Trauma-II (Lynch) Flashcards
1
Q
Objectives
A
- rescuscitation options for trauma
- analgesia plan for trauma patient
- consider factors influence timing of procedues
- understand concepts of damage control
2
Q
Where is fluid lost from during trauma
A
- intravascular space
- lose
- red cells
- water
- protein
- smallest fluid compartment
- doesn’t take much to see signs of shock
- lose
3
Q
IV volume deficits
A
- 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
4
Q
Resuscitation in severely injured patients
A
- 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
5
Q
Resuscitation with isotonic crystalloids
A
- 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
6
Q
Concerns with large volume resuscitation
A
- Lethal triad of trauma
- dilution of clotting factors
- acidemia (Cl gets rid of bicarb)
- hypothermia
7
Q
Alternative to large vol resuscitation
A
- Low volume resuscitation
- hypertonic saline
- synthetic colloids
- Hypotensive (delayed) resuscitation
- Hemostatic resuscitation
- blood products
8
Q
Low volume resuscitation
A
- 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
9
Q
Hypotensive (delayed resuscitation
A
- 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)
10
Q
Hemostatic resuscitation
A
- 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
11
Q
Massive transfusion
A
- large volume blood products
- whole blood volume in 24 hours
- half blood volume in 3 hours
12
Q
hemostatic resuscitation
benefits
A
- 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
13
Q
Autotransfusion
A
- large volume shed blood from cavitary bleeds
- infection risk-lack of sterility
- give antimicrobial
- deficient in clotting factors
- cheap and readily available
14
Q
Oxygen supplementation
A
- 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
15
Q
Analgesia
A
- Multimodal approach helpful
- assess locomotor ability before analgesia admin
16
Q
Analgesia
opioids
A
- 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
17
Q
Analgesia - NSAIDs
A
- good for hemodynamically stable patients
- risk of GI ulceration and AKI
- Not usually given day of trauma
- good for at home pain-relief
18
Q
Analgesia other options
A
- 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
19
Q
Antimicrobials
A
- consider amount of contamination
- bite wounds inherently contaminated
- amoxicillin clavulante PO
- ampicillin-sulbactam IV
- clindamycin IV or PO
- think about C/S
20
Q
Superficial non-bite wound
A
cefazolin probs sufficient
-culture if you see a necrotic wound later or a second time
21
Q
Steroids
A
- Not indicated for trauma
- never use for head trauma
22
Q
Anti-arrhythmics
A
- Arrhythmia associated with precipitating factor
- shock
- anemia
- Myocardial contusions
- traumatic myocarditis
- Ventricular ectopy most common concern
- lidocaine
23
Q
Temp stabilization
Damage control
A
- initial care without definitive tx
- reasons
- patient stability
- avoid long anesthesia
- lack of personnel
- specialist required
- definitive therapy not appropriate
- contaminated wounds
- patient stability
24
Q
Wound
damage control
A
- Clip and clean
- copious lavage
- cover up
- soft tissue bandage
- wet to dry dressing
25
urinary tract rupture
damage control
* stabilize prior to sx
* urinary cath keeps bladder small
* drain effusion
* cath collection
* peritoneal dialysis
26
flail chest
damage control
* lie patient flail side down
* increases patient comfort
* bandages around chest possible
27
bandaging and splinting
damage control
* Anesthesia for fracture repairs delayed until stable
* stabilization provides analgesia
* no coaptation for femoral fractures
* ensure good pain-relief
28
Surgical decision
* deciding on timing can be difficult
* wait for patient stability if possible
29
Conditions benefiting from early surgery
1. wounds penetrating body cavities
2. GI tract rupture
3. Ongoing hemorrhage not responsive to med management
4. diaphragmatic hernia
5. body wall hernia with organ entrapment
6. neuro work up if no pain sensation
30
Conditions performed when patient stable
1. Open fractures
2. Body wall hernia without organ entrapment
3. extensive skin wounds
4. urinary tract rupture
5. neurological work up with intact pain sensation
31
Conditions performed at convenience of surgeon
* Closed fractures
* reconstructive procedures
* skin flaps
* Neuro work-up if motor present
32
Head trauma
* head trauma doesn't equal TBI
* inc intracranial pressure is life threatening
* advanced imaging recommended
* not performed very often
* MRI over CT
33
Head trauma
Cushing's response
* Systemic hypertension with inappropriate bradycardia
* interpret in light of physical exam
* clearly abnormal mentation
* emergent tx required
* lower IC pressure
* mannitol
* hypertonic saline
* hyperventilation (short term only)
* maintina normal perfusion
* don't limit fluids
* maintain normal oxygenation
* O2 supplementation
* **NEVER GIVE STEROIDS**
* **DON'T FORGET ABOUT THE EYES**
34
Traumatic hemoabdomen
* Usually non-surgical
* hemodynamic stabilization priority
* abdominal pressure wraps no-longer recommended
* Progressive bleeding may require sx
* liver/spleen laceration
* Consider coagulopathy before sx
35
Roll over injuries
* VERY BAD
* low impact injuries, high pressure
* four injuries to rule in/out
* bladder rupture
* pelvic fractures
* body wall rupture
* diaphragmatic hernia
36
Summary
* hemostatic resuscitation likely helpful in more severe trauma
* do not neglect analgesia and antimicrobials
* decision making
* wait until patient stable
* some conditions can't wait
* damage control where appropriate
