Principles III > Trauma > Flashcards

Trauma Flashcards

Lisa material (93 cards)

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1
Q

3 major assumptions you make for trauma airways

A

Full stomach.
C spine instability
hypotensive/hypoxic

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2
Q

What induction type are we doing on trauma airways?

A

RSI w neuromuscular blockade

Inc success + rapidly secures airway

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3
Q

Lethal triad

A

Acidosis
Coagulopathy
Hypothermia

(ACH like acetylcholine)

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4
Q

Leading cause of death for those 1 to 44 years old

A

Trauma

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5
Q

Most common blunt trauma

A

MVA + falls

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6
Q

What is a key element of taking care of a patient with blunt force trauma?

A

Assume unstable C spine until confirmed otherwise

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7
Q

With thoracic blunt from trauma, should you use N2O?

A

NO

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8
Q

S/S of Tension PTX

A

Hypotension
Subcu emphysema
unilateral dec BS
chest wall motion
distended neck veins
tracheal shift

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9
Q

Tension PTX treatment

A

Emergent needle aspiration @ 2nd ICS (above 3rd rib), MCL

Need chest tube ASAP

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10
Q

S/S of pericardial tamponade

A

Beck’s Triad (HoTN, inc CVP, jugular distention, muffled heart tones)

Pulsus paradoxus - dec SBP on inspiration

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11
Q

Possible induction choices for Blunt force thoracic trauma

A

Lisa specifically mentioned ketamine

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12
Q

Tracheal injury management

A

Not a lot of cases make it to trauma center because mostly die before arrival

But if they do…
Intubate/perform tracheostomy/surgical repair

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13
Q

Massive hemothorax (from heart and great vessels) management

A

Chest tube after fluid resus

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14
Q

What does penetrating trauma staged refer to?

A

Damage Control Surgery (DCS) with Damage Control Resuscitation (DCR)

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15
Q

What is Damage Control Surgery (DCS) with Damage Control Resuscitation (DCR)?

A
  1. Immediate surgical control of bleeding
  2. Prevent Lethal Triad
  3. Limit crystalloids, target blood products
  4. DCS ex: abdominal packing, external fixator
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16
Q

What is used to determine blood products for targeted therapy during TDR?

A

POC testing like TEG and ROTEM

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17
Q

What does FAST for blunt abdominal trauma stand for?

A

Focused Assessment with Sonography in Trauma

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18
Q

FAST details

A

First used in 1996

Rapid, Accurate

Sensitivity 86-99%

Can detect 100mL of blood

Cost effective

4 Different Views
1. Pericardiac
2. Perihepatic
3. Perisplenic
4. Peripelvic Space

Eliminates unnecessary CT scans

Helps in management plan

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19
Q

Trauma Anesthesia: A stands for?

A

AIRWAY

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20
Q

How many people do you need to help intubate trauma patents IDEALLY?

A

3!

One to intubate, one doing MILS, and one to do cricoid!

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21
Q

What is the point of Manual in-line stabilization (MILS) ?

A

Once the front of the c-collar is removed, it just ensures that the head/neck stays neutral and doesn’t get hyperextended during intubation

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22
Q

When getting the airways, what is the outcome difference between DL, VL, and FOB?

A

There isn’t one. It’s just provider dependent.

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23
Q

What guidelines do you follow what taking care of a trauma airway?

A

ASA difficult airway algorithm
Pt may end up needing FONA or a trach

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24
Q

What is the B for in trauma anesthesia?

A

Breathing!

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25
What percentage of chest trauma includes pulmonary contusions?
70% This can progress to ARDS
26
When talking about B: Breathing as part of trauma anesthesia, what is the dilemma?
Decreased compliance + the need for increased PIP = barotrauma w worsening disease Damned if ya do or don't!
27
B:Breathing management
Low TVs, PEEPS, permissible hypercapnia, limited fluids, prone positioning, NMBs
28
B:Breathing options
HFJV, oscillators, CP bypass
29
What is the goal of B: Breathing in trauma anesthesia?
Protective ventilation Dec TV, PIP < 32 cm H20, SpO2 90-94%, avoid 02 toxicity
30
What is 02 tox?
Decreased mucociliary transport Atelectasis (resulting in ventilation–perfusion mismatching) Inflammation Pulmonary edema... Eventually, interstitial fibrosis. Excess oxygen l/t tissue damage from free radicals/reactive oxygen species (ROS) ROS-mediated reactions = cellular necrosis or apoptosis Paradoxically, hypoxia l/t ROS production ROS: Key players in reperfusion injury
31
The confusing thing about Oxygen Tox...
Difficult to distinguish from other lung injury processes Does excess oxygen cause damage, make damage worse, or is worsening lung injury due to disease??? -- Difficult to say
32
What does the C stand for in trauma anesthesia?
Circulation **35% of pre-hospital deaths are r/t hemorrhage + 40% of trauma deaths within 24 hours d/t hemorrhage.
33
What does the Golden Hour refer to?
Refers to C: Circulation Victims* survive hemorrhagic shock if perfusion restored within 60 minutes (*young, male, military in Vietnam) Current theory: The Golden Hour is nonspecific time that is age and health status dependent.
34
Stages of Hemorrhagic Shock: Stage 1
Non-progressive or compensated --> Blood volume normalized by shifting fluids
35
Stages of Hemorrhagic Shock: Stage 2
Progressive --> CV depression d/t ischemia, thrombosis, toxins, cellular damage
36
Stages of Hemorrhagic Shock: Stage 3 definition
Irreversible--> ATP depleted, cellular death with toxins released
37
Stages of Hemorrhagic Shock: Stage 3 catagories
Acute Irreversible: Massive hemorrhage = death Sub-acute Irreversible: Significant shock and cellular ischemia = multi-organ failure/death over time.
38
What does current Advanced Trauma Life Support (ATLS) say about hemorrhagic shock treatment?
For minimal bleeding, 2 L crystalloid; targeted components for greater blood loss why? Because inc fluids can worsen clinical picture
39
Hypotension resuscitation maintains a SBP of what?
85-95 mmHg until bleeding is controlled.
40
During hypotension resuscitation and after bleeding is controlled, what is the SBP and HR goal?
>100 mmHg and HR <100
41
What group should you avoid hypotensive resuscitation with?
TBI patients
42
Applying Poiseuille's Law what is the best kind of IV catheter?
Short and fat one
43
Vasoconstriction may effect your ability to place an ____; so you may need a ____.
IV; CVL
44
Until labs are back, how should you replace EBL?
1:1:1 --> PRBCs, FFP, platelets
45
Risk with colloid use
Inc risk of pulm edema and bleeding *starch based colloids can cause platelet dysfunction
46
What fluids are best for perfusion?
Isotonic crystalloids!
47
Why should we avoid fluid w dextrose (except for in peds and documented hypoglycemia)?
BG >170 mg/dL  adverse neuro outcomes Maintain BG at 140 - 180.
48
What should blood sugar be maintained at?
140-180
49
5 causes for TIC (Trauma-Induced Coagulopathy )
Dilution Hypothermia Acidosis TBI Shock
50
What cause of TIC (Trauma-Induced Coagulopathy) are we (providers) most responsible for?
Dilution
51
ASA recommended INR
Less than or equal to 1.5
52
ASA recommended platelet level
>50K
53
Ways to avoid Dilutional Coagulopathy
-DCR protocols -Targeted transfusion with 1:1:1 until labs are available -Get TEG/ROTEM if possible
54
How does hypothermia cause TIC?
Straight from notes: Hypothermia probably alters platelet function & dec fibrin formation. Inhibits initiation phase and fibrinogen Net result: Slowly formed, fragile, dysfunctional clot
55
How to prevent hypothermia during trauma
WARM EVERYTHING
56
How does acidosis affect/cause TIC?
Not a lot of effect alone However, acidosis + hypothermia = significant coagulopathy Impairs coagulation proteases NaHCO3 not effective for clotting function -inc CO2 and dec Ca++  l/t myocardial depression.
57
How does TBI/shock lead to TIC?
Theory: TBIs and shock (neural damage) leads to increlease of tissues factor which creates T-T complex. T-T complex = thrombin + thrombomodulin T-T complex l/t activated protein C (APC) pathway o Inhibits V & VIII o Promotes fibrinolysis Result with hypoperfusion and injury: Systemic anticoagulation
58
Implication of activated protein C pathway
Inhibits V & VIII
59
What is recommended for preventing TBI/Shock patients to avoid TIC?
Early FFP (before coag values determined)
60
How is mass transfusion protocol (MTP) defined?
-10 units PRBCs in 24 hrs -Loss of 1 BV ->5 units PRBCs in 4 hrs w/ continued hemorrhage
61
Assessment of Blood Consumption (ABC) score & Trauma-Associated Severe Hemorrhage score criteria
Penetrating injury SBP ≤ 90 HR ≥ 120 Positive FAST (slide 12 on her ppt) ABC score ≥ 2 = inc risk of needing massive transfusion (each variable = 1 point)
62
GCS below what needs to be intubated?
8
63
MTP disadvantages
expensive and labor intensive
64
What does D in the trauma ABCs?
Disability --> neurologic
65
According to D:Disability as a part of the trauma ABCs what should be your intubation approach?
Probably RSI W cricoid but def not awake in these patients because of inc ICP l/t poss herniation
66
What patient do you want to avoid a nasal intubation in?
Basilar skull fracture and cranial vault sepsis
67
ICP clinical target
IC HTN = ICP >10; Treat ICP >25 mmHg
68
MAP and CPP clinical target
Maintain MAP ≥ 80 mmHg to maintain CPP ≥ 60 mmHg (until ICP monitoring is available).
69
Clinical target: PaCO2
Maintain PaCO2 30-35 mmHg if cerebral hypoxia not suspected.
70
ACS 3-Tiered Approach is a part of what element/letter in the Trauma ABCs?
D: Disability
71
ACS 3-Tiered Approach: Tier 1 ICP and treatment
ICP 10 – 20 mmHg Tx: Elevate HOB 30 deg, short acting sedation/analgesia, monitor ventricular drainage, repeat diagnostics
72
ACS 3-Tiered Approach: Tier 2 ICP and treatment
ICP > 20 - 25 mmHg Tx: External ventricular device (EVD), mannitol or hypertonic saline, neuromonitoring, CT, NMBs
73
ACS 3-Tiered Approach: Tier 3 ICP and treatment
unresolved ICP > 20 – 25 mmHg Tx: Surgical evacuation, med-induced coma, hypothermia IMPEDING HERNIATION: Cushing’s Triad (hypertension, bradycardia, irregular respirations)
74
Drugs to avoid in increased ICP
Ketamine --> inc ICP) Etomidate --> adrenal suppression Propofol is probably best choice for neuro protection unless myocardial depression is a risk
75
General increased ICP treatment
Consider incremental propofol, moderate hyperventilation, mannitol (0.25–1 gm/kg), furosemide, and head elevation. Steroids not effective for inc ICP.
76
How should we treat trauma patients' c spines?
LIKE ITS INJURED UNTIL PROVEN OTHERWISE
77
Six signs of SCI (spinal cord injury)
Paralysis pain position paresthesias ptosis priapism
78
Why should we use Sch cautiously in trauma/SCI patients?
Fasciculations can worsen SCIs After 24 hours: Up-regulation can l/t potentially lethal hyperkalemia Contraindicated in children? --> poss. undiagnosed dystrophies and bradycardia make Sch a bit of a no-no to use!
79
Spinal shock triad
Hypotension, bradycardia, hypothermia
80
T6 and above injury would mean what?
major CNS impairment
81
Spinal shock causes what?
Loss of cardiac accelerators, vasodilation, dec CO, heat loss, and inability to compensate
82
Spinal shock is similar to ____ shock?
warm
83
What do you need for SCIs to guide pressor therapy?
Arterial line is a MUST to guide pressor therapy & avoid pulmonary edema.
84
W
-SCIWORA = Spinal Cord Injury WithOut Radiographic Abnormalities -VAI = Vertebral Artery Injury
85
Anesthesia implications for SCI patients
Prepare for difficult intubation with neutral positioning (MILS), C-collars, halos… Awake FOB intubation? VL? DL with straight blade? Document all pre-op deficits. Prepare for heavy blood loss. Avoid Sux (for life) & N20 Intra-op evoked potentials (EPs)? Anesthesia implications with EPs: NMBs okay for sensory, but nothing motor related Maintain MAP of 85 – 90 to optimize spinal cord perfusion.
86
Autonomic dysreflexia is what?
Massive SNS response d/t stimulus below injury level (frequently r/t bladder)
87
Autonomic dysreflexia most common injury level
Lesions above T6
88
Autonomic dysreflexia common causes
Bladder distention and fecal impaction Seen after spinal shock phase Can occur during N2O/opioid GA or regional anesthesia (not seen with volatile agents).
89
Autonomic dysreflexia S/S
Hypertension, seizures, pulmonary edema, MI, acute renal injury, cerebral hemorrhage
90
Autonomic dysreflexia treatment
nitrates, nifedipine, hydralazine, labetalol
91
Major risk in orthopedics
Hemorrhage, shock, fat emboli, PE emboli -- especially with pelvic and long bones Hypoxic respiratory failure d/t continuous fat emboli (FES); ARDS HIGH M&M with pelvic fractures.
92
How should we treat orthopedics intubation wise??
Like full stomach
93
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