Trauma/SIRS/Shock

Question 1

Leading cause of death in all trauma cases

Answer 1

Head trauma

2/3 of all deaths in MVCs

Question 2

Scalp lac: treatment and monitoring

Answer 2

• Monitor for signs and symptoms of hypovolemia (tachy and hypotension)
• apply direct pressure…but FIRST access for skull fx
• suture/staple after cleansing. Use lidocaine 1% with epi to control bleeding

Question 3

Do not use lidocaine with epi where??

Answer 3

Nose or ears

Question 4

Simple skull fx

Answer 4

No displacement of bone
May indicate brain injury
Protect c spine

Question 5

Depressed skull fx: what is it?,

Answer 5

Bone fragment depressing the skull

Patient be asymptomatic or may have altered LOC

Surgery is often indicated
Initiate prophylactic broad spectrum antibiotics give tetanus shot if indicated and start seizure precautions

Question 6

Surviving Sepsis Campaign recommendations: Resuscitation steps: Type of fluids

Answer 6

•Start resuscitation early with source control, intravenous fluids (at least 30ml/kg of IV crystalloid within first 3 hours) and empiric broad-spectrum IV antibiotics (within 1 hour).

Question 7

Surviving Sepsis Campaign recommendations: Resuscitation steps: What level to normalize

Answer 7

•We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion.

Question 8

Surviving Sepsis Campaign recommendations: Resuscitation steps: -First choice vasopressor

Answer 8

•We recommend Norepinephrine as the first choice vasopressor.

Question 9

Surviving Sepsis Campaign recommendations: Resuscitation steps: -When to get cultures

Answer 9

•We recommend that appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis and septic shock if doing so results in no substantial delay in the start of antimicrobials.

Question 10

Surviving Sepsis Campaign recommendations: Resuscitation steps: Antimicrobial therapy

Answer 10

• We recommend against combination therapy for the routine treatment of neutropenic sepsis/bacteremia.
• We recommend that empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted.

Question 11

Surviving Sepsis Campaign recommendations: Resuscitation steps: Steroid therapy

Answer 11

•We suggest against using intravenous hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest intravenous hydrocortisone at a dose of 200 mg per day.

Question 12

Surviving Sepsis Campaign recommendations: Resuscitation steps: Positioning

Answer 12

•We recommend using prone over supine position in adult patients with sepsis-induced ARDS and a PaO2/FIO2 ratio <150.

Question 13

Surviving Sepsis Campaign recommendations: Resuscitation steps: -Special recs for ARDS

Answer 13

• We recommend against the use of HFOV in adult patients with sepsis-induced ARDS.
• We recommend against the use of beta-2 agonists for the treatment of patients with sepsis-induced ARDS without bronchospasm
• We suggest using higher PEEP in adult patients with sepsis-induced moderate-severe ARDS.
• We suggest using lower tidal volumes over higher tidal volumes in adult patients with sepsis-induced respiratory failure without ARDS.

Question 14

Surviving Sepsis Campaign recommendations: Resuscitation steps: -Maintaining BG

Answer 14

•We recommend a protocolized approach to blood glucose management in ICU patients with sepsis, commencing insulin dosing when 2 consecutive BG levels are >180 mg/dL. This approach should target an upper BG level ≤180 mg/dL rather than upper target BG ≤110 mg/dL.

Question 15

Surviving Sepsis Campaign recommendations: Resuscitation steps:Nutrition

Answer 15

•We recommend against administration of parenteral nutrition alone or in combination with enteral feeds (but rather initiate IV glucose and advance enteral feeds as tolerated) over first 7 days in critically ill patients with sepsis or septic shock when early enteral feeding is not feasible.

Question 16

Surviving Sepsis Campaign recommendations: Resuscitation steps: General

Answer 16

• Frequent assessment of the patient’s’ volume status is crucial throughout resuscitation period.
• We recommend that hospitals and hospital systems have a performance improvement program for sepsis including sepsis screening for acutely ill, high-risk patients.
• We suggest against the use of renal replacement therapy in patients with sepsis and acute kidney injury for increase in creatinine or oliguria without other definitive indications for dialysis.
• We recommend that goals of care and prognosis be discussed with patients and families.
• We recommend that the goals of care be incorporated into treatment and end-of-life care planning, utilizing palliative care principles where appropriate.