Trauma II Flashcards
Significant abnormalities on the neurological exam are an indication for ______
immediate cranial CT
Eye Opening
- Spontaneous
- To Speech
- To Pain
- None
Speech
- Oriented to name
- Responds, but confused
- Inappropriate speech
- Incomprehensible
- None
Motor
- Follows commands
- Localizes pain
- Withdrawals from pain
- Decorticate
- Decerebrate
- Nothing
What can cause secondary brain damage after a TBI (4)
bleeding
edema
ICP
hypoxia + shock
GCS 13 - 15
mild TBI
watch for 24h (unless elderly, hold longer)
GCS 9 - 12
early CT
intracranial lesions that require surgical evacuation
high potential for deterioration (+/- ett)
GCS < 8
mortality rate 3x higher
direct care at perfusion of injured brain
Severe TBI considerations (8)
CPP 60 - 70 mm Hg Hct 30% PaCO2 = 35 mmHg Ventriculostomy +/- HOB at 30 degrees Judicious use of analgesics/sedation Mannitol @ 0.25 - 1 g/kg Hypertonic saline
Hyperventilate
to 30 if herniation is imminent and not responsive to:
sedative, CSF drainage, NMB, osmotics, barbiturate coma
TBI + Airway
Intubate
Normoventilation
TBI + CV (5)
avoid ICP > 20 avoid systolic hypotension A-Line Low concentrations of sevo/iso/des Avoid nitrous
Where do most SCI occur
C4 - C7
What does the SCI outcome depend on
severity of injury
prevention of exacerbation
avoiding hypoxia and hypotension
Autonomic hyperreflexia
develops in 85% of SCI w/complete injury above T5
Main goal w/SCI
increase oxygen and MAP (>85) for at least one week to prevent worsening of injury!!
Neurogenic shock
hypotension + bradycardia
massive vasodilation
loss of cardiac accelerator neurons
give fluid bolus, if no increase in BP it’s neurogenic shock!
Incomplete vs complete lesion
emergent (incomplete)
complete - more ominous, less of an emergency
SCI + airway
- intubate
- chin lift + MIS + video
- sux if < 24 h
Three types of ortho trauma
- isolated closed
- open fx of major long bones + joints
- multiple fx of long bones, spinal columns
Fixed vs open fx
fixed = OR in 24 h (PNA, ARDS, fat emboli) open = OR in 12h (infection)
Dislocated hip
emergent d/t avascular necrosis (GA d/t full stomach)
Fractured pelvis
BLOOOOODY
+/- angiography if they can’t stop blood
+/- laparotomy to pack abdomen
T+C for 4 U
Crush injuries
muscle damage = myoglobinuria
want it clear in 8 hours
fluids, mannitol, bicarb (prevents clogs)
compartment syndrome
common in tibial and FA fracture
Ortho Trauma + Anesthesia
GA
Lower requirements if pt has hypovolemia
Controlled hypotension
use spontaneous ventilations at end of case to guide narcotic use
thoracotomy (3 reasons) & anesthesia implications
if drainage > 1500 mL if first few hours
if tracheal/bronchial injury or massive air leak
HD instability
**RSI w/normal ETT. Then, double lumen tube
Traumatic aortic injury
dx made via CXR, angiography, CT, TEE
surgery = necessary d/t rupture risk
partial bypass versus endovascular repair
SBP < 100
Rib fracture
flail chest w/paradoxical respiration
beck’s triad
cardiac tamponade
hotn, muffled, JVD
contusion (cardiac)
can’t distinguish from MI
arrhythmias, hotn, need CV support
dx: TTE or TEE
RF for ARDS
old pre-existing conditions direct chest wall injury aspiration prolonged vent TBI severe SCI w/quadriplegia massive tx shock occult hypoperfusion wound/body cavity infectrion
