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Advanced Principles 2 > Trauma part 3 > Flashcards

Trauma part 3 Flashcards

1
Q

The Glasgow coma scale assesses for

A

disability/neurological status

classification of severity of head injury

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2
Q

Significant abnormalities on the neurological exam are an indication ofr

A

immediate cranial CT

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3
Q

________ will have a strong influence on outcome of disability

A

timeliness of diagnosis and treatment

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4
Q

The goal of care for the traumatic brain injury patient is to

A 
prevent secondary brain damage resulting from:
intracranial bleeding
edema
increased ICP
hypoxia & shock
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5
Q

Classification of traumatic brain injury can be

A

mild TBI, moderate TBI, severe TBI

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6
Q

Describe the classification of mild TBI.

A

GCS 13-15

short period of observation usually 24 hours

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7
Q

Describe the classification of moderate TBI.

A

GCS 9-12
manifested as intracranial lesions that require surgical evacuation
early CT
high potential for deterioration requires early intubation mechanical ventilation

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8
Q

Describe the classification of severe TBI.

A

GCS less than 8 (intubate)
carries a significant rate of mortality
care is directed at perfusion of injured brain

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9
Q

Guidelines for severe TBI include:

A 
after primary survey approach maintain CPP
maintain a CPP 60-70 mmHg at all times
fluid resuscitation- keep euvolemic
correction of anemia (Hct of 30%)
PaCO2--> 35 mmHg
insertion of ventriculostomy & control of ICP <20
positional therapy
judicious use of analgesics/sedation
mannitol
hypertonic saline
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10
Q

Describe the AW & ventilatory management of the TBI patient.

A

hyperventilation only if herniation is imminent
hyperventilate to PaCO2 of 30 if elevated ICP is no responsive to- sedatives, CSF drainage, NM blockade, osmotic agents, barbiturate coma

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11
Q

Hyperventilation to PaCO2 of 30 is indicated when elevated ICP is not responsive to

A

sedatives, CSF drainage, NM blockade, osmotic agents, barbiturate coma

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12
Q

CPP=

A

MAP-ICP

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13
Q

Anesthetic management of the patient with a TBI includes

A

early control of airway
establishing cardiovascular stability
management of intracranial pressure in the OR

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14
Q

Describe early control of the airway for the patient with a TBI

A

orotracheal intubation to maintain SpO2 >90%
maintain normoventilation to help in the reduction of hypercarbia and hypoxemia
judicious use of induction agents- propofol, etomidate, neuromuscular blocking agents to avoid coughing and bucking

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15
Q

Describe establishing cardiovascular stability for the patient with a TBI.

A

avoid intracranial hypertension (ICP>20)
avoid systolic hypotension
placement of an a-line in addition to standard monitors
low concentrations of sevoflurane, isoflurane or desflurane (cerebrovasodilators)
avoid nitrous oxide

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16
Q

Describe the management of intracranial pressure in the OR for the patient with a TBI.

A

mannitol 0.25-1.0 g/kg for control of ICP
consider hyperosmolar therapy as ordered by surgeon
corticosteroids increase mortality and are no longer recommended
dilantin or keppra
smooth induction & emergence

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17
Q

SCI can be a result of

A

MVA
falls
penetrating injury

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18
Q

Most SCI occur at the

A

low cervical spine-typically C4-C7

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19
Q

SCI injury includes

A

sensory deficits
motor deficits
sensory & motor

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20
Q

Outcomes of the SCI patient depends on 3 factors:

A

severity of the acute injury
prevention of exacerbation of the injury during rescue, transport, & hospitalization
avoidance of hypoxia & hypotension

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21
Q

Early treatment of SCI is focused on

A

adequate perfusion to prevent secondary injury

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22
Q

Autonomic hyperreflexia develops in 85% of SCI

A

with complete injury above T5

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23
Q

Treatment of SCI is aimed at

A

preservation of adequate perfusion

-avoid hypotension or correct immediately if encountered

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24
Q

_____ & _____ can further accentuate the damage sustained with SCI

A

Hypoxia & hypercarbia

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25
Q

MAP for SCI is

A

maintained normal to high

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26
Q

SCI management includes

A

prevention of neurogenic shock (hypotension & bradycardia)
adequate circulation
glucocorticoid bolus- controversial, might depend on surgeon dependent

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27
Q

C-spine evaluation should

A

include all 7 cervical vertebrae- C1-C2 & C7-T1 b/c difficult to image these spots

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28
Q

Describe emergency intubation in SCI.

A

100% oxygen administered immediately
simple chin lift with manual in-line stabilization
avoid extension, flexion, and rotation- direct vision laryngoscopy with MILS

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29
Q

Use of succinylcholine is allowable for patients with SCI if

A

<24 hours

30
Q

When intubating for a patient with a SCI, the clinician should use equipment and techniques that are most familiar.

A

goals: achieve tracheal intubation while minimizing motion of C-spine
preserve the ability to assess neurologic function after positioning
No evidence that DL worsens outcomes

31
Q

The gold standard for a patient with an SCI intubation wise is

A

awake fiberoptic intubation as long as patient is cooperative
-oral vs. nasal intubation–> oral is challenging but better suited if pt requires post-op ventilation

32
Q

A frequent indication for operative management in trauma patients is

A

orthopedic and soft tissue trauma

33
Q

Three types of orthopedic and soft tissue trauma include

A

isolated closed
open fractures of major long bones & joints
multiple fractures of major long bones, spinal column, and joints associated with multisystem injuries

34
Q

If a closed fractures is fixed within

A

the first 24 hours, there will be a decrease in ARDS, PNA, & fat emboli complications

35
Q

An open fracture should be fixed within

A

12 hours to prevent infection

36
Q

Ortho trauma includes

A

dislocated hip- needs fixation because avascular necrosis of femoral head can develop
fracture pelvis- requires stabilization, very high bleeding cases, T & C for at least 4 units
crush injuries-> will see myoglobinuria
open fractures
long bone fractures are high risk for DVT
Compartment syndrome

37
Q

Ortho trauma anesthesia management includes

A

most frequently requires GA
anesthetic requirements comparable to those of non-trauma patient- if lower requirements are being used consider if your patient has hypovolemia
controlled hypotension (MAP 20 mmHg below baseline) if not contraindicated
allow spontaneous ventilations at near end of procedure to guide narcotic use

38
Q

Advantages of regional anesthesia

A
  • allows for continued mental status assessment
  • increased vascular flow
  • avoidance of airway instrumentation
  • improved postoperative mental status
  • decreased blood loss
  • decreased incidence of DVT
  • improved postoperative analgesia
  • better pulmonary toilet
  • earlier mobilization
39
Q

Disadvantages of regional anesthesia

A
  • peripheral nerve function difficult assess
  • patient refusal is common
  • requirement for sedation
  • longer time to achieve anesthesia
  • not suitable for multiple body regions
  • difficult to judge length of surgical procedures
40
Q

Advantages of general anesthesia

A

speed on onset
duration-can be maintained as long as needed
-allows multiple procedures for multiple injuries
-greater patient acceptance
-allows for positive-pressure ventilation

41
Q

Disadvantages of general anesthesia

A
  • impairment of neurological examination
  • requires airway instrumentation
  • hemodynamic management more complex
  • increased potential for barotrauma
42
Q

Chest injuries include

A

pulmonary
traumatic aortic injury
rib fractures
cardiac injury

43
Q

Pulmonary injuries may require a

A

chest tube
thoracotomy
double lumen tube- but often after initial intubation via RSI with standard ETT

44
Q

Thoracotomy for pulmonary injuries indications include

A

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

45
Q

Traumatic aortic injury has a high

A

incidence of morbidity and mortality- particularly if complete transection

46
Q

Traumatic aortic injury must be ruled out if patient has

A

suffered a high energy injury such as a MVA or fall

47
Q

Diagnosis of traumatic aortic injury is made through

A

CXR, angiography, CT, and TEE

48
Q

Surgery for traumatic aortic injury is indicated due to

A

high risk of rupture in hours to days

49
Q

Anesthetic treatment of traumatic aortic injury includes

A

partial bypass technique using inflow from the left atrium, a centrifugal pump and outflow to descending aorta

50
Q

_____ repair is now more common for a traumatic aortic injury

A

endovascular

51
Q

With traumatic aortic injury, it is important to keep systolic BP

A

<100 to keep injury from extending

52
Q

Most common injury from blunt chest trauma is

A

rib fractures

53
Q

A flail chest is the result of

A

comminuted fractures of at least 3 ribs

54
Q

Flail chest is characterized by

A

paradoxical respiration

55
Q

For flail chest consider

A

pain management or epidural placement to maintain ventilation/perfusion

56
Q

Cardiac injury includes

A

penetrating trauma–> have a high pre-hospital mortality

cardiac tamponade

57
Q

Bruising or contusion is functionally

A

indistinguishable from MI

58
Q

_____ can be used to diagnose cardiac injury

A

TTE or TEE

59
Q

Cardiac injury is managed as

A

ischemic cardiac injury with careful control of volume, vasodilators, monitoring and treatment of rhythm disturbances

60
Q

Cardiac injuries may require

A

a cardiology consult if appropriate

61
Q

Describe management for the trauma patient who is a Jehovah’s witness

A
  • deliberate hypotension
  • use of salvaged blood cells from intra-op or chest tube collection
  • early hemodynamic monitoring
  • post-op use of erythropoietin
62
Q

Describe management for the trauma patient who is elderly.

A

-more serious outcomes in the elderly for equivalent trauma
-decreased cardio-pulmonary reserve higher incidence of postop mechanical ventilation
MOSF after hemorrhagic shock
-post traumatic myocardial dysfunction
-cannot tolerate as much volume

63
Q

Describe management of the trauma patient who is pregant

A

high incidence of spontaneous abortion, pre-term labor, or premature delivery
OB consult for immediate management and follow-op
requires rapid & complete resuscitation of the mother
in the 2nd or 3rd trimester–> left lateral decubitus to get uterus off of great vessels
spontaneous abortion requires D&C
if Rh negative will need to get Rhogam if fetus is positive

64
Q

Criteria for extubation post-op includes

A

mental status
airway anatomy and reflexes
respiratory mechanics
systemic stability

65
Q

Criteria for extubation in regards to mental status includes

A

resolution of intoxication
able to follow commands
non-combative
pain adequately controlled

66
Q

Criteria for extubation in regards to airway anatomy & reflexes includes

A

appropriate cough & gag
ability to protect airway from aspiration
no excessive airway edema or instability

67
Q

Criteria for extubation in regards to respiratory mechanics includes

A

adequate tidal volume & respiratory rate
normal motor strength
required FiO2 less than 50%

68
Q

Criteria for extubation in regards to systemic stability includes

A

adequately resuscitated
small likelihood of urgent return to the operating room (at least in very short-term)
normovolemic, without signs of sepsis

69
Q

Risk factors for development of ARDS after trauma

A 
elderly 
preexisting physiologic impairment 
direct pulmonary or chest wall injury 
aspiration of blood or stomach contents
prolonged mechanical ventilation 
severe traumatic brain injury 
spinal cord injury with quadriplegia 
massive transfusion
hemorrhagic shock
occult hypoperfusion 
wound or body cavity infection
70
Q

Recommendations for ventilator settings in acutely injured patients include

A 
tidal volumes 6-8 mL/kg
PEEP 10-15 cm H2O
limit peak pressures to <40 cmH2O
adjust I:E ratio as necessary
wean Fio2 to obtain PaO2 of 80-100, sats 93-97%
71
Q

Post-operative complication concerns for trauma patients includes

A

infection/sepsis
thromboembolism
abdominal compartment syndrome
ARDS

Advanced Principles 2 (42 decks)

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