Trauma Part 2 Flashcards

1
Q

3 sequential components of trauma evaluation

A
  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)
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2
Q

surgical priorities in trauma patients (in order)

A
  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
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3
Q

classification of TBI: mild

A

GCS 13-15

short period of observation, usually 24h

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4
Q

classification of TBI: moderate

A

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

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5
Q

classification of TBI: severe

A

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

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6
Q

2 hours post TBI, there is an increase in

A

amyloid B peptide or amyloid plaques

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7
Q

severe TBI guidelines for managment/tx

A

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)

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8
Q

TBI aw and ventilatory management

A

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

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9
Q

anesthetic management of TBI: early control of aw

A

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)

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10
Q

anesthetic management of TBI: establishing CV stability

A

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)

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11
Q

anesthetic mangement of TBI: management of ICP in OR

A

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

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12
Q

most SCI’s occur at

A

low cervical spine

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13
Q

outcome of SCI patient depends on 3 factors

A

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

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14
Q

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

A

T5

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15
Q

early tx of SCI is focused on

A

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

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16
Q

intubation and SCI: emergency intubation

A

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

17
Q

intubation and SCI: awake fiberoptic intubation

A

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

18
Q

goals of intubation of patient with SCI

A

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

19
Q

SCI and succinylcholine

A

can use in first 24h

20
Q

orthopedic and soft tissues trauma and 3 types

A

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

21
Q

orthopedic trauma examples

A
dislocated hip
fractured pelvis
crush injuries
open fractures
long bone fractures (high risk for DVT)
compartment syndrome
22
Q

ortho trauma and anesthesia managment

A

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

23
Q

advantages of regional anesthesia for trauma

A
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
24
Q

disadvantages of regional anesthesia for trauma

A

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

25
advantages of GA for trauma
speed of onset duration-can be maintained for as long as needed allows multiple procedures for multiple injuries greater patient acceptance allows for PPV
26
disadvantages of GA for trauma
impairment of neuro exam requires aw instrumentation hemodynamic mangement more complex increased potential for barotrauma
27
chest injuries include
pulmonary traumatic aortic injury rib fx cardiac injury
28
pulmonary injuries and trauma considerations
may require chest tube thoracotomy possible double lumen tube, but often after initial intubation via RSI with standard ETT
29
thoracotomy indications
indicated if drainage >1500mL in first several hours when tracheal or bronchial injury or massive air leak are noted hemodynamic instability from thoracic injury
30
traumatic aortic injury
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
31
rib fractures
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)
32
cardiac injury
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
33
special cases: trauma and pregnancy
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
34
criteria for extubation postoperatively includes
``` 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 ```
35
risk factors for development of ARDS after trauma
``` 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 ```
36
ventilator settings recommendations for acutely injured patients
``` 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% ```
37
postop complication concerns
infection/sepsis thromboembolism abdominal compartment syndrome ARDS