Trauma-II (Lynch) Flashcards
Objectives
- rescuscitation options for trauma
- analgesia plan for trauma patient
- consider factors influence timing of procedues
- understand concepts of damage control
Where is fluid lost from during trauma
- intravascular space
- lose
- red cells
- water
- protein
- smallest fluid compartment
- doesn’t take much to see signs of shock
- lose
IV volume deficits
- replace like with like
- lose volume quickly => replace volume quickly
- be careful, rapid admin may worsen bleeding
- dislodging soft clots
- be careful, rapid admin may worsen bleeding
- lose blood => replace blood
- lose volume quickly => replace volume quickly
Resuscitation in severely injured patients
- SIRS (systemic inflammatory response syndrome)
- severe trauma=sepsis like syndrome
- Coagulopathy possible
- ongoing hemorrhage leads to further fluid loss
- sythetic fluids may make worse
- transfusions may be better
Resuscitation with isotonic crystalloids
- Shock dose based on normal blood volume
- dogs: 90 ml/kg
- cats: 60 ml/kg
- 5 kg cat this would be less than a coke can
- Give proportion of shock dose, then re-assess
- improv perfusion parameters
- improv tachycardia
- improv mm color
- improv blood pressure
- lower lactate levels
- improv mentation
- improv perfusion parameters
Concerns with large volume resuscitation
- Lethal triad of trauma
- dilution of clotting factors
- acidemia (Cl gets rid of bicarb)
- hypothermia
Alternative to large vol resuscitation
- Low volume resuscitation
- hypertonic saline
- synthetic colloids
- Hypotensive (delayed) resuscitation
- Hemostatic resuscitation
- blood products
Low volume resuscitation
- Hypertonic saline (7.2%)
- more rapid volume expansion
- must follow with isotonic crystalloids
- depletes other fluid compartments
- don’t give too rapidly
- Synthetic colloids
- hydroxyethylstarches
- more rapidly volume expansion
- theoretical more sustained expansion than isotonic crystalloid
- dose dependent coagulopathy
- may not be good for trauma
- AKI risk in people
- limited availability
Hypotensive (delayed resuscitation
- from military experience
- only appropriate if confirmed surgical lesion
- surgical hemostasis achieved before volume resuscitation
- rarely justifiable in vet med
*has to have a real bleed, not a coagulopathy
*tying off a bleeder
*done quickly (do or die)
Hemostatic resuscitation
- transfusions
- fresh whole blood best
- red cells
- platelets
- plasma
- most hospitals have blood components, not donors
- Ratios of blood can help
- if several transfusions required
- 1:1:1 of packed red cells: platelets: plasma
Massive transfusion
- large volume blood products
- whole blood volume in 24 hours
- half blood volume in 3 hours
hemostatic resuscitation
benefits
- Advantages
- most physiological approach
- Plasma/whole blood can correct coagulopathy
- red cells improve oxygen carrying capacity
- Disadvantages
- Expensive
- not always available
- citrate containing transfusions may worsen coagulopathy
Autotransfusion
- large volume shed blood from cavitary bleeds
- infection risk-lack of sterility
- give antimicrobial
- deficient in clotting factors
- cheap and readily available
Oxygen supplementation
- not harmful short term
- minimally stressful and min invasive methods
- oxygen mask
- oxygen cage
- nasal lines
- intubation/ventilation
- most oxygen carried bound to hemoglobin
- limited help in anemic/hemorrhaging patients
- pleural space dz
- benefits from oxygen AND thoracocentesis
Analgesia
- Multimodal approach helpful
- assess locomotor ability before analgesia admin
Analgesia
opioids
- Opioids
- full mu agonists-reversible with naloxone
- fentanyl
- methadone
- partial mu agonists
- buprenorphine
- full mu agonists-reversible with naloxone
- Full mu agonists preferable in unstable patients
- buprenorhpine is good for cats
Analgesia - NSAIDs
- good for hemodynamically stable patients
- risk of GI ulceration and AKI
- Not usually given day of trauma
- good for at home pain-relief
Analgesia other options
- Ketamine
- dissociative anesthetic
- CRI helpful
- prevents wind-up pain
- Lidocaine
- systemically/for regional blocks
- careful in cats: toxicity
- Dexmedetomidine
- analgesic and anxiolytic
- reserved for hemodynamically stable patients
Antimicrobials
- consider amount of contamination
- bite wounds inherently contaminated
- amoxicillin clavulante PO
- ampicillin-sulbactam IV
- clindamycin IV or PO
- think about C/S
Superficial non-bite wound
cefazolin probs sufficient
-culture if you see a necrotic wound later or a second time
Steroids
- Not indicated for trauma
- never use for head trauma
Anti-arrhythmics
- Arrhythmia associated with precipitating factor
- shock
- anemia
- Myocardial contusions
- traumatic myocarditis
- Ventricular ectopy most common concern
- lidocaine
Temp stabilization
Damage control
- initial care without definitive tx
- reasons
- patient stability
- avoid long anesthesia
- lack of personnel
- specialist required
- definitive therapy not appropriate
- contaminated wounds
- patient stability
Wound
damage control
- Clip and clean
- copious lavage
- cover up
- soft tissue bandage
- wet to dry dressing