Trauma Surgery Flashcards
1
Q
What is the first thing we prioritize with traumas?
A
cervical spine immediately above airway
2
Q
How do we prioritize cervical spine with trauma?
A
c-spine immobilization
3
Q
What is the second thing we prioritize with traumas?
A
airway obstruction
4
Q
What should we anticipate with airway obstruction
A
anticipate tracheostomy for facial injury or upper airway edema
5
Q
what do you need to perform an emergency trach?
A
trach tray
6
Q
what kind of intubation do we want to do with trauma patients?
A
rapid sequence intubation
7
Q
Why would we do rapid sequence intubation with airway obstruction?
A
because we are assuming they have a full stomach
8
Q
What is the sequence of rapid sequence intubation?
A
- pre-oxygenation
- paralysis with induction
- placement with proof
9
Q
What is a maneuver we might do to help with rapid sequence intubation?
A
cricoid pressure or sellik manneuver; push cricoid cartilage back to occlude the esophagus
10
Q
What is the third thing we prioritize with traumas?
A
hemorrhage
11
Q
Surgery is not what?
A
hemodynamically stabilizing to a trauma patient
12
Q
Surgery is not hemodynamically stabilizing unless what?
A
unless the purpose is to stop the bleeding
13
Q
What might you do if a patient is experiencing hemorrhage during surgery in order to prevent too much destabilization?
A
might do a staged procedure. Large procedure divided into smaller surgeries
14
Q
Hemorrhage leads to what?
A
acidosis
15
Q
What can uncorrected hemorrhage shock in trauma patients lead to?
A
profound metabolic acidosis
16
Q
Profound metabolic acidosis leads to what 2 things?
A
1.interferes with blood clotting mechanisms
2. promotes coagulopathy and blood loss
17
Q
Why is acidosis so bad for you? (5 things)?
A
- vasodilation
- myocardial depression
- hyperkalemia
- shift of oxyhemoglobin dissociation curve to the right - hemoglobin has lost affinity for oxygen molecule
- confusion, stupor
18
Q
We want to identify what to help treat metabolic acidosis?
A
identify the cause of bleeding
19
Q
Cause of bleeding can be what 2 things?
A
mechanical vs. non-mechanical bleeding
20
Q
To reverse coagulopathies associated with metabolic acidosis what can we do?
A
warm patient
21
Q
What kind of replacement do we want to do with metabolic acidosis?
A
blood, FFP, and platelet replacement
22
Q
What should not be used to treat severe metabolic acidosis?
A
bicarb
23
Q
If you do give bicarb for severe metabolic acidosis, what is it conditional of?
A
the ventilation needs to be adequate to remove the increased CO2 that is formed.
24
Q
What is the fourth thing we prioritize with traumas?
A
cardiac tamponade
25
What is cardiac tamponade?
blood and fluid is accumulating around the heart in the pericardial sack.
26
What does cardiac tamponade prevents?
it prevents the ventricles from expanding, so the heart can't have adequate cardiac output
27
What are 2 clinical signs of cardiac tamponade?
1. jugular vein distention
2. narrowing pulse pressures
28
What are the 2 actions we would take for emergent treatment of cardiac tamponade?
1. pericardiocentesis
2. prepare for a chest tube, sternotomy or thoracotomy according to direction
29
What do you need for a pericardiocentesis?
spinal needle and 60 cc syringe
30
How does a pericardiocentesis work?
insert spinal needle under the xiphoid process aiming for the left shoulder. Pull back on plunger on syringe and the fluid will begin to evacuate
31
What is the fifth thing we prioritize with traumas?
pneumothorax
32
What is the most severe pneumothorax?
tension pneumothorax
33
What kind of physiology is shifted in pneumothorax?
mediastinal physiology
34
Are pneumo's life threatening?
yes
35
What kind of injury is pneumothorax?
closed chest injury to the lung usually caused by blunt force trauma
36
What is happening with pneumothorax from a physiology perspective?
Every time the patient inhales air is trapped in the pleural space, they can't exhale. The lung becomes more and more compressed
37
What are we going to do to do to help a pneumothorax?
needle the chest.
38
What are the steps for a needle to the chest for a pneumothorax?
1. Locate Midclavicular line 3rd rib down - angle of Louis. You follow that and go one below.
2. You get a big fat angio catheter
3. Punch in 3rd intercostal space midclavicular line
4. pull stylet out
5. get a chest tube setup
39
What is a sucking chest wound with pneumothorax?
penetrating injury (bubbles, gurgles)
40
What kind of involvement is there with sucking chest wound with pneumothroax?
vascular involvement
41
Besides fixing the vascular with a sucking chest wound, what are we going to place? why?
a chest tube to prevent a tension pneumothorax
42
What are 3 things we are going to do to help with placement of a chest tube?
1. set up
2. secure
3. transport
43
What is the sixth thing we prioritize with traumas?
increased ICP
44
How do we know a patient has increased ICP?
cushing's triad
45
What is cushing's triad characterized as?
1. increase in BP
2. drop in HR
3. neuro respiratory pattern (gasping neuro breathing)
46
What can you do to help drop the ICP?
hyperventilate them; drops their ICP - safety net
47
How does hyperventilating a patient decrease ICP?
clamp down the peripheral vascular system to help decrease cerebral blood flow
48
Because we can't hyperventilate a patient too long, what are we looking to do in surgery?
evacuate fluid/blood
49
Prepare for what in surgery to help deal with ICP?
prepare for burr hole
50
What are 3 criteria you measured on for glasgow coma scale?
eye opening, verbal response, best motor response
51
What is the best score you can get on glasgow coma scale?
15
52
What does a dead person get on glasgow coma scale?
3 points
53
Spontaneous eye opening gets you a what on GCS?
4
54
Eye opening to speech gets you a what on the GCS?
3
55
Eye opening to pain gets you a what on GCS?
2
56
No eye opening gets you a what on GCS?
1
57
Oriented verbal response gets you a what on GCS?
5
58
Confused conversation for verbal response gets you a what on GCS?
4
59
inappropriate words for verbal response gets you a what on GCS?
3
60
incomprehensible words for verbal response gets you a what on GCS?
2
61
No words for verbal response gets you a what on GCS?
1
62
Obeying commands for motor responses gets you a what on GCS?
6
63
Localising pain for motor responses gets you a what on GCS?
5
64
Normal flexion for motor responses gets you a what on GCS?
4
65
abnormal flexion for best motor responses gets you a what?
3
66
extend for motor responses gets you a what on GCS?
2
67
no motor responses gets you a what on GCS?
1
68
What is the 7th thing we triage for in trauma surgery?
massive burns
69
What is the biggest issue with burns?
fluid deficit
70
What happens with fluid shifts on days 1 and 2 for burns?
fluid shifts cause hypovolemia
71
Where does the fluid shift in and out of for burns? day 1 and 2
intravascular to intersitial shift
72
What kind of electrolyte change is there on days 1 and 2 for burn patients?
hyperkalemia
73
Day 3 of having a massive burn is characterized by what kind of fluid shift?
fluid shifts back to vascular causing hemodilution
74
Day 3 of having a massive burn causes the fluid to shift from what to what?
interstitial to intravascular
75
What kind of electrolyte change is there on days 3 for burn patients?
hypokalemia
76
What kind of temperature changes do you see with burn patients? what interventions do we take?
hypothermia; so make the room warm and humid
77
Excision of tissue within how many hours of a burn?
72 hours
78
What kind of surgery is an excision of burn?
bloody, so prepare for transfusion
79
Any burns that we are not working on need to be what to prevent insensible loss?
wrapped
80
Additional what commonly accompanies what with burns?
additional trauma
81
What is the 8th thing we do in the order of triage?
spinal cord injury
82
What do we want to do with spinal cord injuries?
stabilize the fracture
83
how do we transport a spinal cord patient?
log roll
84
What kind of effort is it to remove cervical collar?
team effort
85
It is within a nursing scope of practice to remove a backboard from patient and remove a c collar if we have a what?
an order to remove it if their spine is clear
86
What is there a loss of with spinal cord injuries?
loss of vascular tone from area of injury down
87
Due to the loss of vascular tone with spinal cord injuries what happens?
vasodilation and peripheral pooling
88
What is something you can do to help with vasodilation and peripheral pooling with loss of vascular tone?
drop the head of bed 5-10 degrees
89
What are 3 interventions for neurogenic shock (not perfusing for a neuro reason)?
1. place in trendelenbur
2. vasopressors
3. fluid replacement
90
What is number 9 in triage order?
extremity injury
91
Rapair an extremity injury with what 2 things?
supplies and equipment
92
Monitor extremity injury for what?
compartment syndrome
93
What is compartment syndrome?
hematoma and swelling of injury is occluding blood vessels, in which you then lose pulses
94
Do we address extremity injuries sooner if we have compartment syndrome?
yes
95
How do we monitor for compartment syndrome?
check for cap refill and pulses of injured extremities under drapes
96
What do you perform if swelling impedes blood flow with extremity injury?
fasciotomy
97
Disaster drills are held at least how often?
twice a year
98
One of the disaster drills needs to be a what? the other one?
fire drill; the other one can be a power outage, active shooter, mass casualty
99
What is the very first thing you do when there is an internal or external disaster
COMMUNICATION; so
1. notify hospital departments
2. call in off duty staff
3. set up command center and triage
100
Which patients go to surgery first in mass casualty?
red tag patients
101
What are 3 characteristics of red tag patients?
1. life threatening illness or injury
2. lifesaving intervention required
3. first to treat
102
What are 3 characteristics of yellow tag patients or delay?
1. serious but not life-threatening illness or injury
2. delaying treatment will not affect outcome
3. second to treat
103
What is status of yellow tag?
delayed
104
What is status of red tag?
immediate
105
What are 3 characteristics of green tag patients?
1. minor illness or injury
2 walking wounded
3. third to treat
106
What is status of green tag?
minimal
107
What is status of black tag?
expectant
108
What are 3 characteristics of black tag patients?
1. not expected to survive
2. will receive comfort care
2. may be upgraded to red if new resources permit treatment
109
When administering blood what is the first priority?
blood conversation
110
What are tolerated more now than in the past?
low hematocrits are now tolerated more now than in the past
111
4x4 dry sponges hold about how much blood?
10 mL of blood
112
dry ray techs hold about how much blood?
10-20 mL of blood
113
dry lap sponges hold about how much blood?
100 mL of blood
114
Pediatric cases should have what weighed for what?
sponges and gauze weighed for blood loss
115
What is there a risk of transmission with blood transfusions?
transmission of hep B, hep C, and HIV
116
What is there an increased risk of with banked blood?
risk of SSI (decreased oxygenation to the wound, because the red blood cells become cold and therefore cannot fit through the capillary bed normally.)
117
The patient becomes immuno what after a transfusion? what is this known as?
immunosuppressed; otherwise known as TRIM - transfusion associated immunomodulation
118
The more transfusions a patient gets the more what?
the more immunosuppressed they get
119
What can happen to the lungs with blood transfusions?
transfusion-related acute lung injury
120
FUN FACT: blood transfusions are the highest risk for SSI than any other factor
121
If donor has antibodies, what can that cause post a transfusion?
incompatibility reaction
122
We do not use what kind of patients to donate ffp?
women who have had children
123
A type and screen is usually within how many minutes?
15 minutes
124
What does a type and screen look for?
ABO and Rh factors only
125
Type and crossmatch takes how long?
45 minutes
126
What does a type and crossmatch test for?
several common antibody reactions between donor and recipient
127
How does a type and crossmatch work?
takes 1 cc of pt blood per unit requested to do the cross-match
128
Pt's who are Rh+ can receive Rh what blood?
both Rh+ and Rh- blood
129
Pt's who are Rh- cannot receive Rh what blood?
Rh+ blood
130
Rh- patients can be exposed to what only 1 time?
exposed to Rh factor one time without anything bad happening
131
What are Rh- moms given within 72 hours of end of any pregnancy?
Rho Gham
132
What 2 times are moms given Rho gham?
1. 20 weeks gestation
2.within 72 hours of end of any pregnancy
133
Does Type O have any antigens?
NO
134
Does Type A have any antigens?
A antigens
135
Does Type B have any antigens?
B antigens
136
Does type AB have any antigens?
yes A and B antigens
137
What is universal donor?
O negative
138
What is universal recipient?
AB+
139
Autologous transfusions are defined by what 2 characteristics?
1. patients own blood
2. preoperative donation
140
What do autologous transfusions eliminate the risk of?
eliminates risk of blood borne pathogens
141
What is unique about autologous transfusion patients and SSI?
they are more prone to SSI because of the refrigeration of the blood
142
Directed donor transfusions are characterized by what?
friends and family can donate for a patient
143
Directed donor transfusions still go through what?
all the steps of public donation
144
There is no statistically significant decrease in what for directed donor transfusions?
risk
145
Autotransfusion is what?
the quickest form of blood replacement in the case of an emergency
146
What are 5 contraindications for blood salvage?
1. dirty bowel
2. clotting agents
3. amniotic fluid
4. bone cement
5. malignancy
147
Jehovah's witness can accept what? If what?
can accept autotransfusion if they consider it an extension of their own circulatory system; if it disconnects from them and is stored elsewhere they can be excommunicated for that
148
What is normovolemic hemodilution?
1-2 units of blood removed preoperatively
149
With normovolemic hemodilution, what are we doing as we are taking blood from the patient?
volume replacement with crystalloids; 3 mL for every 1 mL they take off the patient
150
Surgical bleeding in normovolemic hemodilution happens with what>
diluted blood
151
You only have how long from taking the blood out of the patient to putting it back in them?
4 hours
152
units of blood in normovolemic hemodilution reinfused with what?
intact clotting factors
153
Acute hemolytic reaction is a reaction to what?
antigen or antibody
154
What are symptoms of acute hemolytic reaction?
1. lumbar pain
2. tightness in chest
3. fever
4. chills
5. hemoglobinuria - dark urine
6. shock
155
Why is acute hemolytic reaction difficult to assess in surgery? (2 things)?
1. sudden onset of uncontrolled surgical bleeding that is unexplained
2. bleeding from non-surgical sites
156
Non-hemolytic reaction is also known as what?
febrile reaction
157
what is non-hemolytic or febrile reaction reaction to what?
reaction to antigen, WBC's or Platelets
158
What are s/sx of non-hemolytic or febrile reaction?
1. fever
2. chills
3. headache
4. back pain
159
Transfusion associated circulatory overload (TACO) is just what?
fluid volume overload with massive transfusions
160
What is the main s/sx of TACO?
noncardiac pulmonary edema
161
What are s/sx of noncardiac pulmonary edema associated with TACO?
hives, cough, fever, chills, cyanosis, shock
162
Noncardiac pulmonary edema is a reaction to what?
antigen
163
Delayed hemolytic reaction is a more what?
mild reaction to antigens or antibodies
164
What are 2 s/sx of delayed hemolytic reaction?
1. jaundice
2. anemia
165
Uncross matched blood is otherwise known as what?
emergency release blood
166
We only give uncross match blood in what situations?
life-threatening bleeding situations
167
What do we want to draw early in uncross matched blood?
draw type and cross from patient early
168
Use blood from who for uncross matched blood?
O negative donor
169
What are 4 complications of massive transfusions?
1. ARDS
2. Coagulopathy
3. hypothermia
4. hypocalcemia
170
What is the definition of massive transfusion?
10 units or more
171
What in massive transfusions cases ARDS?
microaggregates lodge in the pulmonary bed
172
Use a what for ARDS?
a micro aggregate filter on the blood tubing
173
After every 4 units of packed cells during massive transfusion, pt. should be getting what?
platelets and FFP at minimum
174
Banked blood is what that can cause hypothermia, so use what?
banked blood is refrigerated, so use warming devices
175
Blood banked bags are lined with what?
citrite, which binds with patient's circulating ionized calcium causing hypocalcemia
176
Packed Red Blood Cells are what?
RBC's in saline
177
Packed RBC's should only be given with what?
normal saline
178
P RBC's must be what? if not what happens?
must be ABO compatible, and if anything is mislabeled send it back to the blood bank
179
Use what with Packed RBC's?
blood warmer
180
Platelets are pooled from how many donors?
5-10 donors
181
Platelets are stored at what?
room temperature
182
Platelets need what?
frequent gentle agitation
183
What is platelet pharasis?
all from one donor; which is better for patients who are getting multiple transfusions so they desensitize more slowly
184
FFP (Fresh Frozen Plasma) is what only?
plasma and clotting factors only
185
FFP is used to what?
replenish missing coagulation factors (extrinsic clotting factors - VII)
186
FFP reverses what in a hurry?
reverses the effects of coumadin (warfarin) in a hurry
187
Cryoprecipitate contains what?
contains clotting factors (fibrinogen, Factors VIII and XIII and Von Willenbrand's factor - intrinsic to the patient PTT)
188
What is the reversal for heparin?
protamine
189
What do you use to reverse coumadin (warfarin) and elequis?
FFP or vitamin K if you have time
190
Cryoprecipitate is used to what?
prevent or control bleeding
