiac Tamponade Presentation
Beck’s triad
Narrow pulse pressure
Tachycardia
Blunt Cardiac Trauma →
Bruising or contusion → hypotension and/or arrhythmias
Presents similar to MI (functionally indistinguishable)
Treatment - manage as ischemic cardiac injury
Cardiac Bruising or Contusion
Treatment
Volume control
Vasodilators
Monitor & treat rhythm disturbances
Cardiology consult as necessary
OB & Pregnancy
Trauma
High incidence spontaneous abortion, pre-term labor, or premature delivery
OB consult for immediate management & follow-up
Requires rapid & complete resuscitation 1° focus = mother
L lateral uterine displacement
Rh¯ mother admin Rhogam
U/S fetus, assess gestational age, consider viability & delivery
Spontaneous abortion requires surgical D&C
Extubation Criteria
Mental status - not intoxicated, able to follow commands, non-combative, & pain adequately controlled
Airway anatomy & reflexes - appropriate cough & gag, able to protect airway from aspiration, & no excessive airway edema or instability
Respiratory mechanics - adequate tidal volume & RR, normal motor strength, FiO2 requirements < 50%
Systemic stability - adequately resuscitated, repeat surgeries not required in short-term, normovolemic w/o S/S sepsis
Risk factors r/t developing ARDS after trauma:
Elderly Pre-existing physiologic impairment or co-morbidities Direct pulmonary or chest wall injury Aspiration blood or stomach contents Prolonged mechanical ventilation Severe TBI SCI w/ quadriplegia Massive transfusion Hemorrhagic shock Occult hypoperfusion Wound or body cavity infection
Appropriate Ventilator Settings
Vt 6-8mL/kg PEEP 10-15cmH2O Limit peek pressures < 40cmH20 Adjust I:E ratio as necessary Wean FiO2 to obtain PaO2 80-100 w/ SpO2 93-97%
Postoperative Complications
Infection/sepsis Thromboembolism Abdominal compartment syndrome ARDS Volume status
