Trauma Part 2

Question 1

3 sequential components of trauma evaluation

Answer 1

1. rapid overview (takes a few patients, stable v unstable)
2. primary survey (rapid eval for function crucial to survival and includes ABCDE)
3. secondary survey (detailed and systemic evaluation of each anatomic region and continued resuscitation if needed)

Question 2

surgical priorities in trauma patients (in order)

Answer 2

1. aw management (cric?)
2. control of exsanguinating hemorrhage
3. increacranial mass excision (threatened limb or eyesight, high risk of sepsis, control of ongoing hemorrhage)
4. early patient mobilization

Question 3

classification of TBI: mild

Answer 3

GCS 13-15

short period of observation, usually 24h

Question 4

classification of TBI: moderate

Answer 4

GCS 8-12
manifested as intracranial lesions that require surgical evacuation, early CT, high potential for deterioration requires early intubation and mechanical ventilation

Question 5

classification of TBI: severe

Answer 5

GCS <8
carries 3x higher rate of mortality
care directed at perfusion of injured brain

Question 6

2 hours post TBI, there is an increase in

Answer 6

amyloid B peptide or amyloid plaques

Question 7

severe TBI guidelines for managment/tx

Answer 7

after primary survey approach maintain CPP
maintain CPP 60-70 at all times
fluid resuscitation- keep euvolemic
correction of anemia (HCT of 30%)
PaCO2 35mmHg (normocarbia but on lower side of normo)
insertion of ventric drain and control of ICP (or lumbar drain)
positional therapy (HOB 30 degrees)
judicious use of analgesics/sedation
mannitol
hypertonic saline
(may need PRBC, inotropic support, increased FiO2)

Question 8

TBI aw and ventilatory management

Answer 8

hyperventilate only if hernia is imminent
hyperventilate to PaCO2 of 30 if elevated ICP is not responsive to sedatives, CSF drainage, NMB, osmotic agents, barbiturate coma (hyperventilation is not a continuous measure, only an intermediate measure)
CPP=MAP-ICP

Question 9

anesthetic management of TBI: early control of aw

Answer 9

orotracheal intubation to maintain SpO2 >90%
maintain norm-ventilation to help in reduction of hypercarbia and hypoxemia
judicious use of induction agents (prop, etomidate), NMB agents to avoid coughing and bucking)

Question 10

anesthetic management of TBI: establishing CV stability

Answer 10

avoid intracranial HTN (ICP >20)
avoid systolic hypotension
placement of aline in addition to standard monitors
low concentrations of sevo, iso, des (remember theyre cerebrovasodilators. this is more acceptable when dura is open but otherwise TIVA is great option)
avoid nitrous oxide (pneumoenchephalogram)

Question 11

anesthetic mangement of TBI: management of ICP in OR

Answer 11

mannitol .25-1mg/kg for control of ICP
consider hyper osmolar therapy as ordered by surgeon
corticosteroids increase in mortality (may order antiseizure meds)

Question 12

most SCI’s occur at

Answer 12

low cervical spine

Question 13

outcome of SCI patient depends on 3 factors

Answer 13

severity of acute injury
prevention of exacerbation of injury during rescue, transport, hospitalization
avoidance of hypoxia and HoTN

Question 14

autonomic hyperreflexia occurs in 85% of SCI with complete injury above

Answer 14

T5

Question 15

early tx of SCI is focused on

Answer 15

preservation of adequate perfusion to prevent secondary injury. avoid HoTN or correct immediately if encountered. avoid hypoxemia.
maintain MAP normal to high
manage neurogenic shock
maintain adequate circulation
glucocorticoid bolus
c spine eval should include all 7 vertebrae

Question 16

intubation and SCI: emergency intubation

Answer 16

100% oxygen administered immediately
simple chin lift with manual in line stabilization
avoid extension, flexion, and rotation with DVL with manual in line stabilization

Question 17

intubation and SCI: awake fiberoptic intubation

Answer 17

oral versus nasal: oral is challenging but better suites if patient requires postop ventilation

Question 18

goals of intubation of patient with SCI

Answer 18

achieve tracheal intubation while minimizing motion of c spine. preserve ability to assess neurologic function after positioning. no evidence that DL worsens outcomes

Question 19

SCI and succinylcholine

Answer 19

can use in first 24h

Question 20

orthopedic and soft tissues trauma and 3 types

Answer 20

frequent indication for operative management in trauma patients
1. isolated (closed), 2. open fx of major long bones and joints, 3. multiple fx of major long bones, spinal column, and joints associated with multi system injuries

Question 21

orthopedic trauma examples

Answer 21

dislocated hip
fractured pelvis
crush injuries
open fractures
long bone fractures (high risk for DVT)
compartment syndrome

Question 22

ortho trauma and anesthesia managment

Answer 22

most frequently require GA
anesthetic requirements comparable to those of non trauma patients (if lower requirements are being used, consider if patient has hypovolemia)
controlled HoTN (MAP 20mmHg below baseline) if not contraindicated
allow spontaneous ventilations near end of procedure to guide narc use

Question 23

advantages of regional anesthesia for trauma

Answer 23

allows for continued mental status assessment 
increased vascular flow
avoidance of aw instrumentation
improved postop mental status
decreased blood loss
decreased incidence of DVT
improved postop analgesia
better pulmonary toileting 
earlier mobilization

Question 24

disadvantages of regional anesthesia for trauma

Answer 24

peripheral nerve function difficult to assess
patient refusal common
requirement for sedation
longer time to achieve anesthesia
not suitable for multiple body regions
difficult to judge length of surgical procedure

Question 25

advantages of GA for trauma

Answer 25

speed of onset
duration-can be maintained for as long as needed
allows multiple procedures for multiple injuries
greater patient acceptance
allows for PPV

Question 26

disadvantages of GA for trauma

Answer 26

impairment of neuro exam
requires aw instrumentation
hemodynamic mangement more complex
increased potential for barotrauma

Question 27

chest injuries include

Answer 27

pulmonary
traumatic aortic injury
rib fx
cardiac injury

Question 28

pulmonary injuries and trauma considerations

Answer 28

may require chest tube
thoracotomy possible
double lumen tube, but often after initial intubation via RSI with standard ETT

Question 29

thoracotomy indications

Answer 29

indicated if drainage >1500mL in first several hours
when tracheal or bronchial injury or massive air leak are noted
hemodynamic instability from thoracic injury

Question 30

traumatic aortic injury

Answer 30

high incidence of morbidity and mortality
must be r/o if paitent has suffered high energy injury such as MVA or fall
dx made through CXR, angiography, CT and TEE
surgery indicated d/t high risk of rupture in hours to days
anesthetic tx includes partial bypass technique using inflow from left atrium, centrifugal pump and outflow to descending aorta
endovascular repair now more common

Question 31

rib fractures

Answer 31

most common injury from blunt chest trauma
flail chest is an example (commuted fx of at least 3 ribs, paradoxical respirations, consideration pain management or epidural over mechanical ventilation first)

Question 32

cardiac injury

Answer 32

penetrating trauma has high pre hospital mortality
cardiac tamponade
bruising or contusion is functionally indistinguishable from MI
TEE or TTE can be used to diagnose
managed as ischemic cardiac injury with careful control of volume, vasodilators, monitoring, and tx of rhythm disturbances
consider cardiac consult

Question 33

special cases: trauma and pregnancy

Answer 33

high incidence of spontaneous abortion, pre term labor, or premature delivery
OB consult for immediate management and follow up
requires rapid and complete resuscitation of mom

Question 34

criteria for extubation postoperatively includes

Answer 34

mental status
resolution of intoxication
able to follow commands
non combative
pain adequately controlled 
maintain airway anatomy and reflexes
appropriate cough and gag
ability to protect aw from aspiration
no excessive aw edema or instability
respiratory mechanics: adequate TV and RR, normal motor strength, required FiO2 <50%
systemic stability: adequately resuscitated, small likelihood of urgent return to OR in short term, normovolemic without signs of sepsis

Question 35

risk factors for development of ARDS after trauma

Answer 35

elderly
preexisting physiologic impairment
direct pulmonary or chest wall injury
aspiration of blood or stomach contents
prolonged mechanical ventialtion
severe TBI
SCI with quadriplegia
massive transfusion
hemorrhagic shock
occult hypoperfusion
wound or body cavity infection

Question 36

ventilator settings recommendations for acutely injured patients

Answer 36

Vt 6-8ml/kg
PEEP 10-15cmH2O
limit peak pressure to <40cmH2O
adjust I:E as necessary
wean FiO2 to obtain PaO2 80-100
sats 93-97%

Question 37

postop complication concerns

Answer 37

infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS