Trauma II Flashcards
(51 cards)
1
Q
TBI goal of care
A
-prevention of secondary brain damage resulting from intracranial bleeding, edema, increased ICP, hypoxia and shock
2
Q
mild TBI
A
- GCS of 13-15
- short period of observation, usually 24 hours
3
Q
moderate TBI
A
- GCS 9-12
- manifested as intracranial lesions that require surgical evacuation
- early CT
- high potential for deterioration requires early intubation and mechanical ventilation
4
Q
severe TBI
A
- GCS less than 8
- carries a significant rate of mortality
- care is directed at perfusion of injured brain
5
Q
severe TBI care guidelines
A
- after a primary survey approach, maintain CPP 60-70 mmHg at all times
- fluid resuscitation keep euvolemic
- correction of anemia, maintain Hct 30%
- PaCO2 around 35 mmHg
- insertion of ventriculostomy and control ICP (<20 mmHg)
- positional therapy (HOB 15-30 degrees)
- judicious use of analgesics/sedation
- mannitol
- hypertonic saline
6
Q
TBI airway and ventilatory management
A
- hyperventilation only if herniation is imminent
- hyperventilate to PaCO2 of 30 if elevated ICP is not responsive to sedatives, CSF drainage, NMBD, osmotic agents, and barbiturate coma
7
Q
early control of airway in TBI
A
- orotracheal intubation to maintain SpO2 >90%
- maintain normoventilation to help in the reduction of hypercarbia and hypoxemia
- judicious use of induction agents (Prop and etomidate)
- NMBD to avoid coughing and bucking
8
Q
establish CV stability in TBI
A
- avoid intracranial hypertension (ICP > 20)
- avoid systolic hypotension
- placement of A line in addition to standard monitors
- low concentrations of sevo, iso, or des (all cerebral vasodilators so use with caution)
- avoid N2O
9
Q
management of ICP in OR for TBI
A
- mannitol 0.25-1 g/kg for control of ICP
- consider hyperosmolar therapy as ordered by surgeon
- corticosteroids have been shown to increase mortality in TBI, so avoid use
10
Q
mannitol dose
A
0.25-1 g/kg
11
Q
SCI causes
A
MVA
falls
penetrating trauma
12
Q
SCI incidence
A
10,000 americans each year
13
Q
most common location for SCI
A
low cervical spine (C4-C7)
14
Q
SCI injuries include
A
- sensory deficits
- motor deficits
- OR BOTH YIKES
15
Q
3 factors that determine outcome of SCI patient
A
- severity of acute injury
- prevention of exacerbation of injury during rescue, transport and hospitalization
- avoidance of hypoxia and hypotension
16
Q
early SCI treatment focus
A
-adequate perfusion to prevent secondary injury from forming
17
Q
when does autonomic hyperreflexia occur?
A
- complete injury above T5
- occurs in 85% if SCI
18
Q
SCI management
A
- treatment = aimed at preservation of perfusion (avoid hypotension or correct immediately)
- avoid hypoxemia (hypoxia and hypercarbia can further accentuate the damage sustained with SCI)
- MAP maintained normal to high
- neurogenic shock can occur (hypotension and bradycardia)
- adequate circulation
- glucocorticoid bolus OK (controversial)
- C spine evaluation
19
Q
C spine clearance includes
A
- X ray of all 7 cervical vertebrae
- non-obtunded and non-sedated patient can move their neck without pain
20
Q
what C spine injuries are commonly missed
A
- C1-2
- C7-T1
- difficult to image
21
Q
emergency intubation with SCI
A
- 100% oxygen IMMEDIATELY
- simple chin left with manual in line stabilization (MILS)
- avoid extension, flexion and rotation with DVL
- video laryngoscope may be better option for these patients
22
Q
awake fiberoptic intubation with SCI
A
- gold standard for SCI as long as patient is cooperative
- oral vs nasal intubation –> oral is challenging but butter suited if patient requires post-operative ventilation
23
Q
SCI intubation
A
- clinician should use equipment and techniques that are most familiar
- goals = achieve tracheal intubation while minimizing motion of C-spine
- preserve ability to assess neurologic functioning after positioning
- no evidence that DL worsens outcomes
24
Q
can you use SUCC with SCI intubation?
A
-yes if less than 24 hours since the initial injury
25
ortho and soft tissue trauma types of injury (3)
- isolated closed
- open fractures of major long bones and joints
- multiple fractures of major long bones, spinal column, and joints associated with multisystem injuries
26
different types of ortho trauma injuries
- dislocated hip
- fractured pelvis
- crush injuries
- open fractures
- long bone fractures are HIGH risk for DVT
- compartment syndrome
27
dislocated hip
- avascular necrosis of the femoral head can occur if the hip remains dislocated
- usually a GA
28
fractured pelvis
- can be VERY bloody due to close proximity to large venous vascular structures
- sometimes need embolization of these structures
- type and cross for AT LEAST 4 units of blood and tell blood bank to have two ahead
29
crush injuries
- muscle damage
- causes myoglobinuria so need fluid to flush out
- mannitol to flush out kidneys
- bicarb so the renal tubules don't get clogged
30
ortho trauma anesthesia management
- most often require GA (because coming in as trauma/full stomach)
- anesthetic requirements comparable to those of non-trauma patient
- controlled hypotension may be used if not contraindicated
- allow spontaneous ventilations near end of case to guide narcotic admin
31
advantages of regional anesthesia
- continued mental status assessment
- increased vascular flow
- avoidance of airway instrumentation
- improved post-op mental status
- decreased blood loss
- decreased incidence of DVT
- improved post-op analgesia
- better pulmonary toilet
- earlier mobilization
32
disadvantages of regional anesthesia
- peripheral nerve function difficult to assess
- patient refusal is common
- requirement for sedation
- longer time to achieve anesthesia
- not suitable for multiple body regions
- difficult to judge length of surgical procedures
33
advantages of GA
- speed of onset
- duration can be maintained as long as needed
- allows multiple procedures for multiple injuries
- greater patient acceptance
- allows for PPV
34
disadvantages of GA
- impairment of neuro exam
- requires airway instrumentation
- hemodynamic management more complex
- increased potential for barotrauma
35
pulmonary injuries
- chest tube
- thoracotomy - indicated if drainage greater than 1500 mL in first several hours, when tracheal or bronchial injury/large air leak noted, or hemodynamic instability from thoracic injury
- double lumen tube but often after initial intubation via RSI with standard ETT
36
traumatic aortic injury
- high incidence of morbidity and mortality
- must be ruled out if patient has suffered a high energy injury such as MVA or fall
- diagnosis is made through CXR, angiography, CT, and TEE
- surgery indicated due to high risk of rupture in hours to days
- anesthetic treatment include partial bypass technique using inflow from LA, centrifigual pump, and outflow to descending aorta
- endovascular repair now more common (good bc no bypass)
37
most common area for aortic damage
- after subclavian in thoracic aorta because most immobile part of aorta
- heart and others structures bang against it and tear aorta
38
SBP goal for aortic case
<100 mmHg to keep injury from extending further
39
rib fractures
- most common injury from blunt chest trauma
- flail chest occurs if comminuted fractures of at least 3 ribs
- characterized by paradoxical respiratory movements
- consider pain management or epidural placement to maintain ventilation/perfusion
40
cardiac injury
- penetrating trauma --> have high pre-hospital mortality
- cardiac tamponade (look for beck's triad)
- bruising or contusion is functionally indistinguishable from MI (treat same way too)
- TTE or TEE can be used for diagnosis
- managed as ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances
- cardiology consult if appropriate
41
Beck's triad
- hypotension
- muffled heart sounds
- JVD
42
Jehovah's witness + trauma
- deliberate hypotension
- use of salvaged blood cells from intra-op or chest tube collection
- early hemodynamic monitoring
- post-op use of EPO
43
elderly + trauma
- more serious outcomes in elderly for equivalent trauma
- decreased cardio-pulmonary reserve so higher incidence of post-op mechanical ventilation
- MOSF after hemorrhagic shock
- post traumatic myocardial dysfunction
44
pregnancy + trauma
- high incidence of spontaneous abortion, pre-term labor or premature delivery
- OB consult for immediate management and follow-up
- requires rapid and complete resuscitation of mother
45
mental status criteria for extubation
- resolution of intoxication
- able to follow commands
- non-combative
- pain adequately controlled
46
airway anatomy and reflexes criteria for extubation
- appropriate cough and gag
- ability to protect airway from aspiration
- no excessive airway edema or instability
47
respiratory mechanics criteria for extubation
- adequate tidal volume and RR
- normal motor strength
- require FiO2 less than 50%
48
systemic stability criteria for extubation
- adequately resuscitated
- small likelihood of urgent return to the OR (at least in very short term)
- normovolemic without signs of sepsis
49
risk factors for development of ARDS after trauma
- elderly
- preexisting physiologic impairment
- direct pulmonary or chest wall injury
- aspiration of blood or stomach contents
- prolonged mechanical ventilation
- severe traumatic brain injury
- SCI with quadriplegia
- massive transfusion
- hemorrhagic shock
- occult hypoperfusion
- wound or body cavity infection
50
vent settings in acutely injured patients
- Vt 6-8 mL/kg
- PEEP 10-15 cmH2O
- limit peak pressure <40 cmH2O
- adjust I:E ratio as necessary
- wean FiO2 to obtain PaO2 80-100, sats 93-97%
51
post-op complications trauma
- infection/sepsis
- thromboembolism
- abdominal compartment syndrome
- ARDS
