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Principles IV > CNS and Musculoskeletal Trauma > Flashcards

CNS and Musculoskeletal Trauma Flashcards

1
Q

Age 15-24 yrs old are more apt to be involved in what types of trauma

A

MVC and violence often involving ETOH

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2
Q

Age >75 yrs old are more apt to be involved in what types of trauma

A

Falls

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3
Q

How many head injuries in the US per yr

A

1.6 million

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4
Q

How many permanent neurologic injuries in the US per yr

A

70,000-90,000

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5
Q

Types of primary traumatic brain injuries

A

Skull fx, vascular injuries, subdural and epidural hemorrhage, brain parenchyma injuries such as contusions and axonal injuries

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6
Q

Types of secondary traumatic brain injuries

A

Occur after the initial event and potentially preventable

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7
Q

Types of preventable secondary injuries are

A

Hypoxia, hypercapnia, hyperthermia

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8
Q

Secondary injuries may involve

A

Reperfusion, superoxide production, exciotoxic amnion acid release, necrosis and apoptosis

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9
Q

What types of skull fractures require early surgery to decrease the incidents of meningitis

A

Open skull fx, deep scalp lacs and fractures extending into sinuses

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10
Q

Are all skull Fx assoc with intarcrainal lesions

A

NO, but it should alert the CRNA to a potential underlying brain injury

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11
Q

What is the most common focal intracranial injury

A

Subdrual hematomato, yes tomato, LOL

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12
Q

What percentage of TBI have hematomatos

A

24%

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13
Q

What TBI has the highest mortality rate

A

Subdural Hematomatos (squishy tomato’s)

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14
Q

How do you fix a subdural hematomato

A

surgical decompression

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15
Q

What percentage of TBI have eipdural tomatoes

A

6%

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16
Q

Classic presentation of an epidural hematomato

A

period of lucidity followed by neurologic decompensation and coma

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17
Q

Do all epidural hemotomatos need surgical intervention

A

NO small ones can be observed

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18
Q

Where is a cerebral contusion/hemotomato located

A

In the brain parenchyma

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19
Q

Determinants of outcomes for cerebral contusion/hemotomato are

A

GCS, presence of hypoxia, hematomato volume

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20
Q

Interventions may include

A

Surgical evacuation, with or without craniotomy if elevated Intercarranial hypertension is present

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21
Q

Diffuse injuries are caused by

A

acceleration deceleration or rotational injuries

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22
Q

The best diagnostic tool for diffuse injuries is

A

MRI

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23
Q

Diffuse injuries are classified as

A

Mild- coma 6-24 hr, Moderate- >24 hrs without decerbrate posturing, Sever- > 24 hrs with decerbrate posturing or faccidity

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24
Q

CRNA goals are to prevent further ________ injuries

A

secondary

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25
Q

Contribution cerebral factors to secondary TBIs

A

Increased ICP, expanding mass leasions, hypercapnia, hypoxia, venous obstruction with positioning and C collar, hypotension causing compensatory cerebral vasodilation, hyperventilation, SZ, and vasospasm.

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26
Q

Contribution systemic factors to secondary TBIs

A

hypotension, hypoxia, anemia, hypoventilation, hyperglycemia, hyponatremia, hyperosmolar state, coagulapathy

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27
Q

Preferred method of intubation? nasal or oral

A

Oral

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28
Q

Drugs to facilitate Intubation

A

Propofol, Etomidate, Lidocaine 1.5 mg/kg, Sucs vs Roc (Roc you buy till you get a twitch) Keep FIO2 at 100%, PaCO2 low normal range

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29
Q

Goals for TBI ICP is a CPP of

A

60-70

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30
Q

Goals for MAP without ICP monitoring

A

MAP 70-80

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31
Q

While restoring intervascular volume with isotonic IVF can you use vasopressors

A

YES!!!!

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32
Q

Strong Indications for ICP monitoring

A

Sever head injury (GCS 40, motor posturing, SBP < 90

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33
Q

Possible indications of ICP monitoring

A

Head injury and unable to follow neuro exam due to ETT placement with deep sedation or immediate non-neurosurgical procedure

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34
Q

Ways to decrease ICP are

A

Decompression, elevate the HOB, Hyperventilation to reduce PaCO2, osmotic diuretic w a loop diuretic, use propofol and a minimum volatile agents

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35
Q

volatile agents lead to an increase or decrease in ICP

A

Increase due to increase CBF

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36
Q

Goals of Musculoskeletal Trauma Treatment

A

resuscitation, pain relief, improved stability and alignment, enhanced mobility, restoration of function

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37
Q

MS resuscitation what type of shock is the most common

A

Hypovolemic Shock

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38
Q

What type of MS trauma causes Hypovolemic shock

A

Long bone and Pelvic FX

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39
Q

Pain induced sympathetic discharge causes

A

hyper-inflamatory response and increased morbidity and mortality, Splinting causes impaired ventilation

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40
Q

Within 24 hr the following Fx should be stabilized

A

pelvis, femur, acetabulum fx

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41
Q

Early fixation by intramedulary nails, plates and external fixation devices reduce the following

A

Morbidity, ARDS, sepsis

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42
Q

Why are fractures definitively treated on a delayed basis

A

allows for swelling to decrease and improves wound healing

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43
Q

The following can be life threatening MS injuries

A

Multiple Fx, pelvic Fx, Femur Fx, and when assoc with massive hemorrhage

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44
Q

Average blood loss for a femur Fx

A

1500 mls

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45
Q

Blood loss for a pelvic Fx can range for what to what

A

3 to 10 L

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46
Q

75% of vascualr trauma are from what type of trauma

A

Penetrating

47
Q

Compartment Syndrome is

A

A rise in interstitial pressure in a closed osteofascial compartment, compromising capillaries and causeing tissue ischemia

48
Q

Compartment Syndrome causes

A

Fractures, sever soft tissue injury, arterial hemorrhage

49
Q

Compartment Syndrome occurs most commonly

A

lower legs and volar forearm

50
Q

Only treatmentf or Compartment Syndrome is

A

fasciotomy

51
Q

Urgent MS Problem requiring surgery in 6-8 hrs

A

Open fx, traumatic arthrotomy, dislocations, displaced femoral neck fx

52
Q

Preop considerations for Ortho trauma

A

Degree of urgency,Full stomach,Uncleared spines Positioning injuries, Hypothermia, Major blood loss, Tourniquet problems with injury to underlying nerves, muscle, blood vessels Fat embolism after long-bone fractures with delayed emergence, ARDS, cardiovascular collapse Deep venous thrombosis Compartmental syndrome Severe postoperative pain

53
Q

ETOH causes what in trauma Pt

A

vasodilation and inability to shiver, suppression of ADH, decreased airway reflexes and a decrease in MAC

54
Q

Cocaine in trauma Pt can cause

A

coronary spasms, Iso can cause arrhythmias, Precedex and versed are good choices for anesthesia

55
Q

Amphetamines in trauma Pts

A

Decrease MAC due to dopaminergic and serotonergic depletion

56
Q

Weed in trauma Pts

A

tachycardia and vasodilation may manifest as orthostatic hypotension, Antisialogogic properties may actual facilitate intubation Chronic use has no effect on MAC, Decreased MAC in users under the influence May lead to delayed awakening

57
Q

Fat emboli are identified inthe lungs what % of Skeletal trauma

A

90

58
Q

Fat embolism syndrome occurs in up to ____ of patients after long bone fracture

A

10

59
Q

S&S of a fat emboli

A

Respiratory insufficiency / Hypoxia / hypercapnia Petechial rash on conjunctiva, upper thorax, and axilla. Altered mental status Tachypnea / Tachycardia Pulmonary hypertension and right heart failure can occur. Cerebral edema Pulmonary edema Fat globules may appear in urine. May pass to systemic circulation through a patent foramen ovale

60
Q

Risk factor of a fat emboli

A

Delayed stabilization of Fx, manipulation of FX, male, age 10-40, muptiple Fx, intramedullary reaming

61
Q

Fat emboli Tx

A

supportive care measures, O2, maintain intravascular volume, inotropes PRN

62
Q

Differential Diagnosis of a Fat emboli

A

Pneumo, pulmonary contusion, aspiration, massive transfusion volume over load

63
Q

Transfusion related Lung Injury S&S

A

Occur 1-2 hours after transfusion Peak within 6 hours Hypoxia Fever Dyspnea Fluid in ETT possible Most recover in 96 hrs w supportive care

64
Q

Majority of trauma in pregnancy are R/T

A

2/3 MVC, falls, domestic violence and penetrating injuries

65
Q

Drugs and ETOH are indicated in what % of cases

A

20

66
Q

Best strategy to save the fetus is

A

save the MOM, DUHHHH!!!!

67
Q

cardiovascular changes in pregnance

A

↑Blood volume may ↑Cardiac output may ↓Blood pressure EKG changes Mimic myocardial ischemia or cardiac contusion ↓ Cardiac filling pressures Aortocaval compression

68
Q

Pulmonary Changes in pregnancy

A

↑Functional residual capacity may cause Rapid onset of hypoxemia Increased uptake of inhaled agents ↑Oxygen consumption Alveolar hyperventilation and respiratory alkalosis causes ↓ Buffering capacity

69
Q

GI changes in pregnancy

A

↓Gastric emptying causes ↑ Incidence of reflux and aspiration ↓Gastroesophageal sphincter tone Displacement of small intestine into the abdomen ↑ Risk of upper abdominal penetrating injuries

70
Q

hematologic changes

A

↓Hematocrit from Anemia, internal bleeding ↑White blood cells R/T Infection ↑ Coagulation factors Thromboembolic disease

71
Q

Most common injury is what type of injury

A

Blunt

72
Q

Most common cause of fetal death

A

placental abruption

73
Q

Loss of placental surface of ______% or more has a likelihood of fetal demise

A

50

74
Q

Pregnancy and Burns

A

Treat the same

75
Q

Cardiac Arrest in Pregos mainly from

A

PE, Eclampsia, Hemorrhage, trauma (head, Penetrating/blunt), Sepsis, MI, CHF, Amniotic Fluid embolism, and Iatrogenic (hyper magnesemia, failed airway, high spinal, local toxicity)

76
Q

After how many weeks should the goal be to save both mom and fetus??

A

24 weeks

77
Q

If initial resuscitation efforts are unsuccessful fetal delivery via C section should begin within how many min

A

5

78
Q

Complications of CPR in Pregnancy

A

Liver Lac, uterine rupture, hemothorax, Fetal: cardiac arrythmia/asystole, hypoxia, acidosis, neuro damage

79
Q

Pergo Airway managment, anatomical/physiologic changes

A

Mucosal edema, increased O2 requirment, Decreased FRC

80
Q

Prego airway difficulty in about how often

A

1:2500

81
Q

Anesthetic Managment goals in Prego trauma

A

Optimization of gas exchange Restoration of blood volume and tissue perfusion Protection of brain and spinal cord Maintenance of uteroplacental circulation and fetal oxygenation Prevention of maternal awareness Detection of unrecognized injuries Correction of coagulopathy Maintenance of normothermia Avoidance of teratogenic drugs (during the first trimester)

82
Q

Ways to improve placental perfusion

A

Left uterine displacement, raise maternal BP, Increase FiO2, Ensure surgical retraction is not a factor

83
Q

Volital agents should be used at less then what to avoid uterine relaxation and increased bleeding

A

1 MAC

84
Q

Avoid what inhaled anesthetic in pregos

A

N2O

85
Q

Ketamine > ___ /kg can increase uterine tone in 2nd trimester and decrease uterine perfusion / fetal oxygenation

A

2mg

86
Q

What drug will potentiate NMB that pregos get for Pre eclampsia and will cause hypotension in volume depleated Pts

A

Magnesium

87
Q

Terbutaline and ephedrine or atropine can cause

A

Ventricular ectopy

88
Q

Leading cause of Mortality and morbidity in Peds is

A

Pedi Trauma

89
Q

Anatomical differences with Peds

A

Large head, prominent occiput, Large epiglottis,

90
Q

Gen ETT sizes

A

Newborn 3-3.5 < 1 yr old 3.5-4 1 yr old 4-4.5 2 yrs old and older is 4 +age/4

91
Q

Reasons to intubate a Pedi

A

Loss of consciousness or altered level of consciousness with inability to protect the airway Inability to maintain patency of airway or clear secretions Provide positive pressure ventilation and adequate oxygenation Significant burn with airway injury.

92
Q

Abnormal breathing / ventilation may consist of

A

Irregular RR and pattern Stridor Grunting Nasal flaring Retractions Head bobbing Use of accessory muscles Paradoxical pattern (“rocking boat”) suggests airway obstruction

93
Q

In a Pedi the BP may not be effected until what % is lost

A

30-40

94
Q

Persistant tachycardia w narrowing pulse pressure may indicate

A

impending cardiavascular collapse

95
Q

Fluid resuscitation in a Pedi is

A

20ml/ kg of LR once or twice

96
Q

PRBC resuscitation in a Pedi is

A

10-20 ml/kg in increments

97
Q

Signs of adequate volume resuscitation

A

Normal BP Pulse pressure > 20 mm/hg Pulse rate and col

98
Q

Succinylcholine in Peds

A

Large volume of distribution incareses dose to 2-3 mg/kg May cause bradycardia, junctional, or sinus arrest.

99
Q

Dose for atropine if a parasympathetic response occurs in infants 6 mths of less

A

10 mcg/kg

100
Q

Pediatric VItal Normal Values

A
101
Q

NDNMB Roc dose for peds is

A

0.9 to 1.2 mg/kg for Rapid conditions

102
Q

Avoid N20 in Pedi Traumas due to

A

Unknown pneumothorax, air embolism or pneumocephalus

103
Q

Pedi Hct levels

A

Normal Acceptable

Premature 40–45 35–40

Newborn 45–65 35–40

3 months 30–42 25

1 year 34–42 20–25

6 years 35–43 20–25

104
Q

Effects of Hypothermia in Peds

A

Increased oxygen consumption

Left shift of oxyhemoglobin dissociation curve

Coagulopathy with prolonged bleeding

Metabolic and lactic acidosis, hypoglycemia

Apnea

Depressed myocardial contractility, arrhythmias

Impaired drug metabolism, delayed emergence from anesthesia

Increased mortality!

105
Q

Elderly Cardiovascular Changes

A

Decreased connective tissue compliance and distensibilty

Arteries, especially aorta, becomes stiff and non-compliant

Chromic increase in afterload

Concentric LVH and decline in diastolic compliance

Maximum aerobic capacity decreases with age

106
Q

Elderly Pulmonary Changes

A

Predisposition to perioperative pulmonary problems

Primary cause of morbidity and mortality

Decreased strength of respiratory muscles

Progressive loss of alveolar surface area

Impaired nervous control of ventilation

Reduction in elastic recoil of chest wall

Dangerous predisposition to hypoxemia in the elderly trauma patient

Arterial oxygenation is impaired

Age related V/Q mismatch

80% can have marked atelectasis after induction

Tendency for upper airway collapse

Hypercapnic and hypoxic respiratory drives are impaired

Decrease in airway protective reflexes

Denitrogenation takes longer

Tracheal intubation unchanged

107
Q

Propofol

A

Induction dose reduced by 20% (slower induction requires lower doses) (20-year-old: 2.0–3.0 mg/kg IV; ↓ Central volume of distribution; ↓ intercompartmental clearance

80-year-old: 1.7 mg/kg IV or less). Maintenance dose: same requirements 120 min after starting a continuous infusion.

108
Q

Midazolam

A

↑ Sensitivity of the brain ↓ Clearance

Sedation/induction dose reduced by 50% (20-year-old: 0.07–0.15 mg/kg IV; 80-year-old: 0.02–0.03 mg/kg IV). Maintenance dose reduced by 25%. Recovery: delayed (hours)

109
Q

Etomidate

A

Central clearance; ↓ volume of distribution oInduction dose reduced by 20% (20-year-old: 0.3 mg/kg IV; 80-year-old: 0.2 mg/kg IV).

110
Q

Ketamine

A

Use with caution: hallucinations, seizures, mental disturbance, release of catecholamines; avoid in combination with levodopa (tachycardia, arterial hypertension)

111
Q

Opoids

A

Fentanyl, alfentanil, sufentanil •↑ Sensitivity of the brain •Induction dose reduced by 50%. Maintenance doses reduced by 30–50%. Emergence: may be delayed

Remifentanil •↑ Sensitivity of the brain; ↓ Central volume of distribution; ↓ intercompartmental clearance •Induction dose reduced by 50%. Maintenance dose reduced by 70%. Emergence: may be delayed

112
Q

Muscle Relaxants

A

Succinylcholine •↓ Plasma cholinesterase; ↓ muscle blood flow; ↓ cardiac output; ↓ intercompartmental clearance •↓ Onset time. ↓ Maintenance dose requirements. Duration of action clinically indistinguishable from mivacurium. Differences: no changes in initial dose. •prolonged block with metoclopramide

Pancuronium,vecuronium,rocuronium •↓ Muscle blood flow; ↓ cardiac output; ↓ intercompartmental clearance; ↓ clearance; (volume of distribution) •↓ Onset time. ↓ Maintenance dose requirements. ↑Duration of action. Recommended dose reduced by 20%.

113
Q

Neostigmine

A

↓ Clearance; ↑ Duration of action; because muscle relaxants have a markedly prolonged duration of action, larger doses of reversal agents are needed in elderly patients

114
Q

Local Anesthetics

A

↑ Sensitivity of the nervous tissue (?)

↓ Hepatic microsomal metabolism of amide local anesthetics (lidocaine, bupivacaine);

↓ plasma protein binding;

↑ cephalad spread

↓ Epidural (and spinal) dose requirements. Duration of spinal and epidural anesthesia seems clinically independent of age

Principles IV (19 decks)

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