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Trauma part 2 Flashcards

1
Q

Initial response to shock is mediated by

A

the neuroendocrine system

  • hypotension leads to vasoconstriction & catecholamine release
  • heart, kidney, and brain blood flow is preserved while other regional beds are constricted
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2
Q

Hypotension in the state of shock leads to

A

vasoconstriction and catecholamine release

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3
Q

___________ blood flow is preserved while other regional beds are constricted.

A

Heart, kidney, & brain blood flow

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4
Q

Traumatic injuries lead to a release in

A

hormones that set the stage for microcirculatory response

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5
Q

Ischemic cells response to hemorrhage by taking up

A

interstitial fluid & depleting intravascular volume & producing lactate & free radicals

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6
Q

Inadequate organ perfusion interferes with

A

aerobic metabolism–> producing lactic acid & metabolic acidosis

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7
Q

_______ accumulate in the circulation while perfusion is diminished

A

lactate & free radicals

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8
Q

Lactate & free radicals can cause:

A

direct damage to cell

a toxic load that will be washed into circulation once re-established

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9
Q

Ischemic cells also produce inflammatory factors

A

(leukotrienes, interleukins, etc.)

  • systemic inflammatory process
  • becomes a disease process unto itself
  • lays the foundation for multiple organ failure and nigh mortality rates
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10
Q

_______ temporarily maintain perfusion to vital organs

A

catecholamine release, regional vasoconstriction (adrenal/neuroendocrine)

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11
Q

The cellular response to shock includes:

A

uptake interstitial fluid–> swell
swelling may cause obstruction of capillaries–> no perfusion
this may inhibit reversal of ischemia
ischemic cells produce lactate, free radicals, and inflammatory mediators

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12
Q

In response to pain & hemorrhage, the following hormones are released:

A 
renin/angiotensin
vasopressin
ADH
growth hormone
glucagon
cortisol 
epi/norepi
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13
Q

Describe the CNS response to shock.

A

responsible for maintaining blood flow to heart, kidney, & brain at expense of other tissues

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14
Q

Describe the kidney/adrenal glands response to shock.

A

maintains GF during hypotension by selective vasoconstriction and concentration of blood flow in medulla and deep cortical areas

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15
Q

Describe the heart’s response to shock.

A

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

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16
Q

Describe the lung’s response to shock

A

the destination of inflammatory byproducts–> accumulate in capillary beds and results in ARDS. sentinel organ for the development of MOSF

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17
Q

Describe the Gut/intestinal response to shock.

A

one of the earliest organs affected by hypo-perfusion and may be trigger for MOSF

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18
Q

Resuscitation includes early treatment of

A

acute traumatic coagulopathy

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19
Q

Acute traumatic coagulopathy begins in the early presence of reduced clot strength

A

hypotension & tissue injury–> inflammatory response—> endothelial activation of protein C
-hyperfibrinolysis due to APC formation

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20
Q

Base deficit reflects the

A 
severity of shock
oxygen debt
changes in O2 delivery
adequacy of fluid resuscitation 
likelihood of multi-organ failure
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21
Q

Admission base deficit of _____ correlates with increased mortality

A

5-8 mmol/L

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22
Q

Describe the base deficit difference in mild, moderate, and severe shock.

A

mild: 2-5 mmol/L
moderate: 6-14 mmol/L
severe: greater than 14 mmol/L

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23
Q

Blood lactate level is

A

less specific than base deficit but nonetheless improtant

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24
Q

Elevated lactate levels correlate to

A

hypoperfusion

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25
Q

Normal plasma lactate level is

A

0.5-1.5 mmol/L and its half life is 3 hours

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26
Q

Plasma lactate levels above

A

5 mmol/L indicate significant lactic acidosis

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27
Q

Failure to clear lactate within

A

24 hours after reversal of shock is predictor of increased mortality

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28
Q

Symptoms of shock include

A 
pallor
diaphoresis
agitation or obtundation
hypotension
tachycardia
prolonged capillary refill
diminished urine output
narrowed pulse pressure
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29
Q

Assessment of systemic perfusion includes

A 
vital signs
urine output
systemic acid-base status
lactate clearance
cardiac output
mixed-venous oxygenation
gastric tonometry
tissue specific oxygenation
stroke volume variation
acoustic blood flow
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30
Q

Urine output in assessment of systemic perfusion may be

A

inaccurate due to diuretic therapy, intoxication, & renal injury

31
Q

Systemic acid base status is

A

confounded by respiratory status

32
Q

Cardiac output measurement requires

A

PA catheter/non invasive technology

33
Q

Gastric tonometry needs

A

time to equilibrate, subject to artifact

34
Q

Stroke volume variation is

A

an emerging technology, uses art line

35
Q

Mixed- venous oxygenation is

A

an accurate marker, difficult to obtain

36
Q

Goals for early resuscitation include

A 
maintain SBP at 80-100 mmHg
maintain hct at 25-30%
maintain PTT and PT within normal range
maintain platelet count >50,000
maintain normal serum ionized calcium
maintain core temp >35 degrees C
maintain function of pulse ox
prevent increase in serum lactate
prevent worsening acidosis
adequate anesthesia/analgesia
37
Q

Site for emergency intravenous access in order of desirability includes:

A

large bore IV’s- AC vein
other large bore IV sites
subclavian vein- easiest to place and does not require neck manipulation in circumstance of cervical neck injury
femoral vein- infection risk, belly full of blood indicates possible vascular damage so could end up dumping more blood into the stomach
internal jugular vein
intraosseous

38
Q

Risks of aggressive volume replacement during early resuscitation includes

A 
increased blood pressure
decreased blood viscosity
decreased hematocrit
decreased clotting factor concentration
greater transfusion requirement
disruption of electrolyte balance
direct immune suppression
premature reperfusion
39
Q

Resuscitation goals for anesthesia include:

A 
oxygenate & ventilate
restore organ perfusion
restore homeostasis/repay "oxygen debt"
treat coagulopathy
restore the circulating volume
continuous monitoring of the response
40
Q

Resuscitation goals for surgery include:

A

STOP the bleeding

41
Q

Goals for late resuscitation include:

A

maintain systolic blood pressure >100 mmHg
maintain hematocrit above individual transfusion threshold
normalize coagulation status
normalize electrolyte balance
normalize body temperature
restore urine output
maximize cardiac output by invasive/noninvasive monitoring
reverse systemic acidosis
document decrease in lactate to normal range

42
Q

End point for resuscitation lab levels include

A

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

43
Q

The four stops in management of shock include:

A
  1. control the source of the hemorrhage
  2. begin fluid resuscitation: isotonic crystalloids, hypertonic saline, colloids, PRBCs, & plasma
  3. Possibly use Rapid infusing system (1500 cc/min.)
  4. reasonable blood pressure (early resusc. 80-100 vs. late >100)
44
Q

Describe the use of isotonic crystalloids:

A

monitor electrolytes & lactate will direct fluid therapy plasmalyte is a good option

45
Q

Describe the use of hypertonic saline:

A

traumatic brain injury HS is used as an osmotic agent in the management of increased ICP

46
Q

Describe the use of colloids:

A

rapid plasma volume expansion

47
Q

Describe the use of FFP:

A

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

48
Q

Describe the use of PRBCs:

A

provided to adequate oxygen carrying capacity- mainstay of hemorrhagic shock
blood loss replacement:
-1:1 with RBC
3:1 with crystalloid
Rh negative blood is preferable if crossmatch is not complete (ABO & Rh)
especially if woman of childbearing age

49
Q

Damage control with hemostatic resuscitation includes

A

administration of set protocol of blood & hemostatic products to mimic whole blood
massive transfusion protocol
limited crystalloid

50
Q

Goal directed therapy with hemostatic resuscitation includes:

A

utilizes “point of care” visoelastic (TEG) monitoring to direct therapy

51
Q

Tranexamic acid is a

A

antifibrinolytic

-benefit when instituted within 1 hour of admission

52
Q

Additional hemostatic agents include

A

recombinant activated human coagulation factor VII

it’s expensive so not commonly kept on hand

53
Q

Describe the lethal triad***

A

acidosis
hypothermia
coagulopathy

54
Q

Principle goal of early management of the hemorrhaging trauma patient is

A

to avoid the development of the lethal triad

55
Q

________ are major factors in the induction of coaguloapthy

A

acidosis & hypothermia

56
Q

Resuscitation with fluids & PRBC without hemostasis properties can

A

dilute already dysfunctional platelets

57
Q

Fluid inflation system is an

A

active mechanical pump that enables fluid administration rates up to 1500 mL/min.

58
Q

The fluid inflation system is compatible with

A

crystalloid, colloid, PRBCs, washed salvaged blood & plasma

59
Q

Additional facts regarding the fluid inflation system include:

A

reservoir allows for mixing of products in preparation for rapid blood loss
fluids infused at a controlled temperature (38-40 C)
able to pump simultaneously through multiple intravenous lines
accurate recording of fluid volume administration
portable enough to travel with patient between units

60
Q

Hypothermia causes worsening of

A 
acid base disorders
coagulopathy
myocardial function
shifts oxygen-hgb curve to left
decreases the metabolism of lactate, citrate, and some anesthetic drugs
61
Q

Hypothermia results in

A

vasoconstriction***; can ultimately make BP appear higher than volume status really is… BP may drop as patient warms

62
Q

Hypothermia leads to

A

abnormal potassium and calcium homeostasis
impairs platelet and clotting function
left shift of oxygen dissociation curve- decreased tissue oxygenation

63
Q

Combined disorders of platelet & clotting factors

A

massive transfusion causes dilution of factors and platelets

hypothermia slows coagulation and causes sequestering of platelets

64
Q

At 29 degrees C _____ increase 50%

A

PT & PTT

65
Q

At 29 degrees C _____ decrease 40%

A

platelets

66
Q

Activation of the clotting cascade causes

A

consumption of clotting factors

67
Q

Blood loss causes a loss of

A

clotting factors

68
Q

_______ further dilutes clotting factors

A

Hemodilution

69
Q

Severely injured trauma patients become

A

hypercoagulable

70
Q

Treatment of coagulopathy includes

A

avoidance or reversal of the lethal triad
judicious resuscitation… avoid hemodilution
treat coagulopathies

71
Q

Trauma disrupts the equilibrium between

A

hemostatic and fibrinolytic processes

72
Q

Changes are complex and can either result in

A

hypercoagulable or hypocoagulable states

73
Q

Avoidance or reversal of the lethal triad includes

A

control hemorrhage
avoid/correct hypothermia
actively re-warm

Advanced Principles 2 (42 decks)

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