Trauma patient presentation Flashcards
At what temp. should you stop active cooling?
39.5’C
Toxic substances that can cause seizures (4)
bromethelin
permethrin
nicotine
metaldehyde
(salt)
What electrolyte abnormalities can cause seizures? (4)
hypocalcemia
hypernatremia
both hyper and hypoglycemia
hypokalemia (opisthotonos though not seizures)
Status epilepticus =
Continous seizure activity for 30 min or longer,
or repeated seizures with failure to return to normal behavior in 30 minutes.
Can cause permanent neurological damage or death. In addition profound hemodynamic and metabolic damages that increase morbidity.
First line meds for status epilepticus?
Diazepam 0,5-2,0mg/kg IV or per rectum
Midazolam 0,07-0,22mg/kg IV or IM
Cluster seizures =
Occurance of multiple seizure events within 24 hour period.
Etiology of status epilepticus. (3)
- Around 28% cases are primary epilepsy
- Metabolic
- Toxins
FIRST LINE MANAGEMENT for SEIZURE CONTROL other than benzos?
Phenobarbital
* 2-4mg/kg IV or IM; max 24mg/kg in 24H
Propofol
* 4-8mg/kg or CRI bolus 6mg/kg then 0,1-0,6mg/kg/min
Isoflurane as last resort
Describe intralipid dosage.
Bolus: 1.5 ml/kg IV over 2-3 minutes. Is usually followed by a continuous infusion.
Continuous infusion: 0.025 ml/kg/min (1.5 ml/kg/hr) for 30-120 minutes
Repeat doses:
* Blood test at 4-6 hrs following completion of continuous infusion.
* If no lipemia is observed, and the patient is still clinically unwell because of toxicosis, the bolus and/or the infusion dose may be repeated.
- If lipemia present, withhold treatment; retest for lipemia q 2 hrs.
- Repeat dose only if lipemia has resolved
.
Maximum dose: 8 ml/kg/24hrs.
FIRST LINE MANAGEMENT of a seizuring patient - SYSTEMIC MANAGEMENT (4)
- Airway- intubation
- Breathing – provide oxygen
- Circulation – place 2 x IV catheters, one in front in one in back.
- Temperature regulation- manage hyperthermia
DIAGNOSTICS for a seizuring patient (7)
- History
- General and neurological examination
- Hematology
- Biochemistry:
- Electrolytes: sodium, glucose, calcium
- Kidney and liver enzymes
- Diagnostic imaging
Who should you triage?
Triage every patient!
Modified ATT
Animal Trauma Triage assessment and scoring
3 categories:
- Perfusion
- Respiration
- Neurological
Grade 0-3
- The higher the score, the worse the prognosis.
MGCS
Modified Glasgow Coma Scale assessment and scoring
3 categories:
- Motor activity
- Brainstem reflexes
- Level of consciousness
The lower the score, the worse the prognosis.
VetCOT score-in research (3)
The VetCOT score is a more frugal model with comparable discriminatory performance and superior calibration to the ATT score for risk stratification in dogs following trauma.
- Plasma lactate
- Ionized Ca
- Clinical signs indicating head and/or spinal trauma.
Head traumas.
Skull
- Fractures
- Intracranial injuries-TBI
Mouth
- Lip avulsion (suture fast cause prone to necrosis)
- Tongue injuries
- Tooth fractures (consider plucking out a badly fractured tooth so the animal can close its mouth, retrieve root later)
- Jaw fractures
- Symphysis luxation (more common in cats)
- Joint luxation (may be visibly lopsided)
- Palate
Eyes
- Proptosis (not so common in big, if in big: suspect very big trauma)
- Eyelid lacerations
Traumatic /neurological postures. (3)
Schiff Sherrington syndrome (thoracic or lumbar spinal trauma; T2-L3)
Decerebellate rigidity (trauma to cerebellar region)
Decerebrate rigidity (cerebrum damage; unconscious or inadequate mentation)
Schiff Sherrington syndrome indicates thoracic or lumbar spinal trauma. T2-L3
Characterized by neck in opisthotonos, front legs rigid, hindlegs paralyzed but mentally adequate or “there”. Prognosis dependent on trauma severity.
Decerebellate rigidity indicates trauma to cerebellar region.
Characterized by neck in opisthotonos,
front limbs rigid, hind flexed, normal mentation. Prognosis fair to good.
Decerebrate rigidity indicates cerebrum damage.
Characterized by neck in opisthotonos, and all leg rigidity. Cerebrum damage; unconscious or inadequate mentation. Poor prognosis.
Thorax traumas. (6)
Lung contusion
Pneumothorax
Hemothorax
Rib fractures
Pneumomediastinum
Diaphragmatic hernia
(concurrent head trauma in every 4th thorax trauma patient)
Traumatic arrhythmias. (4)
Sinus tachycardia
VPC- ventricular premature contractions
Accelerated idioventricular rhythm
Ventricular tachycardia
Sinus tachycardia
sinus tachycardia is usually a sign of an underlying issue, and addressing the root cause (e.g., blood loss, pain, hypoxia) is the primary treatment goal. Directly treating the tachycardia without fixing the cause is typically not recommended and could be harmful.
VPC- ventricular premature contractions
treat with lidocaine
Accelerated idioventricular rhythm
treat if continuous but if only a few then just monitor
AIVR typically does not require specific treatment if the patient is stable and asymptomatic.
Ventricular tachycardia
treat this one.
Ventricular tachycardia in trauma cases requires immediate treatment, especially if the patient is unstable or pulseless. In hemodynamically unstable cases, synchronized cardioversion is the first-line treatment, while defibrillation is essential in pulseless VT. In stable cases, antiarrhythmic medications can be used.
Abdominal traumas. (3+)
Hemoperitoneum
- Spleen
- Liver
Traumatic hernia
Urinary tract injuries
- Uroabdomen
- Kidney rupture/hematoma
- Urethra injuries (Inguinal and penile injuries)
Common traumatic Fractures
Front limbs
- Radius- ulna fractures
- Elbow joint lux
- Humeral fracture
- Scapula fracture
Hind libs
- Pelvic fractures
- Femoral fracture
- Hip luxation
- Distal bone fractures
Most common Traumatic nerve injuries
Brachial plexus avulsion
Caudal gluteal nerve damage
Sciatic nerve damage
Tibial nerve damage
Causes:
- Fractures
- Bite wounds
- Gunshots
Most common traumatic Spinal injuries (3)
Spinal cord contusion
Vertebral luxation, fracture
Stabilization: aim of oxygen therapy? (4)
Its aim is to increase the fraction of inspired oxygen (FiO2).
To improve PaO2(partial pressure of arterial O2).
To improve hemoglobin saturation.
To increase oxygen delivery to tissues: to avoid hypoxemia, tissue hypoxia and lactic acidosis.
Stabilization: fluid therapy options (4)
Options are isotonic, hypertonic, colloids and blood products.
Blood transfusion Indications (4)
Anemia
Coagulopathy
Thrombocytopenia
Hypoproteinemia
What blood products can we use?
Whole blood
- Erythrocytes, platelets, coag. factors, plasma proteins.
- Use within 8h or refrigerate
Packed Red Blood Cells (pRBCs)
- PCV 70-80%
- In refrigerator, standing position
Frozen plasma (FP)
- Freeze
Blood transfusion in Dogs
More than 12 DEA groups.
Most common DEA 1
- Positive or negative
Blood typing for every patient receiving blood products is good practice!
DEA 1 negative is considered as universal donor.
Blood transfusion in cats.
A, B, AB
Have naturally occurring
alloantibodies so Blood typing extremely important!
Blood transfusion formula.
Blood transfusion rate.
Start at 0.5–1 ml/kg/hour for the first 15 minutes (highest likelihood for reactions).
Increase to 2 ml/kg/hour for a further 15 minutes.
Monitor:
- Temperature
- Heart rate; pulse rate,
- Respiratory rate,
- Mucous membrane color
- General demeanor
After 30 minutes if no signs of a transfusion reaction, then 5–10 ml/kg/hour for the rest of the transfusion. The transfusion must be complete within 4 hours.
Potential Side effects of blood transfusion.
e.g. anaphylaxis or intravascular hemolysis within min.-hours
Common clinical signs of transfusion reactions.
Immunologic and nonimmunologic
Describe Autotransfusion
Autologous blood transfusion
Used:
- Hemothorax
- Hemoperitoneum
Do it as sterile as you can!
Use a blood filter!
Describe Xenotransfusion
Can be beneficial.
Few adverse reactions.
Low risk of infection (FIV, FeLV).
Low volume of blood needed.
Clinical improvement for 2-4 days.
Analgesia and anesthesia in trauma patients.
Opioids:
- Methadone 0,1-0,2mg/kg (1mg/kg) 4-6h; CRI 0,12mg/kg/h
- Fentanyl 10-50 mikrogr/kg; prefer CRI
- Butorfanol 0,1-0,5mg/kg; sedatsion vs analgesia
- Consider CRI for everything very acute and painful.
Drugs in addition to analgesia to consider in trauma cases. (2)
Vasopressors:
- Dopamine 2-2,5mikrogr/kg/min
Antibiotics:
- Use when needed
Hematology and biochemistry in trauma cases.
PCV/plasma protein
Hemogram (CBC)
Biochemistry
- ALT, AST
- CK
- Lactate
- TP/Alb, Glob
- Blood gases
Very acute traumas should be hooked to monitors for how long?
at least 4-6 hours on BP, pulse SPO2, ECG
Prognosis in traumas.
Poor in the following non survivors:
- Severe head trauma
- Skull fractures
- Lateral, no contact in reception
- Rectal bleeding
- ARDS & MODS & DIC
- Development of pneumonia
- Necessity of lung ventilation
- Cardio-respiratory arrest: need for CPR
