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N934 Advanced Principles of Anesthesia II > Trauma II > Flashcards

Trauma II Flashcards

1
Q

TBI goal of care

A

-prevention of secondary brain damage resulting from intracranial bleeding, edema, increased ICP, hypoxia and shock

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2
Q

mild TBI

A
  • GCS of 13-15

- short period of observation, usually 24 hours

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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
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4
Q

severe TBI

A
  • GCS less than 8
  • carries a significant rate of mortality
  • care is directed at perfusion of injured brain
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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
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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
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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
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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
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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
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10
Q

mannitol dose

A

0.25-1 g/kg

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11
Q

SCI causes

A

MVA
falls
penetrating trauma

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12
Q

SCI incidence

A

10,000 americans each year

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13
Q

most common location for SCI

A

low cervical spine (C4-C7)

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14
Q

SCI injuries include

A
  • sensory deficits
  • motor deficits
  • OR BOTH YIKES
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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
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16
Q

early SCI treatment focus

A

-adequate perfusion to prevent secondary injury from forming

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17
Q

when does autonomic hyperreflexia occur?

A
  • complete injury above T5

- occurs in 85% if SCI

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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
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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

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20
Q

what C spine injuries are commonly missed

A
  • C1-2
  • C7-T1
  • difficult to image
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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
Q

ortho and soft tissue trauma types of injury (3)

A
  • 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
Q

different types of ortho trauma injuries

A
  • dislocated hip
  • fractured pelvis
  • crush injuries
  • open fractures
  • long bone fractures are HIGH risk for DVT
  • compartment syndrome
27
Q

dislocated hip

A
  • avascular necrosis of the femoral head can occur if the hip remains dislocated
  • usually a GA
28
Q

fractured pelvis

A
  • 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
Q

crush injuries

A
  • 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
Q

ortho trauma anesthesia management

A
  • 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
Q

advantages of regional anesthesia

A
  • 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
Q

disadvantages of regional anesthesia

A
  • 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
Q

advantages of GA

A
  • speed of onset
  • duration can be maintained as long as needed
  • allows multiple procedures for multiple injuries
  • greater patient acceptance
  • allows for PPV
34
Q

disadvantages of GA

A
  • impairment of neuro exam
  • requires airway instrumentation
  • hemodynamic management more complex
  • increased potential for barotrauma
35
Q

pulmonary injuries

A
  • 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
Q

traumatic aortic injury

A
  • 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
Q

most common area for aortic damage

A
  • after subclavian in thoracic aorta because most immobile part of aorta
  • heart and others structures bang against it and tear aorta
38
Q

SBP goal for aortic case

A

<100 mmHg to keep injury from extending further

39
Q

rib fractures

A
  • 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
Q

cardiac injury

A
  • 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
Q

Beck’s triad

A
  • hypotension
  • muffled heart sounds
  • JVD
42
Q

Jehovah’s witness + trauma

A
  • deliberate hypotension
  • use of salvaged blood cells from intra-op or chest tube collection
  • early hemodynamic monitoring
  • post-op use of EPO
43
Q

elderly + trauma

A
  • 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
Q

pregnancy + trauma

A
  • 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
Q

mental status criteria for extubation

A
  • resolution of intoxication
  • able to follow commands
  • non-combative
  • pain adequately controlled
46
Q

airway anatomy and reflexes criteria for extubation

A
  • appropriate cough and gag
  • ability to protect airway from aspiration
  • no excessive airway edema or instability
47
Q

respiratory mechanics criteria for extubation

A
  • adequate tidal volume and RR
  • normal motor strength
  • require FiO2 less than 50%
48
Q

systemic stability criteria for extubation

A
  • adequately resuscitated
  • small likelihood of urgent return to the OR (at least in very short term)
  • normovolemic without signs of sepsis
49
Q

risk factors for development of ARDS after trauma

A
  • 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
Q

vent settings in acutely injured patients

A
  • 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
Q

post-op complications trauma

A
  • infection/sepsis
  • thromboembolism
  • abdominal compartment syndrome
  • ARDS

N934 Advanced Principles of Anesthesia II (17 decks)

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