Acute Care & Trauma Flashcards
(43 cards)
Acute respiratory distress syndrome
Non-cardiogenic pulmonary oedema and diffuse lung inflammation syndrome that often complicates critical illness.
The diagnosis of ARDS is based on fulfilling 3 criteria: acute onset (within 1 week), bilateral opacities on CXR, and a PaO2/FiO2 (inspired oxygen) ratio of ≤300 on PEEP or CPAP ≥5 cm H2O.
ARDS: Complications
death ventilator-associated pneumonia multiple organ failure pneumothorax persistent dyspnoea abnormal lung function reduced quality of life
ARDS: Management plan
ABCDE
low tidal volume ventilation
supportive care
strategies to optimise ventilation
if septic/pneumonia - antibiotic therapy
Aspirin overdose: symptoms
nausea, vomiting, haematemesis, epigastric pain
fever and diaphoresis
shortness of breath
tachypnoea, hyperpnoea, Kussmaul’s respirations
tinnitus and/or deafness
malaise and/or dizziness
movement disorders, asterixis, stupor
confusion and/or delirium (irritability, hallucinations)
coma and/or papilloedema
seizures
Aspirin overdose: complications and prognosis
ADRS, CA, Seizures, Hepatitis
Serum salicylate levels >80 mg/dL in adults and >70 mg/dL in children or older people indicate severe poisoning and increased likelihood of fatal ingestion.
Patients with chronic salicylism and levels 40 to 60 mg/dL can be severely ill and at risk of death.
Non-fatal salicylate poisoning is associated with a full recovery
Aspirin overdose: Rx
ABCDE
ICU admission + supportive care
serum and urinary alkalinisation (sodium bicarbonate: consult local hospital protocol for guidance)
GI tract decontamination (activated charcoal: children: 1 g/kg orally as a single dose)
emergency haemodialysis
Burns injury
First-degree burns:
- Erythema involving the epidermis only
- Usually dry and painful
- Typical of severe sunburn.
Second-degree burns:
- Superficial partial-thickness burns involving the epidermis and upper dermis
- Deep partial-thickness burns involving the epidermis and dermis
- Usually wet and painful
- Typical of scalding injury.
Third-degree burns:
• Full-thickness burns involving the epidermis and dermis and damage to appendages
• Usually dry and insensate
• Typical of flame or contact injury.
Fourth-degree burns:
• Involve underlying subcutaneous tissue, tendon, or bone
• Typical of high-voltage electrical injury.
Burns injury: Rx
ABCDE
assessment for admission to a burn centre
fluid resuscitation
supplemental oxygen and supportive care
tetanus immunisation
surgery
DVT prophylaxis
intravenous opioid plus benzodiazepine ± non-pharmacological therapy
with suspected wound infection - antibiotics ± surgical excision
outpatient - wound cleaning and topical antibiotic prophylaxis
Central venous cannulation: Indications
CVC is a cannula placed in a central vein (e.g. subclavian, internal jugular or femoral)
IV access (especially if difficult peripheral access)
CVP monitoring
ScvO2 monitoring/sampling
Infusions of irritant substances (e.g. vasoactive agents, chemotherapy or TPN administration)
Renal replacement therapy,
Transvenous pacing
Central venous cannulation: Complications
Immediate
pneumothorax (highest for SCV) failure to locate vein accidental arterial puncture haemothorax haematoma arrhythmia thoracic duct injury guide wire embolus air embolus
Early
haemopericardium and tamponade pneumothorax catheter blockage chylothorax catheter knots Late
infection (no difference in the rate of catheter-related bloodstream infections between the IJ, SC and Femoral sites -> 2.5 infections/ 1000 catheter days) catheter fracture vascular erosion vessel stenosis thrombosis osteomyelitis of clavicle
Central venous cannulation: CI
coagulopathy
respiratory failure
raised ICP (cannot tilt head down)
-> can use femoral approach in all the situations above
obstructed vein (e.g. thrombus, or tumour)
overlying skin infection, burn or other disease process
hemorrhage from target vessel
uncooperative patient
Extradural haemorrhage
(biconvex shape hemorrhage).collection of blood in the potential space between the dura and the bone - can occur in the spinal column.
There is usually a history of trauma and head injury esp to pterion and middle meningeal art that causes loss of consciousness.
Classically, this is followed by a lucid interval after which the patient deteriorates (in less than a third of cases).
EDH in the posterior fossa can produce a very rapid deterioration to death, measured in minutes.
Always remember may also have a traumatic cervical spine injury.
Extradural haemorrhage: Rx
ABCDE (ATLS)
Raised ICP IV mannitol/Hypertonic
If ventilation is required, hyperventilation, with elevation of the head of the bed to 30°, will help further but excessive hypocapnia should be avoided, as it causes cerebral vasoconstriction.
Burr holes may be required to evacuate a haematoma.
other injuries that also need attention and priorities must be set.
Anticoagulation in the presence of EDH has potential danger and TED® stockings alone may be safer. It is a difficult balance.
Extradural haemorrhage: Complications + Prognosis
Neurological deficits can be temporary or permanent. Death may occur.
Post-traumatic seizures due to cortical damage may develop 1 to 3 months after the injury
Prognosis in children is excellent.
The overall mortality rate is about 30%. Those who are alert on admission rarely die but a low GCS worsens the prognosis.
Traumatic brain injury, acute
Head injury is defined as any trauma to the head, with or without injury to the brain.
Traumatic brain injury (TBI) is a non-specific term describing blunt, penetrating, or blast injuries to the brain
Mild/Minor TBI: GCS 13-15; mortality 0.1%
Moderate TBI: GCS 9-12; mortality 10%
Severe TBI: GCS <9; mortality 40%.
Traumatic brain injury, acute: Red flags
Skull fracture (excl. base of skull) Base of skull fracture Cerebral contusion Intracerebral haemorrhage (ICH) Subdural haematoma (SDH) Epidural haematoma (EDH) Intraventricular haemorrhage (IVH) Traumatic subarachnoid haemorrhage (SAH) Penetrating injuries Diffuse axonal injury (DAI)
Traumatic brain injury, acute: Rx
ABCDE (ATLS)
Adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
- GCS less than 13 on initial assessment in the emergency department.
- GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture
- Post-traumatic seizure.
- Focal neurological deficit.
- More than 1 episode of vomiting.
Assessing range of movement in the neck only if safe to do so
Traumatic brain injury: Admission
New, clinically significant abnormalities on imaging.
Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results.
When a patient has indications for CT scanning but this cannot be done within the appropriate period.
Continuing worrying signs
Perform and record observations on a half-hourly basis until GCS equal to 15
• Half-hourly for 2 hours.
• Then 1-hourly for 4 hours.
• Then 2-hourly thereafter
Traumatic brain injury: Complications and prognosis
- Amnesia: common, and may be retrograde and/or antegrade.
- Raised intracranial pressure, cerebral oedema.
- Cerebral herniation.
- CSF leak
- Meningitis:
- Intracranial haemorrhage:
- Extracranial haemorrhage:
- Skull fractures: up to 50%
- Diffuse axonal injury.
- Penetrating injuries - eg, gunshot wounds. There is a high incidence of infection and mortality.
- Seizures: more common following penetrating injury
- Concussion: symptoms of amnesia and confusion.
- Late complications of head injury include chronic daily headache, post-traumatic stress disorder, vertigo and cognitive impairment.[20
- Head injury is the leading cause of death in people aged 1-40 years
- Death rates are estimated at 0.2% of all patients who attend A&E
- Survival with moderate or severe disability has been reported as common after mild (GCS 13-15) head injury.
Intubation and Mechanical Ventilation Indications
Intubation describes the use of an intubation tube (also called an endotracheal tube) to get air into your throat and lungs.
Mechanical ventilation refers to the ventilating machine that pumps the air.
A – protection and patency
B – respiratory failure (hypercapnic or hypoxic), increase FRC, decrease WOB, secretion management/ pulmonary toilet, to facilitate bronchoscopy
C – minimise oxygen consumption and optimize oxygen delivery (e.g. sepsis)
D – unresponsive to pain, terminate seizure, prevent secondary brain injury
E — temperature control (e.g. serotonin syndrome)
Other — safety for transport (e.g. psychosis), humanitarian reasons
Intubation and Mechanical Ventilation: Complications
Complications are rare, but may include:
Damage to teeth, lips or tongue
Damage to trachea (windpipe), resulting in pain, hoarseness and sometimes difficulty breathing after tube removal
Esophageal intubation (when the tube is accidentally inserted into the esophagus and stomach rather than the trachea)
Low blood pressure
Pneumonia
Lung injury
Infection
Some factors that may increase the risk of complications include:
Smoking Neck or cervical spine injury Pre-existing lung disease (such as emphysema) Poor condition of teeth Recent meal Dehydration
Multiorgan dysfunction syndrome
- MODS is a hypometabolic, immunodepressed state with clinical and biochemical evidence of decreased functioning of the body’s organ systems that develops subsequent to an acute injury or illness.
- MODS contributes to about 50% of ICU deaths
- Severity may be quantified using scoring systems such as the MODS score or the SOFA score
- Organ recovery is frequently the rule in surviving patients without pre-existing organ disease
- It remains unclear what triggers MODS or why it only seems to occur in certain patients
Multiorgan dysfunction syndrome: Rx
Early recognition is important
Resuscitation
- aggressive early therapy
- manage in an ICU setting following initial resuscitation
Specific therapies
• recognition and early control of inflammatory foci
unclear role for glucocorticoids
• unclear role for thyroxine supplementation
Supportive care and monitoring
• multi-organ supports
• glucose control (e.g. BSL 6-10 mmol/L)
• nutrition (preferably enteric; uncertain targets, composition of macronutrients or role for supplements)
• avoid fluid overload
Seek and treat underlying cause, comorbidities, and complications
Multiorgan dysfunction syndrome: Complications and prognosis
Mortality 60-98% if 3 or more organ failures for >1 week (varies with age)
Circulatory failure is the most important predictor of poor outcome
SOFA ( Sepsis-related Organ Failure Assessment) score at day 6 is more predictive of Day 7 mortality than SOFA score on admission
About 50% of people with MODS will not return to work or normal function at 1 year follow-up
