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N934 Adv Principles Fa 21 > Trauma Part 1 > Flashcards

Trauma Part 1 Flashcards

1
Q

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

A

1-45

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2
Q

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

A

15-44

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3
Q

3 sequential components of evaluation

A
  1. rapid overview (stable v unstable)
  2. primary survey (5-10 minutes max), ABCDE
  3. secondary survey
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4
Q

Primary Survey ABCDE stands for

A

airway, breathing, circulation, disability, exposure

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5
Q

Primary Survey: airway

A

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

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6
Q

Primary survey: breathing

A

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

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7
Q

primary survey: circulation

A

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

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8
Q

Primary Survey: Disability

A

mentation (neuro, GCS)

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9
Q

Primary Survey: exposure

A

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

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10
Q

GCS: eye opening response

A

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

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11
Q

GCS: verbal response

A

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

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12
Q

GCS: motor response

A

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

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13
Q

percent mortality of GCS <8

A

35%

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14
Q

Secondary Survey

A

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.

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15
Q

airway: most trauma patients require

A

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.

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16
Q

airway obstruction considerations

A

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

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17
Q

airway management considerations

A 
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
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18
Q

tracheal intubation considerations

A

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

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19
Q

naso tracheal intubation: when you can and cant!

A

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

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20
Q

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

A

breath sounds and capnometry at the least.

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21
Q

what happens to your CO2 if your pt is hypotensive

A

low CO2 ma’am.

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22
Q

difference between RSI and MRSI

A

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.

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23
Q

cricoid pressure?

A

dont “have to” anymore, not in algorithm.

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24
Q

indications for ETT

A

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

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25
Q

flail chest, need ETT?

A

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

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26
Q

tracheostomy versus cricothyroidotomy

A

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.

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27
Q

consider cricothyroidotomy when

A 
massive facial trauma/hemorrhage
supreglottic foreign body obstruction
angioneurotic edema
inhalation thermal injury
epiglottis/croup
tracheal/laryngeal damage
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28
Q

complications of cricothyroidotomy

A

esophageal perforation
SQ emphysema
bleeding/hemorrhage

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29
Q

gold standard airway technique for spinal injury and cervical spinal injurries

A

fiberoptic

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30
Q

aw management and full stomach

A

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)

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31
Q

suggested emergency aw algorithm for trauma

A
  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
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32
Q

succinylcholine for burns and SCI

A

ok in first 24 hours, contraindicated after

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33
Q

induction drug suggestions for trauma (and doses)

A

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)

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34
Q

NMB drug suggestions for trauma

A

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)

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35
Q

succinylcholine defasciculating dose

A

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

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36
Q

anesthetic drugs in trauma, other drugs to consider

A

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

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37
Q

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

A

fall, MVA, diving accident

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38
Q

cervical spine injuries management includes

A

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

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39
Q

how to rule out cervical spine injury

A

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

40
Q

how to do manual in line stabilization (MILS)

A

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

41
Q

head, open eye, major vessels injuries and aw management

A

ensure adequate oxygenation and ventilation

deep anesthesia and profound relaxation prior to aw manipulation and intubation

42
Q

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

A

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

43
Q

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

A

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

44
Q

maxillofacial injuries and aw management

A

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

45
Q

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

A

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

46
Q

cervical injuries and aw management: blind injury

A

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

47
Q

cervical injuries and aw management: ways to establish secure aw

A

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

48
Q

C4-5 injury and aw

A

intubate!

49
Q

C6-7 injury and aw

A

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

50
Q

breathing abnormalities that require intubation

A 
tension pneumothorax
flail chest (probably, not always)
open pneumothorax
hemothorax
pulmonary contusion 
diaphragmatic rupture
chest wall splinting
51
Q

hemothorax symptoms, tx, anesthetic considerations

A

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.

52
Q

pneumothorax categories (3) and tx

A

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

53
Q

tension pneumothorax hallmark symptoms and tx

A

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

54
Q

flail chest results from

A

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

55
Q

flail chest sx, considerations, tx

A

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

56
Q

most common cause of traumatic HoTN and shock in trauma patients

A

hemorrhage

57
Q

resuscitation refers to:

A

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

58
Q

physiologic response to shock

A
  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
59
Q

lactate and free radicals can cause

A

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

60
Q

blunt trauma can be responsible for what type of shock

A

cardiogenic

61
Q

neurogenic trauma can be responsible for what type of shock

A

distributive

62
Q

hormones released during shock include

A

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

63
Q

organ responses to shock: CNS

A

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

64
Q

organ responses to shock: kidney/adrenal

A

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

65
Q

organ responses to shock: heart

A

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

66
Q

organ responses to shock: lung

A

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

67
Q

organ responses to shock: gut/intestinal

A

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

68
Q

acute traumatic coagulopathy pathophys cascade

A

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

69
Q

base deficit reflects

A

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

70
Q

base deficit: mild shock

A

2-5mmol/L

71
Q

base deficit: moderate shock

A

6-14mmol/L

72
Q

base deficit: severe shock

A

> 14mmol/L

73
Q

admission base deficit of ____correlates with increased mortality

A

5-8mmol/L

74
Q

is blood lactate or base deficit more specific?

A

base deficit

75
Q

elevated lactate levels correlate with

A

hypoperfusion

76
Q

normal plasma lactate level and half life is

A

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

77
Q

plasma level above ____ is significant lactic acidosis

A

> 5mmol/L

78
Q

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

A

24 hours

79
Q

assessment of systemic perfusion includes

A

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)

80
Q

symptoms of shock

A 
pallor
diaphoresis
agitation or obtundation
HoTN
tachycardia
prolonged capillary refill
diminished UOP
narrowed PP
81
Q

sites for emergency IV access in order of desirability

A
  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)
82
Q

goals for early resuscitation

A 
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
83
Q

risks of aggressive volume replacement during early resuscitation

A 
increased BP
decreased blood viscosity
decreased HCT
decreased clotting factor concentration
greater transfusion requirement
disruption of electrolyte balance
direct immune suppression
premature reperfusion
84
Q

resuscitation goals: anesthesia considerations

A 
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
85
Q

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

A

“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

86
Q

end point for resuscitation

A

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

87
Q

blood loss replacement

A

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.

88
Q

blood loss replacement and FFP

A

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

89
Q

hemostatic agents to consider during trauma

A

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

90
Q

fluid inflation system (rapid transfuser?) pearls

A 
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
91
Q

lethal triad

A

acidosis
hypothermia
coagulopathy

92
Q

hypothermia worsens

A 
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!
93
Q

coagulopathy in the trauma patient pearls

A

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

94
Q

massive transfusion causes dilution of

A

factors and platelets

95
Q

at 29c, PT and PTT ______ and platelets ______

A

PT and PTT increase 50% and platelets decrease 40%

96
Q

tx of coagulopathy

A

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.

N934 Adv Principles Fa 21 (23 decks)

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