Trauma

Question 1

What are the trauma statistics?

Answer 1

• 9% of total annual mortality
• 1.24 million traffic accident fatalities
  
  • usually pedestriants, cyclists, and motorcyclists
• 1.5 million deaths d/t violence
• Most deaths d/t high energy mechanixm of injury
  
  • 1.3 die within first 4 hours
  • deaths d/t low energy impact higher after 7 days
• Leading cause of mortality is head trauma, 2nd is hemorrhagic shock

Question 2

What is the pathophysiology of hemorrhagic shock?

Answer 2

• Problem of supply vs demand: imbalance occurs between systemic O2 delivery and O2 consumption
• hemodynamic instability, coagulopathy, decreased O2 delivery, decreased tissue perfusion, and cellular hypoxia
• Initial response: macrocirculatory and mediated by neuroendocrine system
  
  • release of: renin, antiotensin, vasopressin, ADH, GH, glucagon, cortisol, epinephrine, norepi
    
    • renal and adrenal systems play major role in this
  • this sets stage for the microcirculatory response

Question 3

What is the “ shock cascade?”

(flow chart)

Answer 3

• Ischemia in any part of body will trigger an inflammatory response that will affect the non-ischemic organs even after perfusion has been restored.
  
  • individual ischemic cells respond to hemorrhage by taking up interstitial fluid, further depleting intravascular fluid
  • cellular edema can block adjacent capillaries which prevents reversal of ischemia even with good macroperfusion
• Ischemic cells produce lactate–this washes back into central circulation and sets up for SIRS and Multi organ failure

Question 4

How does CNS system respond to Hemorrhagic shock?

Answer 4

• CNS is the prime trigger of the neuroendocrine response
  
  • controls selective perfusion to heart, kidney, and brain
  • reflexes and cortical electrical activity are both depressed (this is reversible in mild hypoperfusion)

Question 5

How does the cardiac system respond to hemorrhagic shock?

Answer 5

• Cardiac system is preserved from ischemia
  
  • lactate, free radicals, and other humoral factors released by ischemic cells all act as negative inotropes
• Somebody with cardiac disease (esp fixed stroke volume) is at greater risk for decompensation d/t hypovolemia and anemia
• cardiac dysfunction is a LATE SIGN and often a terminal event

Question 6

How does the pulmonary system respond to hemorrhagic shock?

Answer 6

• The lungs are the filter for the inflammatory by-products of the ischemic cells in body.
  
  • immunE complex and cellular factors accumulate in pulmonary capillaries and lead to neutrophil and platelet aggregation, increased capillary permeability, destruction of lung, and ARDS

Question 7

How does the renal system respond to hemorrhagic shock?

Answer 7

• Neuroendocrine response
• GFR maintained with selective vasoconstriction
• Prolonged hypotension affects the ability to concentrate urine
  
  • also tubular epithelial necrosis and renal failure

Question 8

How does hemorrhagic shock affect the gut/intestines?

Answer 8

• One of first organs affected by hypoperfusion
• Intestinal cell death causes a breakdown in the barrier function of the gut that allows bacteria into the liver and lungs
  
  • this potentiates ARDS

Question 9

How does the liver respond to hemorrhagic shock?

Skeletal muscles?

Answer 9

• Failure of synthetic function of the liver–cannot make things like coagulation factors
  
  • this can be lethal
• Skeletal muscles
  
  • tolerate ischemia better than other organs
  • release lactic acid and free radicals that can potentiate the ARDS

Question 10

What are the steps for a Trauma assessment?

Answer 10

1. Initial rapid assessment- is pt stable, unstable, or dead
2. Primary survey: ABCDE
   
   1. ABC- airway patency, breathing, circulation
   2. D- disability: brief neurological examination
   3. E- expose: Undress and inspect for external injuries
   4. Must decide to proceed immediately to surery or continue on to secondary survey
3. Secondary survey: detailed multi-system exam and history
   
   1. further diagnostic evaluation

Question 11

What are the details of ABCDE?

(flow chart)

Answer 11

Question 12

How is the airway managed for a trauma patient?

Answer 12

• Stabilize C-spine
• provide 100% FiO2 (until you have ABG)
• For obstruction if spontaneously breathing:
  
  • Initial- chin lift, jaw thrust, suction, OPA (nasal ok, but avoid if any possibility pt has basilar skull fx or maxillofacial injury)
  • Still inadequate- consider BMV or SGA
• Proceed to intubation
  
  • awake vs RSI vs cricothyroidotomy

Question 13

How does the airway algorithm change when dealing with a trauma?

What is best choice?

Answer 13

• You do not have the option to awaken the patient if you cannot get the airway
• If something does not work, you MUST change something
• Best choice: RSI or awake intubation with topical anesthesia
• Steps:
  
  • Locate cricothyroid membrane
  • pre-oxygenate
  • perform RSI
  • look with video laryngoscopy and attempt intubation
  • consider SGA but do not delay
  • proceed to cricothyrotomy if no view

Question 14

What are the indications for intubation in trauma patients?

(table)

Strong indication

discretionary indication

Answer 14

Question 15

How are cervical spine injuries diagnosed or ruled out?

Gold standard?

Awake?

Answer 15

• C-spine injuries can be missed on initial trauma assessment
• CT (with < 3mm cuts) is typical diagnostic tool
  
  • soft tissue and ligament injuries can only be detected on MRI
  • MRI is gold standard
• *It is very rare to cause cervical cord injury with airway management but we still take precautions
• If pt is wake and sober, check for posterior midline neck tenderness
  
  • if this test is negative with no other distracting injuries, there is low likelihood if c-spine injury

Question 16

How are c-spine precautions maintained during airway management?

Answer 16

• All airway maneuvers cause some s-spine movement
• Rigid collar is NOT enough
• Manual inline stabilization is preferred
• Pt may have unopposed vagal tone during airway manipulation causing severe brady
  
  • may want to premedicate

Question 17

How is manual inline stabilization done?

Answer 17

• Ideally anesthesia provider + two people
• One perso stabilizes and aligns the head in neutral position without applying cephalad traction
• other person stabilizes both shoulders by holding them agains bed
• anterior portion of collar may be removed to improve mouth opening
• MILS can obstruct glottic view

Question 18

Blunt airway injuries:

symptoms

preferred airway management

Answer 18

• Symptoms:
  
  • hoarseness/muffled voice
  • dyspnea/stridor
  • dysphagia
  • odynophagia (painful swallowing)
  • cervical pain and tenderness
  • ecchymosis
  • subQ emphysema
  • flattening of adams apple
• preferred airway management:
  
  • Fiberoptic bronch or surgical airway
  • CT before intervention if stable
• 70% of blunt airway injuries also have C-spine injuries
• blunt airway injuries can be missed

Question 19

Penetrating airway injury:

symptoms

management

Answer 19

• Symptoms:
  
  • air bubbling through wound
  • hemoptysis
  • coughing
• managment:
  
  • ETT inserted in wound
  • tracheostomy distal to wound
  • oral intubation

Question 20

What are pulmonary complications seen in trauma?

Answer 20

• Tension pneumothorax
  
  • no time to confirm with CT or Xray
  • must do needle decompression or chest xray
• Flail chest- two or more sites of at least three adjacent ribs (costocondal separation or sternal fx)
  
  • will decompensate over 3-6 hours
  • ARDS likely if lung contusion >20%
• Open pneumothorax
  
  • risk for vascular air entrainment

Question 21

What are symptoms of tension pneumothoras?

Where do you do needle decompression of pneumothorax?

Where does chest tube go?

Answer 21

• Symptoms:
  
  • cyanosis
  • tachypnea
  • hypotension
  • neck vein tistension (unless hemorrhaging)
  • tracheal deviation
  • diminished breath sounds on affected side
• Needle decompression:
  
  • midclavicular line of 2nd intercostal space
  • remember nerves/veins, arteries are high in intercostal space
    
    • walk off top of third rip
• Chest tube mid-axillary 5th intercostal space

Question 22

How do you treat flail chest?

Answer 22

• Automatic intubation is NOT recommended
• focus on analgesia to maintain adequate excursion and ventilation/oxygenation
  
  • epidural or thoracic paravertebral blocks preferred with O2 and non-invasive PPV

Question 23

What are the different classes of shock?

blood loss (ml)

blood loss (%)

pulse rate

systolic BP

pulse pressure

RR

UOP

CNS/mental state

Answer 23

Question 24

Information about shock:

difinitive treatment?

When should you expect major bleeding?

Ideal SBP?

goal Hgb?

Answer 24

• Difinitive tx- operative control of bleeding at the source
• expect major bleeding with falls >6 ft, high energy deceleration, or high velosity like GSW
  
  • free fluid on Xray or CT warrants immediate intervention
• Ideal SBP = 100-110,
  
  • especially in elderly (90’s ok in young/healthy)
  • Goal Hgb = 7-9

Question 25

What does the base deficit tell us?

Answer 25

* Base deficit is more reliable than pH in: * reflecting the severity of shock * oxygen debt * changes in O2 delivery * adequacy of fluid resuscitation * likelihood of multi-organ failure

Question 26

What are the principles of damage control?

Answer 26

* 1st phase (arrival)- recognize the severity of injury; control bleeding, rapid transport to OR * limit crystalloids * permissive hypotensive * active rewarming * early FFP and platelets at high ratios with PRBCs * 2nd phase (in OR) * surgeons rapidly control bleeding; leave abdomen open * goals: * maintain intravascular volume * temp * acid/base status * coagulation * 3rd phase: ICU management with same goals * 4th phase: multiple returns to OR at 24 and 48 hour intervals for organ repair, washout, and debridement

Question 27

How

Answer 27

* Permissive hypotension (except TBI, spinal cord injury, or elderly) * rapid control of bleeding * Avoid large volume of crystalloid- can cause ARDS and abdominal compartment syndrome by worsening endothelial dysfunction * Early administration of plasma and other product in balanced racio with PRBCs (1:1:1) * tranexamic acid * New PRBCs preferred (\<14 days old)- lower incidence of reaction

Question 28

What kind of blood do you use for uncrossmatched patient? FFP?

Answer 28

O Rh+ PRBCs AB- FFP

Question 29

What is the lethal triad of hemorrhage?

Answer 29

* Hemorrhage causes acidosis, hypothermia, and coagulopathy * acidosis and hypothermia cause factor and platelet dysfunction, enhancing coagulopathy * this causes MORE bleeding

Question 30

What are the two components of coagulopathy in trauma?

Answer 30

* Acute traumatic coagulopathy-occurs shortly after trauma * hyperfibrinolysis and severe tissue injury releases tissue factor--this activates coagulation pathways * Resuscitation-associated coagulopathy * Caused by hypothermia, dilution with crystalloids

Question 31

Traumatic brain injury: primary goal? general management?

Answer 31

* Primary goal: prevent secondary injury * Avoid: * hypotension * hypoxemia * anemia * raised ICP * acidosis * glucose \>200 * Normalize: * BP (mean \>80) * PaO2 \>95 * ICP \<20 to 25 * CPP about 70 mmHG * General management: * HOB 30 degrees * sedation and paralysis PRN * mannitol and hypertonis NA prn * smooth intubation, avoid desat * hyperventilation- wait 24 hours after injury, use only as emergency intervention when osmotic agents are ineffective, guided by ICP monitoring * Avoid hypoxia, hypercarbia, hyperthermia

Question 32

What are the most damaging insults to the brain after a TBI?

Answer 32

* hypotension and hypoxia * a single episode of hypoxemia (PaO2 \< 60) can double the incidence of mortality

Question 33

What is the vasopressor of choice in a TBI and why?

Answer 33

* Phyenylephrine- does not cause cerebral vasoconstriction

Question 34

Drugs and TBI: Succ? Ketamine? Fluids?

Answer 34

* Risk of Increased IOP, ok with defasiculating dose * ketamine- usually no d/t risk of increased ICP, but current literature does not support appreciable increase * NS over LR * LR is slightly hypotonic and can promote swelling

Question 35

How do you determin glascow coma scale?

Answer 35

Question 36

Spinal cord trauma: Complete vs incomplete? What is spinal shock? What injury requires a ventilator?

Answer 36

* Incomplete- anal sphincter tone maintained * spinal shock can make incomplete look like complete * complete- virtually no chance of recovery * Spinal shock- flaccidity and loss of reflexes * subsides in days to weeks * Injury C4 and above require ventilator b/c diaphragm is affected

Question 37

What is Brown-Sequard syndrome?

Answer 37

* Partial cord transection * ipsilateral motor and contralateral sensory deficit below the injury

Question 38

How is blunt cardiac injury evaluated? Symptoms of blunt cardiac injury? What is most commonly injured?

Answer 38

* EKG, troponin, TEE * Symptoms- * angina * dyspnea * chest wall bruising * dysrhythmias * CHF * Right ventricle is most commonly injured

Question 39

What is Commotio cordis?

Answer 39

* Blow to the chest in young people causing VF/VT * treat with defibrillation

Question 40

What are the goals for a patient with blunt cardiac injury? How will this affect your anesthetics?

Answer 40

* maintain cardiac contractility and lower the elevated pulmonary vascular resistance * Give anesthetics only after restoring intravascular volume and titrate to maintain BP

Question 41

Pericardial tamponade: symptoms? Goals of treatment?

Answer 41

* Symptoms: (some may be absent in hypovolemic pt) * tachycardia * hypotension * distant heart sounds * distended neck veins * pulsus paradoxus * pulsus alternans * Goals of treatment: * maintain preload and contractility * ideally evacuate pericardial blood under local * induce with small doses of ketamine if necessary * wait until pt is prepped and draped to induce b/c pt may completely decompensate with induction

Question 42

General information about abdominal trauma. What does unrecognized hypoperfusion cause?

Answer 42

* Laparoscopy/laparotomy is required in most patients after gunshot wound to abdomen * FAST ultrasound or CT- to look for bleeding * Occult bleeding can be massive before abdominal distension is noted * Hypoperfusion causes **splanchnic ischemia** * acidosis in the intestinal wall * translocation of microorganisms and inflammatory mediators from intestines * washes back to lungs causing ARDS * leads to sepsis and multi-organ failure

Question 43

What are the symptoms of abdominal compartment syndrome? How can the incidence of abdominal compartment syndrome be reduced?

Answer 43

* Symptoms * a tense severely distended abdomen * increased peak airway pressure * CO2 retention * oliguri * Intra-abdominal pressure \>20 to 25 mmHg signals decreased perfusion and may require surgical decompression * limiting crystalloids has had the most impact on reducing the incidence * Abdomens are left open to decrease risk of compartment syndrome

Question 44

General information about pelvic injuries.

Answer 44

* 25% of pelvic fractures lead to major hemorrhage * arterial bleeding treated with embolization in IR * vascular injuries can affect perfusion to lower extremities * bladder and urethral injuries may occur concurrently

Question 45

Orthopedic trauma: When is it usually treated? How can vascular injuries be identified?

Answer 45

* Usually treated early to avoid complications * DVT, PNA, sepsis, pulmonary and cerebral complications, fat embolism * infection in open fractures left open more than 6 hours * Vascular injuries: the P's * pain * pulselessness * pallor * paresthesias * paresis

Question 46

Compartment syndrome: treatment?

Answer 46

* Compartment requires emergency fasciotomy * Pressure \> 30 cm H2O needs immediate surgery * caution with regional as it masks pain of compartment syndrome

Question 47

What kind of vascular access/hemodynamic monitoring do you want for trauma patients?

Answer 47

* Minimum of 2 large bore IVs, CVL may be indicated * A-line: R radial artery preferred, b/c if aorta gets cross clamped a femoral or dorsalis pedis would be useless, left can be affected by clamping of descending aorta * Consider PPV and SVV to guide fluid responsiveness (noninvasive monitoring) * \>12% likely a responder * limitations * PA catheter less common but indicated in some populations * TEE/TTE yields qualitative and quantitative information

Question 48

What can you see qualitatively on a TEE

Answer 48

* Ventricular wals contact each other (kissing) at the end of systole, producing a high EF * IVC collapses during the respiratory cycle

Question 49

What can a PA catheter tell us? What is dysoxia?

Answer 49

* Oxygen consumption * oxygen delivery * Hgb concentration, arterial oxygen saturation, and cardiac output * minimum value 500 ml/min/m² * oxygen extraction * below 0.25 or 0.3 suggests no dysoxia * dysoxia- abnormal tissue oxygen metabolism

Question 50

What happens to coagulation in trauma? How can coagulation be measured? What suggests DIC?

Answer 50

* Hemodilutional coagulopathies from fluid resuscitation * rapid consumption of clotting factors * activation of Protein C (inhibits clotting factors V and VIII, decreases the inhibition of TPA) * INR, aPTT, platelets, fibrinogen, and fibrin degradation products (FDPs) * FDP \>40 mg/ml suggests DIC * TEG/ROTEM: clot formation and dissolution measurement * can help indicate best treatment

Question 51

What should you consider with blood administration? What is in FFP? What is the goal for platelet levels? What is in cryo? Why is it usually used?

Answer 51

* PRBCs \<14 days old preferred * old blood has higher risk of Trali * Citrate is present in all blood products * citrate chelates Ca leading to hypocalcemia * hypocalcemia causes defective coagulation, hypotension, decreased pulse pressure, arrhythmias, change in mental status, tetany * FFP: all coagulation components * Ratio administered Blood:FFP:PLT is 1:1:1 or 2:1:1 * PLT: infuse to goal of \>50k * Cryo: * factorVIII, fibrinogen, von Willebrand factor, fibronectin, factor XIII * usually used to replace fibrinogen

Question 52

How does trauma affect anesthetic pharmacology? What are the induction drugs of choice?

Answer 52

* Most anesthetics are direct CV depressants that inhibit compensatory reflexes * hypovolemia leads to higher plasma concentrations and increased sensitivity * dilutional hypoporoteinemia causes increased free fraction of drugs * hypovolemia may be masked by catecholamine surge and revealed with administration of anesthetic * MAC reduced by about 25% in hemorrhagic shock * OVERALL: reduce administered doses of induction agents and opioids * Ketamine and Etomidate are frequent drugs of choice at induction * caution with ketamine in catecholamine depleted patients

Question 53

How does temperature affect the trauma patient?

Answer 53

* Hypothermia is huge problem (core temp \<35 C) * main effects: **acidosis, hypotension, coagulopathy** * Also: cardiac depression & ischemia, arrhythmias, peripheral vasoconstriction, impaired O2 delivery, increased O2 consumption, blunted response to catecholamines, metabolic acidosis, electrolyte imbalance, reduced drug clearance, infection * Coagulation factor function decreased about 10% every 1 degree (C) below 35 * aggressive rewarming is critical!

Question 54

How should you manage ventilation in a trauma patient?

Answer 54

* Lung protective strategies * VT no more than 6 ml/kg * appropriate PEEP * titrate FiO2 to lowest possible level * plateau airway pressures below 35 cm H2) * avoid auto-PEEP

Question 55

What are some miscellaneous things to look out for with a trauma patient?

Answer 55

* Overlooked injuries can be revealed during anesthesia * C-spine, unrecognized pneumo, internal bleeding * monitor serial serum K+'s and treat hyperkalemia prn * Correct the cause of metabolic acidosis rather than using liberal bicarbonate * use only short term when pH is \<7.2 * Thromboembolism precautions are critical: * scd, LMWH, IVC filter

Question 56

What is important during the later resuscitation of a trauma patient?

Answer 56

* Late resuscitation begins once bleeding is difinitively controlled * Vital signs used as markers- no single difinitive marker of adequate resuscitation * maintain volume status, blood composition, and cardiac output * look at all the information to determine if you need to continue resuscitation to prevent MSOF

Question 57

What is occult hyperfusion syndrome?

Answer 57

* common in young posoperative trauma patients * characterized by normal BP maintained by systemic vasoconstriction * decreased intravascular volume, CO, and vasoconstriction can lead to systemic ischemia and MOSF

Question 58

What are the late resuscitation goals? | (6)

Answer 58

* Maintain SBP \>100 * maintain hct \> individual transfusion threshold * normalize coagulation status, electrolyte balance, temperature * restore normal uop * maximize CO * reverse acidosis and decrease lactate * normal lactat in critically ill pt \<2 * BE better than -4

Question 59

What is significant about trauma during pregnancy?

Answer 59

* Can cause spontaneous abortion, preterm labor, or delivery * Best treatment is resuscitation of mother * 2nd/3rd trimester- determine fetal age/viability and have HR monitored continuously if age is viable * Kleihauer Betke blood test: has fetal blood entered mom's circulation? * if yes, administer anti-RhO immune globulin if Rh- mom carrying Rh+ baby * 3rd trimester- on spinal board aortocaval compression requires uterine displacement-- tilt entire board

Question 60

What are the indications for immediate c-section?

Answer 60

* mother is coding * uterus is hemorrhaging * gravid uterus is impairing surgical control of abdominal or pelvic hemorrhage * jplacental abruption- can lead to uterine hemorrhage

Question 61

What is significant about trauma in elderly?

Answer 61

* Elderly are more prone to morbidity * desire higher Hct to optimize tissue oxygenation * high risk for post-traumatic cardiac dysfunction * decreased requirement for post op opioids * potential delirium with sedatives * high risk DVT

Question 62

What is significant in Jehovah's witness?

Answer 62

* May use deliverate hypotension * may need early surgical control of bleeding * patient may consent to cell salvaging if one continuous system is used * colloids (ask first), pressors, and inotropes to keep tissue O2 delivery optimized * post-acute: consider erythropoietin to promote RBC regrowth