Basics

Question 1

What is the distribution of mortality from trauma?

Answer 1

Trimodal

1) Immediate (50% of all deaths)
- Massive brain injuries
- Great vessel injuries
- Airway occlusion
- Cord transection
- Exanguination

2) Early (30% of all deaths) - minutes to hours “golden hour”
- Uncontrolled blood loss
- 2ndry CNS damage

3) Late Phase (20%) - days to weeks
- Sepsis
- MODS

Question 2

In deceleration injuries, which structures are at risk of being avulsed from the site at which they are anchored?

Answer 2

1) C - spine
2) Brain
3) Main Bronchus
4) Thoracic Aorta
5) Renal vessels
6) Transverse Mesocolon

Question 3

What is a crush injury?

Answer 3

Injury + sustained compression of tissues

causing ischaemia & muscle necrosis

Question 4

What are the complications of crush injuries?

Answer 4

1) Fluid loss
2) Rhabdomyolysis - myoglobin release from muscles
3) DIC
4) Release of toxins from muscles
5) Acute tubular necrosis
6) Renal failure

Question 5

In trauma, which type of shock is the cause of the hypotension (until proven otherwise)?

Answer 5

Hypovolaemia

Question 6

Cellular destruction in hypovolaemic shock, what changes does the acidosis cause?

Answer 6

1) Disruption of Na+/K+ pump

Na+ accumulates => cell swells => intercellular spaces enlarge => fluid 3rd spacing => disruption of organ integrity

Question 7

How do you calculate cardiac output?

Answer 7

CO = SV x HR (normal is 6L/min)

Question 8

How do you calculate SBP?

Answer 8

SBP = DBP + PP

Question 9

In Hypovolaemic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

Answer 9

1) HR - Increased
2) CVP/PAOP - Decreased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

Question 10

In Cardiogenic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

Answer 10

1) HR - Increased
2) CVP/PAOP - Increased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

Question 11

In Septic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

Answer 11

1) HR - Increased
2) CVP/PAOP - Decreased
3) CO - Increased
4) SV - Decreased
5) SVR - Decreased

Question 12

In cardiac tamponade shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

Answer 12

1) HR - Increased
2) CVP/PAOP - VERY Increased
3) CO - Decreased
4) SV - Decreased
5) SVR - Increased

Question 13

In neurogenic shock, what is seen in the following parameters?

1) HR
2) CVP/PAOP
3) CO
4) SV
5) SVR

Answer 13

1) HR - Decreased
2) CVP/PAOP - -
3) CO - Decreased
4) SV - -
5) SVR - Decreased

Question 14

What are the main features of class 1 shock?

Answer 14

Volume loss 0-750mls
15% loss
Restless
BE 0 - -2

Question 15

What are the main features of class 2 shock?

Answer 15

Volume loss 750-1500mls
15-30% loss
HR> 100
Pulse Pressure Decreased
Urine 20-30mls/h
RR 20-30
Anxious
BE -2 - -6

Question 16

What are the main features of class 3 shock?

Answer 16

Volume loss 1500-2000mls
30-40% loss
HR> 120
BP Decreased
Pulse pressure Decreased
Urine 5 - 15ml/h
RR 30-40
Anxious/Confused
BE -6 - -10
Must give BLOOD

Question 17

What are the main features of class 4 shock?

Answer 17

Volume loss >2000mls
>40% loss
HR> 140
BP Decreased
Pulse Pressure Decreased
Urine Anuric
RR >40
Confused/Lethargic
BE > -10
Must give BLOOD

Question 18

What is the immediate management of hypovolaemic shock?

Answer 18

Control bleeding

1) Direct Pressure
2) Elevation of injured limb
3) Head down tilt

Establish IV access - 2 16-gauge cannulas

1) Forearm antecubital veins
2) Cut down to Great Sapehnous vein
3) IO Access for <6yrs kids
* CENTRAL ACCESS ONLY WHEN STABLE*

Fluid replacement & identify cause for hypovolaemia

Question 19

Which situations may CVP be falsely raised?

Answer 19

1) Tension penumothorax
2) Pericardial Effusion
3) Air embolus
4) MI

Question 20

Which situations can physiological responses be distorted?

Answer 20

B Blockers
Opiates
IHD
Pacemakers
Pre-hospital fluid resus
Pneumatic anti-shock garments
Spinal Injury
Head injury

Question 21

What are transient responders?

Answer 21

Given fluid bolus and immediately improves => then deteriotates
THINK ONGOING BLOOD LOSS

Question 22

Which of the following parameters can you measure patient response to successful fluid resusitation?

Answer 22

1) Pulse
2) BP
3) Skin colour
4) CNS state

Question 23

What metabolic changes are seen initially in hypovolaemic shock?

Answer 23

Respiratory alkalosis - due to high RR

Question 24

What metabolic changes are seen later on in hypovolaemic shock?

Answer 24

Metabolic acidosis - uncompensated tissue hypoperfusion/insufficient fluid replacement => anaerobic metabolism

On VBG:

• lower pH
• progressive base deficit
• low bicarbonate

Question 25

What spaces can major blood loss be found?

Answer 25

1) Chest 2) Abdo 3) Pelvis - use pelvic binder 4) Long bones - use splint 5) On the floor

Question 26

What causes neurogenic shock?

Answer 26

Injury to descending sympathetic pathways (T2-T6 for heart) Loss of vasomotor tone with pooling in veins Inability to go into tachycardia Treat this with selective ionotropes & atropine

Question 27

What is the endocrine response to trauma?

Answer 27

Stimulates Ascending reticular formation & limbic system => stimulates Hypothylamus => Anterior Pituitary => ACTH, GH, Prolactin Posterior Pituitary => ADH ACTH => Cortisol & Aldosterone

Question 28

What is the immunological response to trauma?

Answer 28

1) Raised Temp 2) Raised WCC 3) Raised IgG

Question 29

Why is there a lucid interval in younger people in extradural bleeds?

Answer 29

Expanding haematoma is being accomodated in extradural bleeds

Question 30

Why is there a rapid decompensation in young people after lucid interval?

Answer 30

ICP rises as the inner edge of temporal lobe descends into tentorial opening

Question 31

Extradural haematomas are limited by what structure in the skull?

Answer 31

Suture lines

Question 32

What is normal ICP?

Answer 32

10mmHg

Question 33

What is abnormal ICP?

Answer 33

>20mmHg

Question 34

In the situation of raised ICP, why does muscle weakness manifest?

Answer 34

corticospinal tract decompression

Question 35

What is Cushings Triad?

Answer 35

1) Decreased RR 2) Decreased HR 3) Widened Pulse Pressure - high systolic & low diastolic

Question 36

How do you measure cerebral perfusion pressure?

Answer 36

CCP = MAP - ICP

Question 37

Increased cerebral blood flow is caused by?

Answer 37

1) Raised CO2 2) Raised extracellular K+ 3) Decreased pO2

Question 38

How do you calculate MAP?

Answer 38

(systolic + 2(diastolic))/3

Question 39

How to manage raised ICP (non-surgical management)?

Answer 39

1) Maintain normal PCO2 (3.5-4.0) 2) Monitor with ICP bolt & transducer 3) Aim to maintain CPP at 60-70mmHg (fluids/ionotropes) 4) Maintain ICP of 10mmHg with a) Mannitol b) Hyperventilation to PCO2 4.5kPa c) Thiopental infusion d) Hypothermia 5) Emergency burr holes / craniotomy