1
Q
Name 5 indications CVP insertion
A
- Infusion inotropes
- total parenteral nutrition
- haemodynamic monitoring
- poor peripheral venous access
- provide venous sheath access to place other devices eg cardiac monitors
2
Q
Name 4 relative contraindications CVP
A
No absolute. All can be resolved by selecting alternative site.
• coagulopathy
• thrombocytopenia
• thrombosed target vein
• infected area at catheter site insention
3
Q
Name 5 complications CVP
A
Mechanical • bleeding • haematoma •Pneumothorax • arterial puncture • haemothorax Infections Thrombotic
4
Q
Which CVP insertion site has the least complications?
A
Subclavian
5
Q
Name 3 sites CVP insertion
A
Subclavian (best)
Internal jugular
Femoral (most complications)
6
Q
Which position should patient be for internal jugular CVP insention?
A
Trendelenburg
7
Q
Which technique is best for CVP insertion?
A
Seldinger technique (over guide wire )
8
Q
How many skin sutures to secure CVP ?
A
4
9
Q
anatomical course of subclavian vein? (4)
A
- Begin at lateral border first rib from axillary vein
- run anterior and inferior to artery
- Cross clavicle just medial to mid-clavicular point 2 cm lateral, 2 cm caudal to middle third clavicle.
- join internal jugular vein medial to anterior scalene muscle to form brachiocephalic vein behind sternoclavicular joint
10
Q
Surface marking for subclavian vein for CVP insertion?
A
Junction of middle and lateral thirds of clavicle
11
Q
Anatomical course of internal jugular vein? (5)
A
- Originate within posterior part of floor of tympanic cavity and is continuous with sigmoid sinus. Origin demarcated by superior bulb of internal jugular vein.
- descends in carotid sheath with carotid artery, just lateral to artery. Cn x lie between artery and vein.
- descend into thorax posterior to space between 2 heads of scm muscle in anterior triangle
- this relationship not present in 20% - may lie deep, medial or superfical to carotid artery
- unite with subclavian vein to form brachiocephalic vein.
12
Q
Surface marking for insertion CVP in internal jugular?
A
Apex of triangle formed by scm heads and clavicle, lateral to carotid pulse. Aim for ipsilateral nipple.
13
Q
Name 5 signs limb ischaemia (arterial injury)
A
5 p Pulselessness Pain severe Pallor Poikilothermia (cold limb) Paralysis
14
Q
What causes pneumopericardium?
A
Penetrating pericardial injury
15
Q
Name 3 xr signs mediastinal haemorrhage
A
- Widened mediastinum
- left apical pleural cap
- deviated trachea or ngt to the right.
16
Q
Define shock
A
Inadequate organ and tissue perfusion with oxygenated blood
17
Q
Name 4 major types of shock and 3 examples of each
A
1 • Hypovolemic : haemorrhagic vs non-haemorrhagic. haemorrhage, severe burns, high output fistulas , dehydration, ascites…
- • cardiogenic: cardiomyopathic vs arrythmic vs mechanical. blunt myocardial injury, dysrhythmias, mi, congestive heart failure, cardiomyopathy…
- • distributive (vasodilation): septic, neurogenic/spinal, anaphylactic, sirs, drug and toxin induced, endocrine
- • obstructive: tension pneumothorax, cardiac tamponade, pulmonary embolisms, aortic stenosis. Constrictive pericarditis, abdominal compartment syndrome
- neuropathic: drugs (type distributive)
- endocrine: adrenal failure, addison’s, myxedema (type distributive)
SHOCKED: septic, spinal/neurogenic, hemornhagic/ hypovolemic, obstructive, cardiogenic, anaphylactik , endocrine, drugs (neuropathic distributive)
18
Q
Name 5 early clinical signs of shock
A
- tachycardia - first sign!
- Tachypnea
- narrow pulse pressure ( sbp decrease first)
- cool extremities
- reduced capillary refill
- reduced CVP
19
Q
Name 3 late clinical signs of shock
A
- Hypotension
- altered mental status
- reduced urine output
20
Q
In which types shock will there be warm skin?
A
Septic and neurogenic/spinal
21
Q
What will blood gas values show in shock? (3)
A
Metabolic acidosis
• high lactate
• low ph
• high (negative ) base deficit
22
Q
Most common type shock in trauma?
A
Haemorrhagic/ hypovolemic
23
Q
Normal CVP? (Cm H2O and mmhg)
A
5-10 cm h2o or 2-6 mmhg
24
Q
Name 5 causes raised CVP
A
>10 cm • fluid overload • heart failure • increased intra-thoracic pressure • pulmonary embolism • vasoconstriction Decreased venous compliance, reclining, squatting, valsalva , resp pump, muscle pump
25
Name 3 causes decreased CVP
<5 cm
. Fluid loss (hemorrhage, vomiting, burns, ketoacidosis)
• excessive use diuretics
• vasodilation (medications, sepsis, neurogenic shock)
26
Beck's triad for cardiac tamponade?
* Hypotension
* distended neck veins
* muffled heart sounds
27
Borders of the "cardiac box"?
Significance: high risk that penetrating injury here could involve heart.
• from below clavicles to xyphoid
• from right mid clavicular line to posterior mid-line
28
Name 2 early physiological response to shock
Tachycardia
| Cutaneous vasoconstriction- cold skin
29
Normal CPR ratio
30 : 2
30
How often should breaths be given in CPR if patient has advanced airway
1 every 6 seconds
31
Name the 4 cardiac arrest rhythms
1. Asystole
2. Ventricular fibrillation
3. Ventricular tachycardia pulseless
4. Pulseless electrical activity
32
Name the 2 shockable cardiac arrest rhythms
* Ventricular fibrillation
| * pulse-less ventricular tachycardia
33
Name 3 scenarios in which you would consider stopping CPR
* no reversible cause: hypovolaemia, oxygenation, tension pneumo, tamponade (hott)
* no shockable rhythm
* compressor is too tired to continue
34
Name 6 complications of massive transfusion protocol
1 hypothermia
2. Dilution coagulopathy
3. Hypocalcemia
4. Volume overload
5. TRALI- transfusion related acute lung injury
6. Transfusion reactions
35
Fluid of choice for initial management shock?
Crystalloid's: ringers, plasmalyte
36
How tell difference between cardiac tamponade and tension pneumothorax clinically?
* Normal or reduced air entry vs none
| * normal percussion vs hyper-resonant
37
Name 5 symptoms and signs cardiac tamponade
```
• Beck's triad in <35%:hypotension, distended neck veins, muffled heart sounds
• abnormal GCS common
• ipsilateral haemothorax common
• anal sphincter relaxation with soiling
. Shock hypovolemic
• low voltage ECG
```
38
Initial management cardiac tamponade ? (4)
• Secure airway
. Ventilate and oxygenate
• minimal fluid resus. Sometimes blood necessary but often not.
• pericardiocentesis while await surgery or transport
39
Definitive management cardiac tamponade ? (3)
* Emergency sternotomy or thoracotomy
* evacuate blood
* suture cardiac injury
40
Formula for awake shock index? (ASI) interpretation?
Bp/ hr
> 0,9 chance for massive haemorrhage
Normal 0,5 - 0,7
41
Name the symptoms of class 1 haemorrhage and treatment.
None except anxiety. Compensated
| <15% blood loss (less than 750ml)
42
Name the symptoms of class 2 haemorrhage and treatment. (4)_
```
Tachycardia >100
Ventilatory rate 20-30
urine output 20-30 ml /h
Still compensated
Treat with crystalloids
15-30% loss (750-1500 ml )
```
43
Name the symptoms of class 3 haemorrhage and treatment. (5)_
```
• Tachycardia >120
• ventilatory: rate 30-40
. SBP decreased
• urine output 5-15 ml . /h
No longer able to compensate. Need transfusion.
30-40% loss. 1500 - 2000 ml
```
44
Name the symptoms of class 4 haemorrhage. (4)_
```
• Tachycardia > 140
• ventilatory. rate >35
. SBP greatly decreased
• urine output minimal.
Minutes to live.
> . 40% loss. 2000 ml
```
45
Compression rate of CPR?
100- 120 per min
46
How often rotate compressors CPR?
2 min
47
Which 3 things make a difference in patient survival after cardiac arrest and CPR?
1. High quality CPR
2. Early defib
3. Find and treat cause
48
Name 10 reversible causes of cardiac arrest
```
5 Hs
Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hypo/hyper Kalaemia
Hypothermia
5 Ts
Tension pneumo
Tamponade
Toxins
Thrombosis (pulmonary)
Thrombosis (coronary)
```
49
When should one consider stopping CPR? (3)
* no reversible cause
* no shockable rhythm
* compressor too tired to continue
50
How calculate mean arterial pressure?
[ SBP + (2x dbp)] /3
51
Define massive transfusion (3)
```
>10 units packed RBC within first 24h of admission (restore entire blood volume)
Or
>4 units in 1 hour
Or
Replace 50% blood volume in 4 hours
```
52
How and when should tranexamic acid (cyclocapron) be administered for haemostatic resuscitation?
* Must be administered within 3 hours injury otherwise increase risk bleed (antifibrinolytic)
* 1g loading dose over 10 min followed by infusion of 1 g over 8 h iv
53
Name 3 endpoints of resuscitation and how to achieve
1. Haemodynamic - restore do2 by volume loading (improve preload and co) and optimize hb
2. Metabolic - eliminate tissue acidosis. Measure serum lactate, base deficit and ph
3. Regional perfusion - cap refill, core-peripheral temperature difference, loc, splanchnic oxygen delivery, ileus, inadequate hepatic oxygen delivery, lack renal blood flow
54
During pericardiocentesis , towards where is needle pointed?
Tip of left scapula
55
Most reliable sign of cardiac tamponade?
Pulsus paradoxus
56
Ideal site for intraosseous puncture and infusion?
1 cm below and medial to tibial tubercle
57
Acute effect of NSAIDs on hypovolaemic patients?
Acute glomerular necrosis
58
How long after Acute limb ischaemia does nerve damage occur?
After 4-6 hours
| Irreversible after 12 hours
59
Gold standard of diagnosing vascular injury?
Arteriography
60
Name 8 signs or injuries of possible vascular injury needing imaging of mediastinum
• Fracture first and second ribs, sternum and scapula
. Sterno - clavicular joint dislocation
• trans axillary gunshot
. Widened mediastinum xray
• obliteration aortic notch, left apical pleural cap, aorta-pulmonary window
. Left haemothorax
• oesophageal and tracheal deviation to right
• depression left main bronchus
61
Name 6 signs of possible vascular injury needing imaging of limbs
* Multiple fractures
* multiple penetrating injuries
* shotgun
* knee or elbow dislocation
* degloving injury
* gunshot tract along axis of vessel
62
Name 6 indications prophylactic fasciotomy
* prolonged hypotension
* extensive soft-tissue injury
* arterial and venous injury
* bone plus vascular injury
* delayed vascular repair more than 6 hours
* inability to assess patient eg head or spinal injury
63
Name indications therapeutic fasciotomy
Concerned about development of compartment syndrome
Signs = increased tissue turgor and extensive deep haematoma in presence of ischaemia
Nb to do fasciotomy before vascular repair to avoid ischaemia reinfusion injury
64
Where is venous cutdown on great saphenous vein usually performed?
1 cm ant to medial malleolus
65
Defib energy/voltage setting for shock?
Most are biphasic: 120-150 J (increase joules with each shock given)
If monophasic, give 360 J
Trauma
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