Trauma Part 1

Question 1

trauma is the leading cause of death between ____ years of age

Answer 1

1-45

Question 2

WHO estimates trauma is leading cause of death world wide between _____ years of age

Answer 2

15-44

Question 3

3 sequential components of evaluation

Answer 3

1. rapid overview (stable v unstable)
2. primary survey (5-10 minutes max), ABCDE
3. secondary survey

Question 4

Primary Survey ABCDE stands for

Answer 4

airway, breathing, circulation, disability, exposure

Question 5

Primary Survey: airway

Answer 5

potency. obstruction? agitated (hypoxia), gurgling, stridor, tracheobronchial obstruction, paradoxical chest movement, pneumothorax, or talking and fine

Question 6

Primary survey: breathing

Answer 6

how to maintain: high flow oxygen, trachea midline, flail chest (3 or more fractured segments of ribs), tension pneumothorax, massive hemothorax (>1500cc of blood)

Question 7

primary survey: circulation

Answer 7

pale, tachycardic, bleed that needs tamponade. large bore IV’s (two 16gauges would be lit)

Question 8

Primary Survey: Disability

Answer 8

mentation (neuro, GCS)

Question 9

Primary Survey: exposure

Answer 9

strip them to examine for contusions, deformities, foreign objects. See if they need emergent OR, log roll patient when turning.

Question 10

GCS: eye opening response

Answer 10

4: spontaneous
3: to speech
2: to pain
1: none

Question 11

GCS: verbal response

Answer 11

5: oriented to name
4: confused
3: inappropriate speech
2: incomprehensible sounds
1: none

Question 12

GCS: motor response

Answer 12

6: follows commands
5: localizes to painful stimuli
4: withdraws to painful stimuli
3: abnormal flexion (decorticate)
2: abnormal extension (decerebrate)
1: none

Question 13

percent mortality of GCS <8

Answer 13

35%

Question 14

Secondary Survey

Answer 14

begins after critical life saving actions including intubation, chest tube placement, fluid resuscitation. focus is history of injury, allergies, medications, last oral intake. focused medical and surgical history
ex) also think: obese, older, those kinds of assessments and implications of.

Question 15

airway: most trauma patients require

Answer 15

assisted or controlled ventilation, self inflating bag with non rebreathing valve is sufficient after intubation and for transport. 100% oxygen is necessary until ABG is complete.

Question 16

airway obstruction considerations

Answer 16

airway edema/direct aw injury (jaw injury, trismus?)
cervical deformity (think cervical injury, sandbags or c collar.)
cervical hematoma
foreign bodies (gsw. internal and external ex) knocked tooth and aspirated, bite tongue off)
dyspnea, hoarseness, stridor, dysphonia
SQ emphysema and crepitation (palpate neck. laceration or tracheal tear with hoarseness or stridor are signs)
hemoptysis/active oral bleeding/copious secretions (fiberoptic not best, you’ll just see red!)
tracheal deviation
JVD (chest wound, stab wound, narrowed PP, muffled heart, hypo perfusion)
hemodynamic condition

Question 17

airway management considerations

Answer 17

100% oxygen administration ma'am
chin lift and jaw thrust (CAN DO if neck is injured)
full stomach (SNS response)
clearing of oropharyngeal aw
oral and nasal aw
immobilization of cervical spine
tracheal intubation if ventilation is inadequate
consider aw adjuncts to secure aw

Question 18

tracheal intubation considerations

Answer 18

if NT tube, smaller hole so switch to ett as soon as you can. sinusitis is SE.

Question 19

naso tracheal intubation: when you can and cant!

Answer 19

basilar skull fx (battle signs behind ear, raccoon eyes, CSF leak are sx) NO
lefort 1 and 2 if you have to~~
lefort 3, nah fam

Question 20

if you go to ED/ICU and patient is intubated, check tube placement via

Answer 20

breath sounds and capnometry at the least.

Question 21

what happens to your CO2 if your pt is hypotensive

Answer 21

low CO2 ma’am.

Question 22

difference between RSI and MRSI

Answer 22

modified is trying to ventilate. like if theyre hypoxic af or obese. but really dont want to put more air in the stomach so like, proceed with caution.

Question 23

cricoid pressure?

Answer 23

dont “have to” anymore, not in algorithm.

Question 24

indications for ETT

Answer 24

cardiac or respiratory arrest
respiratory insufficiency/deteriorating condition
aw protection
need for deep sedation or analgesia (pain control)
GCS <8
delivery of 100% FiO2 in the presence of carbon monoxide poisoning
facilitate w/u in uncooperative or intoxicated patient
transient hyperventilation require
facial burns, consider protecting that airway

Question 25

flail chest, need ETT?

Answer 25

not always. may need pain management so they take deep breaths and ventilate

Question 26

tracheostomy versus cricothyroidotomy

Answer 26

tracheostomy takes longer to perform, requires neck extension which may cause extended neck trauma if cervical injury is present cricothyroidotomy is contraindicated in those younger than 12. do a needle cric if <12y. laryngeal damage precludes the ability to perform a cricothyroidotomy.

Question 27

consider cricothyroidotomy when

Answer 27

``` massive facial trauma/hemorrhage supreglottic foreign body obstruction angioneurotic edema inhalation thermal injury epiglottis/croup tracheal/laryngeal damage ```

Question 28

complications of cricothyroidotomy

Answer 28

esophageal perforation SQ emphysema bleeding/hemorrhage

Question 29

gold standard airway technique for spinal injury and cervical spinal injurries

Answer 29

fiberoptic

Question 30

aw management and full stomach

Answer 30

full stomach is consideration for every trauma patient. no time for pharmacological intervention to decrease gastric contents and acidity. so, RSI (cricoid pressure?) and manual inline stabilization or awake intubation with topical anesthesia and sedation if pt cooperative. LMA use is contraindicated as a definitive aw (yah)

Question 31

suggested emergency aw algorithm for trauma

Answer 31

1. need for emergent intubation 2. preoxygenate with bag valve mask, cricoid pressure and manual in line stabilization 3. induction, muscle relaxation 4. laryngoscopy #1 5. if unsuccessful, laryngoscopy #2 with bougie 6. if unsuccessful, LMA placement 7. if unsuccessful, cricothyroidotomy 8. if unsuccessful (or even successful), OR for definitive aw

Question 32

succinylcholine for burns and SCI

Answer 32

ok in first 24 hours, contraindicated after

Question 33

induction drug suggestions for trauma (and doses)

Answer 33

etomidate .2-.3mg/kg IV (.2-.4) ketamine 2-4mg/kg IV (except for head injuries) ketamine 4-10mg/kg IM propofol 2mg/kg IV (vasodilation tapered if given slowly)

Question 34

NMB drug suggestions for trauma

Answer 34

succinylcholine 1-1.5mg/kg IV (head/globe injury, no succ) | rocuronium 1.2mg/kg IV (30-60 second onset, may need gentle mask vent or MRSI, 60-90m DOA)

Question 35

succinylcholine defasciculating dose

Answer 35

for head/globe injury, can admin defasciculating dose of 3-5mg roc

Question 36

anesthetic drugs in trauma, other drugs to consider

Answer 36

scopolamine .4mg IV (amnesia, Ach inhibition) precedex benzodiazepines

Question 37

cervical spine injuries and aw management: high suspicion in these situations

Answer 37

fall, MVA, diving accident

Question 38

cervical spine injuries management includes

Answer 38

semi rigid collar, sandbags, backboard. always log roll, manual in line stabilization (MIS) best for aw management. stabilization maintained until cervical injury ruled out. orotracheal intubation most desirable

Question 39

how to rule out cervical spine injury

Answer 39

XR C1-7 and patient is not obtunded/high/drunk so they are awake and can communicate pain

Question 40

how to do manual in line stabilization (MILS)

Answer 40

hold near mastoid process and can take front part of collar off if needed

Question 41

head, open eye, major vessels injuries and aw management

Answer 41

ensure adequate oxygenation and ventilation | deep anesthesia and profound relaxation prior to aw manipulation and intubation

Question 42

head, open eye, major vessels injuries and aw management: without sufficient depth of anesthesia, patients may present with

Answer 42

HTN, coughing/bucking, increased ICP, IOP, and intravascular pressure

Question 43

head, open eye, major vessels injuries and aw management: initial assessment considerations

Answer 43

if its a difficult aw, cannot use muscle relaxants or IV induction agents. 4% lido to inhale or to help with cough/bucking.

Question 44

maxillofacial injuries and aw management

Answer 44

blood and debris in oropharyngeal cavity may predispose to partial or complete aw obstruction aspiration of teeth or foreign bodies serious aw compromise may present within few hours of penetrating facial trauma consider limitation of mandibular movement and truisms aw mangement technique is based on presenting condition leave them in whatever position they are with ventilation until they are ready to ventilate

Question 45

cervical injuries and aw management: penetrating injury. damage depends on 3 interactive factors

Answer 45

type of wounding instrument velocity at time of impact characteristic of tissue through which is passes. clinical signs include escape of air, hemoptysis, and coughing

Question 46

cervical injuries and aw management: blind injury

Answer 46

includes direct impact, deceleration, shearing, and rotary forces. laryngotracheal damage clinical signs include hoarseness, muffled voice, dyspnea, stridor, dysphagia, cervical pain and tenderness, flattening of thyroid cartilage

Question 47

cervical injuries and aw management: ways to establish secure aw

Answer 47

intubation of trachea should be with fiberoptic scope or aw should be established surgically

Question 48

C4-5 injury and aw

Answer 48

intubate!

Question 49

C6-7 injury and aw

Answer 49

intubate because they lose respiratory muscle function and lung compliance (diaphragm, airway reflexes)

Question 50

breathing abnormalities that require intubation

Answer 50

``` tension pneumothorax flail chest (probably, not always) open pneumothorax hemothorax pulmonary contusion diaphragmatic rupture chest wall splinting ```

Question 51

hemothorax symptoms, tx, anesthetic considerations

Answer 51

sx: HoTN, hypoxemia, tachycardia, increased CVP tx: eliminate/correct anesthetic considerations: 1 lung ventilation. first put in regular ett to establish aw asap then in a controlled environment switch for a double lumen tube. will likely need CT, assess how much blood and if transfusion is warranted.

Question 52

pneumothorax categories (3) and tx

Answer 52

simple (not open to the world), communicating (open to the world), tension tx: chest tube if pneumothorax is creating >20% lung collapse

Question 53

tension pneumothorax hallmark symptoms and tx

Answer 53

sx: HoTN, hypoxemia, tachycardia, increased CVP, diminished BS on affected side tx: decompression. most common between 2nd and 3rd ICS MCL anteriorly

Question 54

flail chest results from

Answer 54

comminuted fractures of at least 3 ribs, rib fractures associated with costochondral separation, sternal fracture (possible pulmonary contusions)

Question 55

flail chest sx, considerations, tx

Answer 55

sx: respiratory insufficiency and hypoxemia over several hours with deterioration of cxr and abg consider: pain management over mechanical ventilation tx: pain relief and oxygen. ex) epidural anesthesia, intercostal blocks. if patient decompensates, then intubate if necessary. CPAP/BiPAP ok as well

Question 56

most common cause of traumatic HoTN and shock in trauma patients

Answer 56

hemorrhage

Question 57

resuscitation refers to:

Answer 57

restoration of normal circulating blood volume, normal vascular tone, normal tissue perfusion

Question 58

physiologic response to shock

Answer 58

1. initial response mediated by neuroendocrine system (HoTN leads to vasoconstriction and catechol release. blood flow to heart, kidney, brain preserved while others restricted.) 2. ischemic cells respond to hemorrhage by taking up interstitial fluid and depleting intravascular volume and producing lactate and free radicals. "trapped in cell=cell swelling". 3. inadequate organ perfusion interferes with aerobic metabolism producing lactic acid and metabolic acidosis. lactate and free radicals accumulate in circulation while perfusion is diminished 4. ischemic cells also produce inflammatory factors, lays foundation for multiple organ failure and high mortality rates

Question 59

lactate and free radicals can cause

Answer 59

direct damage to the cell, toxic load that will be washed into circulation once it is re established. this is self perpetuating.

Question 60

blunt trauma can be responsible for what type of shock

Answer 60

cardiogenic

Question 61

neurogenic trauma can be responsible for what type of shock

Answer 61

distributive

Question 62

hormones released during shock include

Answer 62

renin, angiotensin, vasopressin, ADH, growth hormone, glucagon, cortisol, epi/norepi

Question 63

organ responses to shock: CNS

Answer 63

responsible for maintaining blood flow to heart kidney and brain at expense of other tissue

Question 64

organ responses to shock: kidney/adrenal

Answer 64

glands maintains BF during HoTN by selective vasoconstriction and concentration of BG in medulla and deep cortical areas

Question 65

organ responses to shock: heart

Answer 65

preserved via increase in nutrient blood flow and cardiac function until later stages

Question 66

organ responses to shock: lung

Answer 66

is the destination of inflammatory byproducts, accumulate in capillary beds and results in ARDS. sentinel organ for development of MSOF

Question 67

organ responses to shock: gut/intestinal

Answer 67

one of earliest organs affected by hypo perfusion and may be trigger for MSOF

Question 68

acute traumatic coagulopathy pathophys cascade

Answer 68

begging in early presence of reduced clot strength. HoTN and tissue injury->inflammatory response->endothelial activation of APC. hyperfibrinolysis d/t APC formation resuscitation includes early tx of ATC

Question 69

base deficit reflects

Answer 69

the severity of shock, oxygen debt, changes in O2 delivery, adequacy of fluid resuscitation, likelihood of multiple organ failure

Question 70

base deficit: mild shock

Answer 70

2-5mmol/L

Question 71

base deficit: moderate shock

Answer 71

6-14mmol/L

Question 72

base deficit: severe shock

Answer 72

>14mmol/L

Question 73

admission base deficit of ____correlates with increased mortality

Answer 73

5-8mmol/L

Question 74

is blood lactate or base deficit more specific?

Answer 74

base deficit

Question 75

elevated lactate levels correlate with

Answer 75

hypoperfusion

Question 76

normal plasma lactate level and half life is

Answer 76

.5-1.5mmol/L and half life is 3h

Question 77

plasma level above ____ is significant lactic acidosis

Answer 77

>5mmol/L

Question 78

failure to clear lactate within ____ hours after reversal of shock is predictor of increased mortality

Answer 78

24 hours

Question 79

assessment of systemic perfusion includes

Answer 79

VSS (will not indicate occult hypo perfusion) UOP (may be inaccurate r/t diuretics, intoxication, renal injury) systemic acid base status (confounded by resp status) lactate clearance (time to obtain lab result) CO (requires PA cath/non invasive technology) mixed venous O2 (accurate, difficult to obtain) gastric tonometry (needs time to equilibrate, subject to artifact) tissue specific oxygenation (emerging technology) SVV (emerging technology, arterial line) acoustic BF (investigational technology)

Question 80

symptoms of shock

Answer 80

``` pallor diaphoresis agitation or obtundation HoTN tachycardia prolonged capillary refill diminished UOP narrowed PP ```

Question 81

sites for emergency IV access in order of desirability

Answer 81

1. large bore IV's in AC 2. other large bore IV site 3. subclavian vein (easiest to place and does not require neck manipulation in circumstance of cervical neck injury) 4. femoral vein (infx risk, access above diaphragm best r/t injuries) 5. IJ 6. IO (tibia)

Question 82

goals for early resuscitation

Answer 82

``` maintain SBP 80-100mmHg maintain Hct 25-30% maintain PTT and PT WNL maintain platelets >50,000 maintain normal serum Ical maintain core temp >35 celsius maintain function of pulse ox prevent increase in serum lactate prevent worsening acidosis adequate anesthesia/analgesia ```

Question 83

risks of aggressive volume replacement during early resuscitation

Answer 83

``` increased BP decreased blood viscosity decreased HCT decreased clotting factor concentration greater transfusion requirement disruption of electrolyte balance direct immune suppression premature reperfusion ```

Question 84

resuscitation goals: anesthesia considerations

Answer 84

``` oxygenation and ventilation restore organ perfusion restore homeostasis, repay oxygen debt tx coagulopathy restore circulating bolume continuous monitoring of response SURGERY STOPS BLEEDING NOT U OKAI ```

Question 85

goals for late resuscitation (late not as in near death, late as in you were successful with early resuscitation)

Answer 85

"normalize" is buzz word maintain SBP >100 maintain HCT above individual transfusion threshold normalize coagulation status normalize electrolyte balance normalize body temperature restore UOP maximize CO by invasive/noninvasive monitoring reverse systemic acidosis document decrease in lactate to normal range

Question 86

end point for resuscitation

Answer 86

lactate <2mmol/L base deficit <3mmol/L gastric intramucosal pH >7.33

Question 87

blood loss replacement

Answer 87

1:1 with PRBC for trauma (1:2 normally) 3:1 with crystalloid Rh negative blood is preferable if crosmatch is not complete (ABORh). esp if woman is child bearing age.

Question 88

blood loss replacement and FFP

Answer 88

2U FFP with every 4U PRBC when massive transfusion is anticipated or ongoing

Question 89

hemostatic agents to consider during trauma

Answer 89

TXA (antifibrinolytic). benefits when instituted within 1 hour of admission recombinant activated human coagulation factor VII (rFVIIa)

Question 90

fluid inflation system (rapid transfuser?) pearls

Answer 90

``` 1500ml/min transfusion infused at controlled temp allows for mixing of products compatible with crystalloid, colloid, PRBC, washed salvaged blood, plasma accurate recording of fluid volume admin portable ```

Question 91

lethal triad

Answer 91

acidosis hypothermia coagulopathy

Question 92

hypothermia worsens

Answer 92

``` acid base DO's coagulopathy myocardial fx shifts oxygen hgb curve to left decreases metabolism of lactate, citrate, and some anesthetic drugs causes vasoconstriction (BP looks higher than it is) abnormal K and Ca hemostasis causes sequestering of platelets! ```

Question 93

coagulopathy in the trauma patient pearls

Answer 93

activation of clotting cascade causes consumption of clotting factors blood loss causes loss of clotting factors hemodilution further dilutes clotting factors severely injured trauma patients because hypocoagulable

Question 94

massive transfusion causes dilution of

Answer 94

factors and platelets

Question 95

at 29c, PT and PTT ______ and platelets ______

Answer 95

PT and PTT increase 50% and platelets decrease 40%

Question 96

tx of coagulopathy

Answer 96

avoidance or reversal of lethal triad avoid hemodilution during resuscitation treat coagulopathies can be hypo coagulable or hyper coagulable state r/t trauma. treat accordingly.