0
Q
what is the goal of trauma services?
A
- Aim to improve the care of injured patients
- Trauma care personnel education
- Maintain current research in trauma
- Hospitals are designated based on needs of the hospital, program costs & population density
1
Q
Trauma Statistics:
- ranked #___ in cause of death among persons age 1-44
- WHO projects ___% of deaths d/t injury 2002-2030
- rank them based on length of stay:
- —heart patients
- —truama patients
- —cancer patients
A
- 3rd leading cause of death overall in the US Leading cause of death among those 1-44 years
- WHO projects 40% in deaths caused by injury between 2002-2030
- Trauma patients spend more days hospitalized than heart and cancer patients
2
Q
what is the trimodal distribution of trauma deaths?
- what is the first phase time frame, what organs are primarily affected, where will we see them?
- what is the second phase and time frame; what organ or situations are involved; where will this be seen?
- what is the third phase; what is the time frame; what is cause of death?
A
-Trimodal Distribution
1. Initial (1st) peak- WITHIN SECONDS OR MINUTES:
Brain, brain stem, upper spinal cord, heart & aorta involvement
(seen in field or in ER)
2. 2nd peak- WITHIN 2 HOURS of injury:
Subdural & epidural hematomas, hemopneumothorax,
ruptured spleen, liver lacerations, fractured femurs, all associated w sig blood loss
(seen in OR or AICU)
3. 3rd peak – death occurs DAYS or WEEKS after injury Sepsis & multiple organ failure
(seen in AICU)
3
Q
- what is shock?
- what causes it?
- what are effects of shock?
- what are the types of shock encountered in the trauma patient
A
- Shock
1. shock is a “generalized state of severe circulatory inadequacy that is caused by reduced perfusion & inadequate delivery of oxygen & nutrients to tissues”
2. Caused by a rapid & sustained loss of blood volume
3. Causes hypoperfusion of peripheral tissues & transcapillary exchange Cascade effect affects multiple organ systems
4. hypovolemic, cardiogenic, obstructive, distributive
4
Q
Compare the difference between level 1 , 2 & 3 trauma centers
- level 1 and level 2 musrt have?
- What’s the defining difference between Level 1&2?
- what is level 3?
A
- -24 hrs/day trauma trained MD staff 24 hr OR staff and capability Continuous Anesthesia staff
- 24 hr/day General surgeons Continuous commitment to research
- basic injuries-low level trauma
5
Q
Discuss assessment of the trauma patient
A
-ABCs
7
Q
trauma assessment:
- what is the B for (2 things)?
- what are you looking at with a trauma breathing assessment?
- what should you always make sure that the ER has done?
A
breathing and blood
- breathing (Ventilation)Ventilation
- rate, rhythm are they exchanginr, airway patency Ventilation
8
Q
trauma assessment: what is the C for (specifically)
- what are you assessing?
- What are some others signs of decreased circulation?
- if you suspect or see bleeding what is your priority (duh)!
- what might you need to do (surgically) in the ER?
- what is the key to treating the trauma patient?
A
C is for Circulation (Adequacy of Circulation)
- Adequacy of Circulation:
- Adequacy of Circulation
11
Q
- what are the 2 goals during induction of anesthesia in the trauma patient
- what is intubation sequence?
- Which induction agent is best? Why?
- what about narcotics for pain?
- When should cricoid pressure be released?
A
- Ideal induction agent provides rapid loss of consciousness with minimal effects on hemodynamic status
- RSI with cricoid pressure
- ketamine (1-4.5 mg/kg); provieds support of respiratory(bronchodilation) & cardiac/ BP (increases catecholamines).
- Limit narcotics until patient hemodynamic status is stabilized
- when tube is in; just before inflation
12
Q
Explain the implications & management of c spine injuries
- C-spine injuries; what are the “Do’s and Don’ts of intubation?
- what is MILS technique? how is it done?
A
- Cervical Spine Injuries
Always document the presence of a C-collar
Avoid neck hyperextension
Jaw thrust technique preferred
Glidescope
MILS Technique–“Manual in line stabilization”
13
Q
Mild hemorrhage:
- definition:
- perfusion changes:
- pH changes:
- what are s/s
A
- <20% blood vol lost
- perfusion changes:
Decreased PERIPHERAL perfusion of:
-skin,
-fat,
-muscle & bone - Ph changes:
-Normal arterial pH - s/s of mild hemorrhage:
-c/o feeling cold
-Postural HoTN & tachycardia
-Cool, pale moist skin
-Collapsd neck veins
-Conc urine
14
Q
moderate hemorrhage:
- defn:
- perfusion changes:
- pH changes:
- s/s of hemorrhage:
A
- 20-40% blood vol lost
- perfusion changes:
Decreased CENTRAL perfusion of:
-liver,
-gut,
-kidneys - PH changes:
Metabolic acidosis present - s/s of moderate hemorrhage:
Thirst
Supine HoTN & tachycardia
Oliguria & anuria
15
Q
severe hemorrhage:
- Defn:
- perfusion changes:
- pH changes:
- s/s of severe hemorrhage:
A
- defn:
->40% lost of blood volume - perfusion changes:
-Decreased perfusion of brain & heart - pH changes:
Severe metabolic acidosis
Respiratory acidosis may present - s/s of severe hemorrhage:
(mental status changes)
-Agitation,
-confusion
-obtunded
-Supine HoTN & tachycardia
-Rapid & deep respirations (kussmal’s)
16
Q
Mechanism of injury: Trauma:
- how does understanding the injury guide the care?
- name types of trauma?
A
- Pattern of injuries can be anticipated by a given traumatic event
17
Q
Identify most common acid-base abnormality in the trauma patient
A
metabolic acidosis
19
Q
Cardiogenic Shock
- what is it?
- what other factors can cause it?
A
- Cardiogenic= failure to circulate blood primarily d/t dysfunction in ventricle effeciency (Pump failure)
- valve dysfunction, arrhythmia
20
Q
assessment of trauma patient: what is the A for?
- why is assessment not always thorough?
- what 4 things (at least) should be considered in your airway plan?
- what should you do if airway looks poor or difficult?
A
A for Airway
- Assessment is often limited (may have injuries that limit assessment (burns, etc), time limitations
- 4 things:
32
Q
Phases of shock: STAGE 1:
- how does the patient compensate in this stage?
- what is maintained in this stage?
- what responses do this?
A
- Stage 1
1. Compensated by negative feedback mechanism
2. CO & arterial pressure are maintained
3. responses that maintain C.O. and arterial BP are:
33
Q
Phases of Shock: STAGE 2:
- what type of shock?
- characterized by what feedback mechanism?
- what system fails?
- what are the causes of this system failure?
A
Stage 2
- Progressive shock
- positive- feedback mechanism
- CV system fails
- Caused by:
34
Q
Injuries:what are the 3 types and their % of injuries:
A
Injuries
- Severe - immediately life threatening, 5% of injuries but 50% of trauma deaths
- Urgent - may become life threatening or result in sig disability, 10-15% of all injuries
- Nonurgent - 80% of all injuries
35
Q
Obstructive Shock:
what causes it (3 things)?
A
Obstructive
Tension pneumo, pulm embolism, obstructive valve disease
36
Q
Distributive Shock:
what are 3 causes?
A
Distributive
Septic, anaphylactic, neurogenic shock
37
Q
- penetrating injuries:
1. what does the location of the injury do for you?
2. what are the 2 different types of penetrating injuries?
3. name some penetrating injuries:
A
- Location of injuries will determine effects and guide management
- –
- High velocity vs Low Velocity insults - –
- GSW’s
- Stab wounds
- Crush injuries
38
Q
blunt trauma:
- types of blunt trauma?
- what are they all associated with?
- what are the usual 2 causes
A
- Multiple Causes
39
burns:
1. what is the Rule of Nines?
2. Direct inhalational injury affects:
3. s/s of Inhalational Injury:
4. Carbon monoxide causes :
5. Thorax burns cause what:
6. What will you see in during the management of this patient?
1. what is the Rule of Nines
- each body part is worth a portion of 9:
head: front and back=9; whole arm: 9; front of leg:9; torso (front): 18 etc.
2. Direct inhalational injury affects:
- the upper airway & leads to edema--- life threatening
3. s/s of Inhalational Injury:
- Stridor
- Hoarseness
- Singed nasal hair
- Soot in the sputum
4. Carbon monoxide causes :
- the oxyhemoglobin curve left shift causing decreased affinity for oxygen
5. Thorax burns cause what:
- may decrease chest wall compliance
6. What will you see in during the management of this patient?
- hypoventilation and resp distress
40
thoracic trauma:
1. #1 cause?
2. what structures are affected?
3. what can occur? what happens in this condition?
4. s/s of tension pneumo?
5. treatment for tension pneumo?
1. Often the result of MVA’s
2. Structures affected—chest wall, lungs, heart, pericardium and great vessels
Often have impaired gas exchange & CO
3. Tension Pneumothorax-Pleural cavity is punctured, air becomes trapped & pressure increases causing a shift of mediastinal structures & collapsed lung
4. S/S----
-HoTN,
-SQ emphysema,
-affected side will have dim Breath sounds,
-distended neck veins,
-tracheal shift (away from affected side)
5. chest tube
41
Massive hemothorax:
1. cause:
2. treatment:
3. what is the goal (with this and all traumas)?
Massive hemothorax
1. Caused by bleeding from heart & great vessels
2. Chest tube will be placed (expect large blood loss)
3. Maintain intravascular volume
42
Pericardial Tamponade
1. what happens?
2. what happens to compensate?
3. what is the "tell tale" sign?
4. what might you see on your art line?
1. blood around heart (pericardial sac)Restricts the filling of cardiac chambers which results in decreased CO, BP & SV
2. HR & PVR increase to compensate
3. Becks Triad---neck vein distension, HoTN, muffled heart sounds
4. Pulsus paradoxus (>10mmHg decline in SBP w inspiration)
43
Cardiac Tamponade
1. need alot of fluids: why?
2. what is a good induction drug?
3. What induction agent should be avoided?
4. if person too unstable, how can a window be done?
Cardiac Tamponade
1. May require elevated filling pressures to maintain CO
2. Ketamine may be the induction drug of choice
3. avoid propofol (decreases CO)
4. Pericardial windows CAN be done under local
44
Thoracic Aortic Dissection
1. what type of ETT?
2. what type of lines?
3. perfusionist?
4. how much fluid?
5. what type of ischemia are we concerned with?
Thoracic Aortic Dissection
1. double ETT
2. arterial lines (femoral and radial)
3. bypass machine
4. alot of fluids
5. kidney and spine
45
abdominal trauma:
1. what do these traumas require as an intervention?
2. what are the 4 major anesthesia management issues for these patients?
3. what can be expected with injuries to liver, spleen and kidneys?
4. why will you be seeing these patients again (if they live)?
1. Blunt & penetrating injuries of the abdomen require surgical exploration
2. Anesthetic intervention involve management of hemorrhage, hypothermia, sepsis & ventilation
3. Major hemorrhage associated w injuries to liver, spleen and kidneys
4. These patients frequently return for multiple washouts (surgical procedures) and eventually abdomen closure.
46
orthopedic trauma:
1. usually not ____?
2. but it can be if the patient develops...?
3. your patient has long bone fractures & pelvic fractures; what are they at risk for?
4. what is seen in fat embolism syndrome?
5. when does it occur?
1. Usually not immediately life threatening
2. hemorrhage & other systemic derangements (emboli)
3. Shock, fat embolism & thromboembolic hypoxic resp failure
4. Fat Embolism Syndrome: Petechial rash, altered mental status, resp insufficiency
5. Occurs 12-24 hrs after injury or surgical manipulation
47
head and neck trauma:
1. you have a patient in the ER with head and neck trauma; you may be called to the ER for...
2. what should you expect to see?
3. who should be present as well?
4. whats the best management for this patient's intubation?
5. what might be helpful?
6. what should be on and ready?
1. airway management
2. Expect bloody & distorted anatomy
3. Surgeon present for surgical airway
4. awake intubation-If possible, allow patient to spontaneously breathe, look for bubbles. You may not see anything else.
5. Glidescope may be helpful,
6. have suction ready
48
Head injury:
1. what should you avoid doing during laryngoscopy
2. what drugs should be avoided?
3. what should you aviod if basilar fx suspected?
1. Avoid increasing ICP during larygoscopy
2. Ketamine (etomidate might be good -decreases cerebral blood flow & o2 consumption)
3. Avoid nasal instrumentation in patients with suspected basilar skull fractures ( Leforte II & III fractures)
49
SCI (spinal column injury)
1. causes:
2. what should be done (as far as intubation & documentation etc.)
3. what drug should be avoided (remember upregulation)
4. what is spinal shock? s/s?
5. what is autonomic hyperreflexia? s/s?
1. Usually result from falls, MVA’s, diving injuries & sports injuries 2. maintain Manual In Line Stabilization (MILS) during intubation & document
3. Avoid use of Succinylcholine if possible
4. Spinal shock: spinal injury affects regulatory mechanisms --s/s: hypotension, hypothermia, bradycardia
5. Autonomic hyperreflexia: seen with lesions above T5; massive sympathetic discharge from levels below fracture
- -s/s: tachy, htn etc.
50
glasgo coma scale:
-
51
1. what is a TRALI?
2. is it serious?
3. what is it/ what happens?
4. when do s/s occur? peak?
5. what are s/s?
1. Transfusion-related acute lung injury
2. Common cause of transfusion related deaths
3. Noncardiogenic pulmonary edema resulting from an immune response post transfusion
4. s/s appear 1-2 hrs after transfusion & peak w/in 6 hrs
5. s/s
- Hypoxia,
- fever,
- dyspnea,
- fluid in the endotracheal tube may occur
52
hypothermia:
1. what are the effects?
2. how should fluids be given?
3. what else can anesthesia do with the breathing circuit?
4. what are other warming means?
1. Effects of hypothermia:
- Cardiac arrhythmias
- cardiac ischemia
- Increased PVR
- Left shift of oxyhemoglobin curve
- Reversible coagulopathy
- Decreased drug metabolism
- Poor wound healing
- Increased infection
2. ALL IV fluids & blood products must be warmed
3. Use HME on breathing circuit
4. Used forced air warming devices & Warm OR
53
trauma room set up:
| what should be in the room and ready (13 things)
```
1-Succinylcholine drawn up
2-2 fluid warmers
3-Level 1 or rapid infusion device
4-A-line set-up & insertion supplies
5-Red chest available (holds 6 PRBC’s 2 FFP’s Platelets?)
6-Suction Canister X 2
7-NGT/OGT
8-Forced air warmer
9-Emergency meds available
10-IV fluids & colloids
11-Stat lab
12-Intubation equipment
13-Glidescope?
```
54
monitoring:
```
ECG
NIBP
SpO2 Temperature
Monitoring
CVP, PA cath (rarely)
Urine output .5ml/kg
Push fluids until you see urine
Arterial line
ABG’s
```
55
anesthetic agents:
1. Inhalation are given how?
2. what might have to be your only anesthetic?
3. what happens if the patient cannot even tolerate versed?
4. what inhalation agent is generally avoided all together?
5. why?
1. Inhalational agents are slowly introduced as patients conditions tolerates
2. May have to administer Versed if inhaled agents are not tolerated
3. Muscle relaxant may be the only drug given, narcotics may not be tolerated
4. Nitrous Oxide is generally avoided:
5. why?
56
post trauma care:
1. what patients will remain intubated?
2. what type of extubation (if the patient meets criteria)?
3. when in doubt... and ...?
1. Most severe trauma patients will remain intubated
2. awake
3. leave the tube in; speak with surgeon
57
Phases of Shock: STAGE 3
1. What type of shock is this?
2. what occurs on a cellular level?
3. this will reslut in...?
1. Irreversible shock
2. Adenosine Triphosphate reserves are depleted
3. Death results if there is no intervention
58
what is Hypovolemic shock?
Hypovolemic shock:
| Extreme Loss of blood or intravascular volume
d. principles exam 4 2013
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