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Principle's D > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What did the Uniformed Anatomical Gift Act in 1968 grant individuals the right to do?

A

To decide before death whether they wished to donate organs

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2
Q

What did the Organ Transplantation Act of 1984 establish?

A

Organ procurement networks; outlawed buying and selling of organs or compensation to donor families

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3
Q

Omnibus Reconciliation Act of 1986 required hospitals with Medicare/Medicaid patients to do what?

A

Required them to ask families about organ donation

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4
Q

List the 5 organ transplant criteria

A
  1. Organ type, blood type and organ size
  2. Distance from organ to patient
  3. Level of medical urgency
  4. Time on waiting list
  5. Typically <55 years of age
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5
Q

Where is an organ first offered?

A

To local OPO

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6
Q

What specific test(s) are required of kidney transplant recipients?

A

antigen tests

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7
Q

What specific test(s) are required for liver transplant recipients?

A

MELD scores which include biliruben, INR and creatinine; This tells us the severity of disease

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8
Q

What specific test(s) are required for lung/heart transplant recipients?

A

Pulmonary artery pressure b/c high pressures can affect the new organ and cause disease to develop in the transplanted organ

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9
Q

Which type of patients provide approximately 80% of donated organs?

A

Brain dead patients

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10
Q

6 leading causes of brain death

A
  1. Trauma
  2. Cerebral ischemia/infarction
  3. Hemorrhage
  4. Meningitis
  5. Encephalitis
  6. Cocaine, lead, organophosphates
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11
Q

List 5 criteria for brain death

A
  1. Irreversible coma
  2. No brain stem function
  3. Absence of respiratory drive
  4. 1 physician is required; 2 may be requested by the family
  5. Must be in the absence of hypothermia and CNS depressants
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12
Q

What is considered as no brain stem function when evaluating a patient for brain death?

A
  1. No pupillary reflexes
  2. No corneal reflexes
  3. Absence of gag and cough reflexes
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13
Q

What does Phase 1 of Cardiac Instability for organ donors involve?

A

Massive release of catecholamines caused by increased ICP and is transient. Tachycardia, HTN, Incr. SVR and O2 consumption.

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14
Q

What is a common disease process seen in Phase 1 of Cardiac instability for organ donors?

A

Acute myocardial injury

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15
Q

What does Phase 2 of Cardiac instability for organ donors involve?

A

Cardiovascular collapse caused by cerebral herniation/spinal cord ischemia that is sustained. Loss of vascular tone, peripheral resistance, and cardiac output.

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16
Q

Why does volume depletion occur during Phase 2 of cardiac instability in organ donors?

A

Diuretics or diabetes insipidus

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17
Q

In organ donors, pulmonary instability can be related to what 3 things?

A
  1. Direct trauma
  2. Neurogenic pulmonary edema
  3. V/Q mismatches
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18
Q

What causes neurogenic pulmonary edema in organ donors?

A
  1. Catecholamine surge in phase 1 cardiac instability
  2. Elevated hydrostatic pressure leads to pulmonary capillary leakage
  3. Systemic inflammatory response due to neutrophil infiltration
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19
Q

What is metabolic instability in organ donors due to?

A

Dysfunction of hypothalamus and pituitary gland in up to 90% of donors

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20
Q

Loss of thermoregulation in organ donors leads to what?

A

Hyperpyrexia and then hypothermia

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21
Q

Why does dysfunction of the hypothalamus and pituitary gland in organ donors lead to metabolic instability? (5)

A
  1. Loss of thermoregulation
  2. Decreased ACTH, cortisol, T3, T4, vasopressin
  3. Decreased insulin concentration and insulin resistance
  4. Electrolyte abnormalities
  5. DIC in up to 33% of patients due to release of tissue thromboplastin from the brain
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22
Q

Describe the anesthetic steps for organ retrieval (10)

A
  1. Patient is supine
  2. Incision from sternal notch to pubis
  3. 100% O2 unless lungs are retrieved
  4. Ao and IVC dissected 1st, have a large line ready
  5. Liver, pancreas, and kidneys dissected
  6. Betadine/Amphotericin B via NGT in divided doses
  7. 30k units of heparin
  8. Organs are perfused with cold solution
  9. Ao x-clamped when everything is ready to remove the heart
  10. Ventilator d/c along with all of the monitors
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23
Q

Anesthesia for organ retrieval calls for __ and not __ until retrieval

A

Anesthesia for organ retrieval calls for stabilization and not anesthetic until retrieval.

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24
Q

Why is there significant bradycardia that does not respond to anticholinergics in organ donors and what do we treat it with.

A

Cardiac instability leads to no response to anticholinergics, so we use isuprel, a pure B1 agonist

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25
Q

What drug that we use daily reduces reperfusion injury in organ donation?

A

Volatiles

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26
Q

Why do we avoid glucose containing solutions in organ donation surgery?

A

The glucose is metabolized into a hypotonic solution which will cause cells to swell

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27
Q

What is the best vent setting for organ donation procedures?

A

PEEP/Lung protective strategies such a low Vt

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28
Q

Why do we use steroids in organ donation procedures?

A

To reduce the immune response in the recipient

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29
Q

Tell me the normal parameters for: CVP, MAP, PaO2, pH, UO, Na, Glucose, EF, Hgb and Pressors for donor organ management goals

A
  • CVP: 4-10 (6-8 for lungs)
  • MAP: 60-120 mmHg
  • PaO2: >300 on 5cm PEEP/100% O2
  • ABG pH: 7.3-7.45
  • UO: >1mL/kg/hr
  • Na: 135-160
  • Glucose: <150
  • EF: >50%
  • Hgb: >10
  • Pressors: 1 and low dose
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30
Q

What temp do we want to maintain for organ donors?

A

34-35C

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31
Q

What type of muscle relaxants do we use for organ donation?

A

Long acting such as pavulon or roc

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32
Q

Which volatile do we use if a patient is hypertensive from surgical stimulation?

A

Iso

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33
Q

Do we treat cardiac arrest in organ donors?

A

Yes

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34
Q

What is DCD doantion?

A

Donation after cardiac death - patient is not brain dead, but no hope of recovery; patient will require ventilator and full support

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35
Q

With DCD patients, what 2 criteria is withdrawal of support based on?

A
  1. Clinical decision of futility

2. Wishes of patient/family

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36
Q

Who is not involved in the decision to withdraw support of a DCD patient?

A

The transplant team

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37
Q

Describe category 1 DCD patients

A

Patients DOA to hospital

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38
Q

Describe category 2 DCD patients

A

Unsuccessfully resuscitated patients on admit to the hospital

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39
Q

Describe category 3 DCD patients

A

Cardiac arrest is imminent - these are the most appropriate patients for donation due to decreased ischemic times

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40
Q

Describe category 4 DCD patients

A

Cardiac arrest has occurred in a brain dead donor; this leads to poor perfusion of the organs

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41
Q

Describe category 5 DCD patients

A

Unexpected arrest in the ICU

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42
Q

Which DCD category of patients are considered for donation due to being more controlled?

A

3 and 4

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43
Q

6 steps of DCD

A
  1. Patient moved to OR with 100% O2 and removed from ventilator with an independent physician
  2. Heparin administered @ 30k units
  3. When heart stops, independent physician declares death
  4. At 2-5 minute mark, post declaration of death, the transplant surgeon begins retrieval
  5. Usually retrieve only the kidney and liver in these patients
  6. If no cardiac arrest after 1 hour, patient is moved out of the OR and no donation occurs
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44
Q

When using criteria to predict cardiac death of DCD patients, a higher or lower number is indicative of a patient who will most likely arrest faster?

A

Higher number

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45
Q

What occurs during the ischemic phase of organs after they are harvested and preserved at 4 degrees C

A

Lack of oxygen leads to depletion of ATP/glycogen, which leads to failure of the Na/K pump, resulting in increased intracellular sodium and edema

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46
Q

What occurs during the reperfusion phase of organs after retrieval?

A

Autoimmune activation leads to cellular migration and hyperkalemia if Wisconsin solution is used. Injury to the organ is decreased if preconditioned with volatiles.

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47
Q

What are the ischemic times for heart/lung, liver, and kidneys?

A
  • Heart/lung: 4-6 hours
  • Liver: 12-24 hours
  • Kidneys: 48-72 hours
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48
Q

What time frame does ischemic time include for organ donation?

A

Ischemic time is the time from organ retrieval from the donor body to reperfusion being reestablished.

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49
Q

What lab is a must have on the day of organ donation for kidneys?

A

K+

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50
Q

What 2 diseases are most common in kidney donors?

A

40% have CAD: Most have HTN

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51
Q

What is the emergence plan for kidney transplant recipients?

A

Extubate on the table, admitted to ICU and then D/C home the next day

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52
Q

Can you use anectin with kidney transplant recipients?

A

Yes if K+ levels appropriate

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53
Q

What animal are the antibodies used against Human T cells to prevent/treat acute rejection of kidney transplants from?

A

Rabbit-derived

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54
Q

What are the signs of cytokine release syndrome post kidney transplant and how do we treat it?

A

High grade fevers (over 39C), chills and possibly rigors.

Treated with steroids (methylprednisolone), benadryl 25-50mg, and acetaminophen 650 mg

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55
Q

Pre-op eval considerations for pancreas transplant recipients

A
  1. Most have Type 1 diabetes and ESRD (80% are transplanted with a kidney)
  2. Consider gastroparesis (RSI)
  3. Antithymocytes commonly used (rabbit-derived antigen)
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56
Q

Which paralytic should we consider using for induction and then maintenance for pancreas transplant recipients?

A

Anectine for induction and Cisatracurium for maint. d/t hoffman elimination

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57
Q

How should the A-line be placed for organ transplant recipients?

A

Sterile!!!

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58
Q

Why do we not treat the blood sugar in pancreas transplant recipients?

A

As soon as the organ has reperfusion, it should start working properly and secrete insulin

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59
Q

What is the emergence plan for pancreas transplant recipients?

A

Extubation on the table

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60
Q

Advantages of living organ donors (4)

A
  1. Eliminates cultural challenges
  2. Organizes time to decrease cold ischemic time
  3. No physiologic alterations from DBD or DCD
  4. Waiting times are avoided
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61
Q

Requirements of living organ donors (3)

A
  1. Healthy
  2. 2 kidneys
  3. No DM, HIV, liver disease or cancer
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62
Q

Which kidney is preferred from living organ donors?

A

Left kidney d/t longer vascular supply

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63
Q

What is the crystalloid hydration goal for living organ donors? Urine output?

A

Crystalloid - 10-20mL/kg/hr

UO - 2mL/kg/hr (considers lasix or mannitol)

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64
Q

When do we heparinize living organ donors during surgery?

A

Prior to ligation

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65
Q

What does lower insufflation pressure during nephrectomy for kidney transplant help with?

A

Helps minimize blunt trauma to the kidneys

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66
Q

What two disease processes do transplant patients having non transplant surgeries usually have?

A

Diabetes and CAD

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67
Q

List 4 big side effects of immunosuppressants in transplant patients having non-transplant surgeries?

A
  1. Lowered seizure threshold
  2. Systemic HTN
  3. Anemia
  4. Thrombocytopenia
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68
Q

What do we expect in regards to bleeding with transplant patients having non-transplant surgeries?

A

Higher blood loss due to adhesions, especially belly cases

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69
Q

What do we have to remember for heart transplant patients having non-transplant surgeries?

A

There is no PNS control, so they will not respond to anticholinergics and will be tachycardic at baseline

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70
Q

What can we expect of kidney function in transplant patients having non-transplant surgeries?

A

Lower GFR/renal blood flow = drug excretion times prolonged

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71
Q

3 common causes of kidney transplant failure

A
  1. Primary non-function
  2. Acute thrombosis
  3. Acute/chronic rejection with pain
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72
Q

A patient presents with a non-functioning kidney post transplant, but does not report pain, what do you expect for surgical intervention?

A

Patient will most likely not have the kidney removed and will not need surgical intervention

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73
Q

Risk factors for head and neck cancers

A
  1. Men > female
  2. Older than 50
  3. History of excessive alcohol use and cigarette smoking (>97%)
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74
Q

Common sites of metastases for head and neck cancers (3)

A
  1. Lung
  2. Liver
  3. Bone
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75
Q

4 common symptoms of head and neck cancers

A
  1. Hoarseness
  2. Stridor
  3. Hemoptysis
  4. Sore that do not go away
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76
Q

What is the normal procedure used when head and neck cancers are suspected

A

Panendoscopy (Esophagoscopy, bronchoscopy, laryngoscopy)

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77
Q

Where do head and neck cancers start on a cellular level

A

Begins in squamous cells that line moist, mucosal surfaces inside mouth, the nose and the throat

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78
Q

What is the TNM system

A 
Tumor size (T)
Lymph node involvement (N)
Distant metastases (M)
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79
Q

What is metastases related to?

A

Lymphatic availability

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80
Q

4 preop labs that we look at for head and neck cancers and why

A
  1. CBC - bone marrow metastases or chemo can causes altered levels of certain blood components
  2. Hypercalcemia - r/t bony metastasis
  3. Elevated LFT’s - r/t alcohol-induced liver disease
  4. Serum albumin - r/t nutritional status and protein binding ability, most likely will be low
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81
Q

3 effects of pre-operative chemo

A
  1. Decreases bulk of primary tumor
  2. Eradicates occult micro-metastasis
  3. Damages bone marrow
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82
Q

What is the most important part of your preoperative airway assessment for patients with head and neck tumors

A

Can the patient be easily ventilated with a mask and intubated with directed laryngoscopy

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83
Q

Pre-op Anesthesia considerations for patients with head and neck cancers (5)

A
  1. Sedatives contraindicated in significant airway obstructions d/t possible losing airway before we are ready
  2. Position of comfort in pre-op
  3. Glyco is helpful
  4. Airway blocks are useful
  5. SCIP antibiotics for all oral/pharyngeal procedures
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84
Q

Glossopharyngeal nerve anatomy

A

Mixed nerve with 6 sensory branches

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85
Q

6 sensory branches of the glossopharyngeal nerve

A
  1. Tympanic: innervate TM
  2. Carotid: innervates carotid sinus and sinus body
  3. Pharyngeal: sensation from pharynx
  4. Muscular: Branches of the tongue
  5. Tonsillar: sensation from tonsils and soft palate
  6. Lingual: innervates epiglottis, posterior 1/3 of tongue and vallecula (this is what we want to block)
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86
Q

Describe the glossopharyngeal nerve block (3)

A
  1. Between internal jugular and internal carotid
  2. Blockade of CN X, XI, XII in addition to CN IX
  3. Spinal needle 0.5cm in, 3-5mL LA injected bilaterally at the tonsillar pillars
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87
Q

Superior laryngeal nerve anatomy (4)

A
  1. Branch of CNX
  2. Internal branch: sensory innervation to larynx, posterior epiglottis, arytenoids
  3. External branch: innervates cricothyroid, which adducts the VC
  4. Found inferior to greater horn of hyoid
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88
Q

Describe the superior laryngeal nerve block (2)

A
  1. 1 cm below the greater cornu of hyoid

2. 25g needle, inject 2mL lidocaine

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89
Q

Describe the laryngeal nerve block (4)

A
  1. Aerosolized
  2. Trans-tracheal injection with a 22g needle and 4mL of lidocaine
  3. Air is aspirated before injection
  4. Direct blocks are contraindicated due to the trauma we can cause
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90
Q

3 oxygenation/ventilation options for head and neck surgereis

A
  1. small endotracheal tubes/inhalation anesthetic (may need laser safe ETT)
  2. intermittent apnea
  3. manual jet ventilation
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91
Q

Describe cardiac stability with head and neck surgery

A
  1. Blood pressure and HR fluctuate greatly

2. Moderate anesthetic with supplementation

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92
Q

4 descriptors of jet ventilation use

A
  1. Inspiration 1-2 seconds to avoid barotrauma
  2. Pressure 30-50 psi hooked up to wall outlet or anesthetic machine
  3. Expiration is passive
  4. Only acceptable for about 30 minutes or less
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93
Q

4 complications of jet ventilation

A
  1. pneumothorax
  2. pneumomediastinum
  3. aspiration
  4. hypercapnia/acidosis
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94
Q

Does jet ventilation require capnography?

A

Yes

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95
Q

Describe the 3 different waveforms of light used for lasers

A
  1. monochromatic - one wave length
  2. coherent - oscillates in same phase
  3. collimated - exists as a narrow, parallel beam
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96
Q

What do lasers allow for?

A

Excellent precision with minimal edema

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Perfectly
97
Q

Describe CO2 lasers (4)

A
  1. long wave length
  2. greater absorption by water (soft tissue)
  3. No touch technique
  4. Great precision, poor coagulation
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98
Q

Describe YAG lasers (4)

A
  1. shorter wave length
  2. less absorption by water
  3. Touch technique
  4. Poor precision, great for coagulation
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99
Q

4 most common problems with laser use

A
  1. organ or vessel perforation
  2. gas embolism
  3. eye exposure
  4. airway fire
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100
Q

3 laser precautions

A
  1. evacuation of toxic fumes (laser plume)
  2. prevention of eye damage
  3. Fire prevention
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101
Q

Polyvinyl chloride tube advantages and disadvantages

A

Advantages: inexpensive, nonreflective
Disadvantages: low melting point, highly combustible

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102
Q

Red rubber catheter advantages and disadvantages

A

Advantages: puncture resistant, maintains structure, nonreflective
Disadvantages: Highly combustible

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103
Q

Silicone rubber advantages and disadvantages

A

Advantages: nonreflective
Disadvantages: combustible, turns to toxic ash

104
Q

Metal tube advantages and disadvantages

A

Advantages: Combustion-resistant, kink-resistant
Disadvantages: Thick-walled flammable cuff, transfers heat, cumbersome, metal

105
Q

Most common type of ETT with laser surgery?

A

Polyvinyl chloride or metal

106
Q

6 steps of airway fire protocol

A
  1. stop ventilation and remove ETT
  2. Turn off oxygen and disconnect circuit from machine
  3. Submerge tube in water
  4. ventilate with face mask and reintubate
  5. assess airway damage with bronchoscopy and blood gases
  6. consider bronchial lavage and steroids to help with initial burn and swelling
107
Q

Describe what happens with the thyroid gland with a tracheostomy

A

Thyroid is typically preserved, isthmus is divided, partial thyroidectomy may be performed with a radical neck

108
Q

Describe anesthesia’s role with tracheostomies (4)

A
  1. Ventilate at 100% O2
  2. Verify tracheostomy tube, inner cannula and syringe is on the mayo stand
  3. After tracheal wall is dissected, ETT withdrawn until tip is cephalad to the incision (superior edge)
  4. Cuffed tracheostomy tube placed, CO2 verified and ETT completely withdrawn
109
Q

Two considerations for glossectomy

A
  1. Induction dependent on tumor size and mobility

2. Can stimulate vagal reflexes by manipulation of base of tongue

110
Q

What type of intubation should we consider for glossectomy

A

Awake fiberoptic or tracheostomy if tumor is significant

111
Q

Describe a fibular free flap (4)

A
  1. Fibula is essential non-weight bearing
  2. Involves muscle, skin and bone being transplanted to a recipient site
  3. Artery and vein supplying graft are connected to an artery and vein at recipient site
  4. Preoperative angiography to make sure there is good distal flow
112
Q

3 things to avoid in fibular free flaps

A
  1. Hypothermia
  2. Hypovolemia
  3. Hypotension
113
Q

Why is dextran 40 used in fibular free flaps

A
  1. Enhances microcirculatory blood flow
  2. Decreases viscosity
  3. Inhibits platelet function
114
Q

Blood volume desired for fibular free flaps

A

Mild anemia is desired

115
Q

3 disease states which may contraindicate a fibular free flap

A
  1. diabetes
  2. venous stasis
  3. significant edema
116
Q

Which free flap is most commonly used in head and neck reconstruction?

A

Radial

117
Q

What makes a radial flap a good choice for head and neck reconstruction?

A

Pliable skin, large vessels and easy to harvest

118
Q

What is the greatest concern with a radial free flap

A

distal circulation to hand

119
Q

When are radial free flaps contraindicated

A

Diabetics, poor wound healing, positive allen tests (good to document but angiogram is gold standard)

120
Q

Describe the 1st level of a neck dissection

A

tissue inferior to mandible, anterior to posterior digastric muscle and superior to hyoid

121
Q

Describe levels 2-4 of a neck dissection

A

tissue beneath and anterior to SCM (superior to hyoid and inferior to cricoid)

122
Q

Describe the 5th level of a neck dissection

A

tissue between posterior edges of SCM and anterior edge of trapezius

123
Q

Differentiate between a modified and radical neck dissection

A

MRND removes all 5 levels of neck contents but leaves vessels and nerves, while a radical neck dissections removes all 5 levels PLUS jugular vein, SCM and crania nerve XI

124
Q

What type of body warmer and temperature probe do we use for neck dissections

A

under body fluid warmer and rectal temp

125
Q

Why do we omit NMBD with neck dissections

A

So the surgeons can identify CN XI

126
Q

How do we handle blood loss in neck dissections

A

we replace blood loss with blood loss; blood loss is gradual unless we lose control of the IJ or CA

127
Q

What is the goal for fluid management in neck dissections

A

Would prefer to stay below 1.5 liters of crystalloid d/t wanting to reduce postoperative edema and loss of clotting factors

128
Q

How do we want to wake-up patients who have had a neck dissection

A

smooth, no coughing if possible

129
Q

4 nerve injuries suspected post neck dissection

A
  1. XI
  2. Facial
  3. Recurrent laryngeal
    4, Phrenic
130
Q

Why is there a sustained hypertensive response in post neck dissection patients and how do we treat it

A

D/t nerve injury, we treat with labetalol

131
Q

When does tracheal stenosis tend to develop

A

after prolonged endotracheal intubation

132
Q

2 effects of tracheal mucosa ischemia

A
  1. destruction of rings

2. constricting scar formation

133
Q

3 contributing factors of tracheal stenosis

A
  1. trauma
  2. infection
  3. HoTN
134
Q

When do we see patients become symptomatic with tracheal stenosis

A

Tracheal diameter <5mm

135
Q

Describe the cotton criteria used to grade tracheal stenosis

A

1: Lumen 50%
2. Lumen 51-70%
3. Lumen 71-99%
4. Lumen 100%

136
Q

4 symptoms of tracheal stenosis

A
  1. dyspnea at rest
  2. accessory muscle use
  3. expiratory flow rates decreased
  4. stridor
137
Q

What test helps demonstrate the severity of tracheal stenosis

A

flow volume loops

138
Q

4 treatments for tracheal stenosis

A
  1. intermittent laser
  2. balloon dilation
  3. tracheal stents
  4. tracheal resection
139
Q

describe short term tracheal stents (3)

A
  1. less than 6 weeks
  2. stabilized cartilage grafts following resection
  3. separation of mucosal surfaces following trauma
140
Q

describe long term tracheal stents (3)

A
  1. more than 6 weeks
  2. collapse above a tracheostomy site
  3. post op stenosis following tracheal reconstruction
141
Q

5 descriptors of silicone tracheal stents

A
  1. easy to place
  2. easy to reposition
  3. plug with mucous easily
  4. migrate more easily
  5. trachea must be predilated
142
Q

3 descriptors of metallic tracheal stents

A
  1. incorporate into epithelial wall to allow ciliary function to continue
  2. unable to remove or reposition
  3. more likely to develop granulation tissue, imitating re-stenosis
143
Q

4 indications for tracheal resection

A
  1. post-intubation lesions
  2. malignancies
  3. tracheoesophageal fistulas
  4. tracheal innominate fistulas
144
Q

Anesthesias part for tracheal resection (5)

A
  1. little to no preoperative sedation
  2. preoperative a-line
  3. inhalation induction/spontaneous ventilation until intubation
  4. surgeon at bedside for emergent trach or rigid bronch
  5. corticosteroids to decrease airway edema
145
Q

What does a CRNA need to handle trauma patients (4)

A
  1. good understanding of the basics
  2. preparation
  3. flexibility
  4. quick reactions
146
Q

What is the standard of care from prehospital to trauma centers?

A

Advanced trauma life support

147
Q

What is the primary survey in ATLS

A

life threatening injuries identified and simultaneously treated

148
Q

ATLS framework for airway (Stabilization, assess, intervene)

A
  1. stabilize cervical spine, which should be immobilized until cleared by CT
  2. assess airway: vocal response vs chin-life vs apnea
  3. intervene: suction, BVM assist/intubation
149
Q

ATLS framework for breathing (Assess, manage, monitors/support)

A
  1. Assess chest: inspection, palpation percussion auscultation
  2. Manage: obstruction, tension pneumo, massive, hemothorax, open pneumothorax, flail chest, tamponade
  3. Pulse ox, ABG, CXR, mechanical ventilation, thoracostomy, pericardiocentesis
150
Q

Describe the 4 classes of hypovolemic shock

A

Class 1: 15% loss; normal vital signs
Class 2: 15-30% loss; tachycardia, normal SBP
Class 3: 30-40% loss; significant reduction in BP and mentation, heart rate >120, and cap refill delayed
Class 4: >40% loss; hypotensive with narrowed pulse pressure, UO absent, more significantly altered mentation

151
Q

When do we presume shock is a result of hemorrhage?

A

Until proven otherwise

152
Q

What is the definition of shock

A

Inadequate perfusion to the tissues

153
Q

ATL Framework Circulation (Assess, manage, surgical)

A

Assess: vital signs, cap refill, CBC, coags, crossmatch, peritoneal lavage, ultrasound, radiology films
Manage: 2 large bore IVs with crystalloud/O neg whole blood, direct pressure
Surgical: Thoracotomy, laparotomy

154
Q

ATLS Framework Disability (Assess and manage)

A

Assess: pupil size, spinal cord injury level, GCS score
Manage: CT, steroid drips

155
Q

Trauma and Exposure (3)

A
  1. Secondary survey of things that aren’t life threatening
  2. Additional lab and xrays
  3. Detailed H&P
156
Q

For induction purposes, how are trauma patients classified as

A

full stomach, RSI

157
Q

When do you want the best conditions for intubating a trauma patient

A

want them on 1st approach, set yourself up for success

158
Q

Succinylcholine and trauma patients (3)

A
  1. Wears off quickly so good for cannot intubate, cannot ventilate
  2. Hyperkalemia not seen until >24 hours with burn patients
  3. Ocular trauma we need to assess the risks/benefits d/t IOP
159
Q

What is the delay on suggamadex

A

3 minutes

160
Q

What do we assume about the c-spine of trauma patients

A

instability is presumed until cleared

161
Q

how many providers are ideal for intubating a patient with a c-collar

A

3

162
Q

should the c-collar be removed for intubation?

A

no

163
Q

2 things to describe hypotension in trauma patients

A
  1. onset of positive pressure ventilation

2. 40% blood loss

164
Q

What induction medication causes the most hemodynamic instability

A

propofol

165
Q

What other benefit does etomidate provide when used for induction of trauma patients

A

inhibition of immune response

166
Q

Describe ketamine and the trauma patient

A

analgesic and sedation; myocardial depressant if catecholamines are depleted

167
Q

Can versed cause hypotension in trauma patients

A

yes, but it helps negate recall

168
Q

3 things related to recall in trauma patients

A
  1. related to TBI
  2. intoxication
  3. depth of hemorrhagic shock
169
Q

2 conditions where nasal intubation should be avoided

A
  1. basilar skull fracture

2. cribiform plate fracture

170
Q

6 steps in the pathophysiology of shock

A
  1. Hemorrhage
  2. Release of catecholamines
  3. Release of hormones and inflammatory mediators
  4. Microcirculatory response
  5. Lactate and free radicals are produced
  6. Inflammatory factors released
171
Q

CNS response to shock (2)

A
  1. decreased glucose uptake

2. decreased cortical activity and reflexes

172
Q

Kidney/adrenal response to shock (2)

A

Early: Maintains GFR
Late: Inability to concentrate urine, ATN if shock is not reversed

173
Q

Heart response to shock (2)

A
  1. Cardiac dysfunction d/t negative inotropes such as lactate
  2. Tachycardia
174
Q

Lung response to shock (3)

A
  1. Accumulation of inflammatory byproducts in capillaries
  2. Increased capillary permeability
  3. ARDS
175
Q

Intestine response to shock (3)

A
  1. Increase bacteria
  2. Triggers MSOF
  3. One of the earliest organs affected
176
Q

Liver response to shock (2)

A
  1. reperfusion injury during recovery

2. unstable blood glucose

177
Q

4 results of previous fluid resuscitation measures with shock patients

A
  1. dilution of red cell mass
  2. hypothermia
  3. coagulopathy
  4. increased hemorrhage d/t increased blood pressure
178
Q

How were the results of coagulopathy worsened with shock patients

A

acidosis and hypothermia

179
Q

what does acidosis and hypothermia affect the activity of with coagulopathy

A
  1. Coagulation factors function
  2. Fibrinogen quantity
  3. Platelet quantity
180
Q

What is the relationship for coagulopathy and death?

A

coagulopathy is an independent risk factor for death

181
Q

What was found to be the best FFP:PRBC ratio in the wigginton article in trauma patients?

A

1:1.4

182
Q

What was the BP goal in the harris article talking about damage control resuscitation?

A

> 80mmHg until bleeding was controlled

183
Q

What did the Cornelius study show about trauma patients receiving TXA?

A

higher percentage of patients survived after receiving TXA despite unsurivable injuries if TXA administered within 3 hours

184
Q

Is calcium administration needed after giving PRBC:FFP:Platelet:Cryo or 1 unit of whole blood

A

PRBC:FFP:Platelet:Cryo d/t citrate concentrations being much higher

185
Q

Describe mild TBI

A

GCS 13-15, postconsussive effects, 50% patients with functional limitations for >12 months

186
Q

Describe moderate TBI

A

GCS 9-12, early CT may indicate sx intervention necessary, early intubation/ventilation, mortality low/long term morbidity significant

187
Q

Describe severe TBI

A

GCS 8 or less, high risk of mortality

188
Q

describe epidural hematomas (4)

A
  1. surgical emergency
  2. tear in the middle meningeal artery
  3. LOC, consious, LOC
  4. Mydriasis, bradycardia, herniation
189
Q

Describe subdural hematoma (4)

A
  1. acute vs chronic
  2. tear of sagittal sinus vein
  3. headache, progressive drowsiness, visual disturbances, gait disturbances
  4. May require surgical drainage
190
Q

What is the current PaCO2 goal in TBI patients

A

30-35 mmHg, intermittent hyperventilation okay if ICP elevates despite treatment

191
Q

What does one hypoxic episode do to patient mortality with TBI

A

increases it by 2x

192
Q

What does one hypoxic episode plus HoTN do to patient mortality with a TBI

A

increases it by 3x

193
Q

Describe incomplete spinal cord deficits after trauma (2)

A
  1. may be worse on one side

2. may rapidly improve

194
Q

Describe complete spinal cord deficits after trauma (2)

A
  1. total disruption of spinal cord

2. little improvement over time

195
Q

What was the recommended bolus and infusion dose of glucocorticoid steroids by the american association of neurosurgeons in 2013 for patients with spinal cord injury post trauma?

A

Bolus: 30mL/kg
Infusion: 5.4 mg/kg/hr

196
Q

Why is c-spine stabilization required postop with injuries above C4?

A

d/t lack of diaphragm control

197
Q

Why is c-spine stabilization required postop with injuries above C6/C7?

A

d/t secretions/pneumonia

198
Q

what is a big emphasis on orthopedic trauma patients?

A

early stabilization of long-bone, pelvic and acetabular fractures will reduce pulmonary complications and length of stay

199
Q

Why is hip discolation/acetabular fx a surgical emergency

A

avascular necrosis

200
Q

Why is pelvic ring fracture a surgical emergency

A

exsanguination, a patient can hide a lot of blood loss in the pelvis

201
Q

advantages of regional anesthesia for orthopedic trauma surgery (4)

A
  1. allows continued assessment of mental status
  2. increased vascular flow
  3. improved postoperative mental status, especially in geriatric patients
  4. decreased incidence of DVT
202
Q

3 disadvantages of regional anesthesia for orthopedic trauma surgery

A
  1. peripheral nerve function difficulty to assess prior to block
  2. not suitable for multiple body regions
  3. may wear off before procedure concludes
203
Q

5 advantages of general anesthesia for orthopedic trauma surgery

A
  1. speed of onset
  2. duration can be maintained for as long as needed
  3. allows for multiple procedures for multiple injuries
  4. greater patient acceptance
  5. allows positive-pressure ventilation
204
Q

4 disadvantages of general anesthesia for orthopedic trauma surgery

A
  1. impairment of global neurological examination
  2. requirement for airway instrumentation
  3. hemodynamic management more complex
  4. increased potential for barotrauma d/t PPV
205
Q

4 signs of PE

A
  1. Hypoxia
  2. Tachycardia
  3. Petechial rash on upper chest
  4. PAP elevates with decreased CI
206
Q

5 Ps of Acute Compartment Syndrome

A
  1. Pallor
  2. Paralysis
  3. Paresthesia
  4. Pain
  5. Pulselessness
207
Q

What orthopedic injury is compartment syndrome most common with

A

tibia fractures

208
Q

What causes crush syndrome

A

continuous prolonged pressure

209
Q

What does tube thoracostomy provide in lung trauma management (3)

A
  1. relieves tension
  2. drains accumulated blood
  3. apply suction until leaks resolve
210
Q

2 types of lung hemorrhage requiring OR and ETT required

A
  1. intercostal or mammary arteries
  2. lung parenchyma
  3. double lumen tubes handy
211
Q

4 indications for thoracotomy

A
  1. mediastinal injury
  2. chest tube output exceeds 1500 mL in first hour
  3. tracheal or bronchial injury with massive air leak
  4. hemodynamically unstable with obvious chest trauma
212
Q

what vent settings do blunt chest trauma patients usually require

A

increased FiO2 and PEEP

213
Q

What are 3 alerts for tracheobronchial injury that we must identify quickly?

A
  1. subcutaneous emphysema
  2. pneumomediastinum
  3. pneumopericardium

all without apparent cause

214
Q

what is the gold standard for diagnosis of aortic injury

A

Angiography

215
Q

what is the aorta tethered by

A

ligamentum arteriosum just distal to the takeoff of the left subclavian

216
Q

what is the most common injury from blunt chest trauma

A

rib fractures

217
Q

what is our main concern with rib fractures

A

pulmonary complications

218
Q

describe flail chest (4)

A
  1. multiple joining ribs fractured
  2. associated with lung contusion
  3. may require PPV
  4. High level of suspicion to minimize ARDS
219
Q

what is the distinguishing factor between cardiac ischemia and blunt cardiac trauma

A

the patient!

220
Q

When should we get a TTE/TEE in patients with blunt cardiac trauma

A

new HTN/EKG changes, new HoTN or dysrhythmias

221
Q

4 management considerations for blunt chest trauma

A
  1. Control of fluid
  2. coronary vasodilators
  3. treatment of rhythm disturbances
  4. possible ASA/heparin
222
Q

Becks triad

A
  1. Hypotension
  2. Muffled heart tones
  3. Distended neck veins
223
Q

What is the FAST assessment for abdominal trauma

A

focused assessment by sonography for trauma

224
Q

what 4 things does the FAST assessment look at

A
  1. spleen
  2. liver
  3. heart
  4. bladder
225
Q

What is the goal of management for abdominal trauma

A

hemorrhage control, re-exploration for the first 24-48 hours

226
Q

4 views of assessment in FAST abdominal trauma

A
  1. RUQ - Morisons pouch
  2. LUQ - Peri-splenic view
  3. Pelvic view - Suprapubic
  4. Cardiac view
227
Q

what are pregnant patients at high risk for post trauma

A

spontaneous AB, preterm labor, and premature delivery

228
Q

1st trimester considerations post trauma (2)

A
  1. HCG in female trauma

2. Birth defects/miscarriage d/t radiation and medications, we must educate on this

229
Q

2nd/3rd trimester considerations post trauma (4)

A
  1. US exam
  2. B-agonists/magnesium for preterm labor
  3. Emergency CS for uterine hemorrhage or gravid uterus in way
  4. Left lateral displacement to relieve pressure and prevent vena cava syndrome
230
Q

4 considerations for Jehovah’s witness patients and trauma

A
  1. early ID and control of bleeding
  2. deliberate hypotension, SBP not >80mmHg
  3. Limited preoperative phlebotomy
  4. Cell saver, albumin and Factor VII may be okay, but we must do extensive education and questioning
231
Q

Organ perfusion indicators in trauma patients (4)

A
  1. base deficit
  2. lactate
  3. PaCO2/ETCO2
  4. TEG
232
Q

describe a first degree burn (3)

A
  1. superficial partial-thickness burn
  2. epidermis and upper dermis
  3. heal spontaneously
233
Q

describe second degree burn (3)

A
  1. deep partial thickness
  2. deep dermis
  3. maybe grafting and blisters
234
Q

describe 3rd degree burns (4)

A
  1. full thickness
  2. does not blanch; insensate
  3. complete destruction of dermis
  4. requires grafting, sepsis is a major concern
235
Q

describe 4th degree burns (3)

A
  1. muscle, fascia and bone
  2. complete excision
  3. patient has limited function
236
Q

5 descriptors of major burns

A
  1. full thickness >10% BSA
  2. partial thickness >25% BSA
  3. Burns involving face, hands, feet or perineum
  4. Inhalation, chemical or electrical
  5. Burn in pts with severe pre-existing disease
237
Q

Airway assessment raising suspicion of burns (6)

A
  1. Singed facial hair
  2. Facial burns
  3. Hoarseness
  4. Cough
  5. Soot in mouth or nose
  6. Difficulty swallowing
238
Q

3 upper airway burn complications

A
  1. glottic and peri-glottic edema
  2. thick secretions
  3. aggravated by fluid resuscitation

(intubate these patients quickly)

239
Q

3 complications of lower airway burns

A
  1. decreased surfactant
  2. decreased mucociliary clearance
  3. edema
240
Q

When do we see changes with lung parenchyma burns and how does it affect mortality?

A
  1. 1-5 days; looks like ARDS

2. markedly increases mortality

241
Q

Adult treatment for burns (5)

A
  1. avoid surgical airway if possible
  2. CXR, ABG, PFT as baseline
  3. Low levels of PEEP; high % O2
  4. Humidification
  5. Bronchodilators prn bronchospasm
242
Q

Treatment for burns in children (2)

A
  1. awake intubation not realistic…sevo/o2 induction

2. intubate prophylactically

243
Q

when do we start chest physiotherapy in burn patients with persistent hypoxemia

A

day 2-5

244
Q

describe fluid shifts immediately post-burn (3)

A
  1. microvascular permeability
  2. changes in interstitial osmotic pressure
  3. decreases cardiac contractility
245
Q

What % of BSA burn indicates fluid resuscitation

A

> 15%

246
Q

What day do we start using albumin for fluid resuscitation in burn patients

A

day 2

247
Q

What is the parkland burn formula

A

4cc/kg/% BSA in 1st 24 hours
1/2 given in 1st 8 hours
1/2 given in next 16 hours

248
Q

Vital sign goals for burn resuscitation (UO, HR, SBP, MAP, Base deficit)

A 
UO: 0.5-1mL/kg/hr
HR: 80-140 BPM
SBP: 60 (infants) 70-90 (children)
MAP: 60 (adults)
Base deficit: <2
249
Q

3 effects of carbon monoxide toxicity

A
  1. impairs oxygen unloading to tissues (left shift)
  2. Impairs mitochondrial function
  3. Reduces ATP production
250
Q

COHb % < 15-20 symptoms

A

headache, dizziness, and occasional confusion

251
Q

COHb% 20-40 symptoms

A

N/V, disorientation, visual impairment

252
Q

COHb% 40-60 symptoms

A

Agitation, combativeness, hallucination, coma

253
Q

COHb% > 60

A

Death

254
Q

Treatment for carbon monoxide toxicity

A

100% O2 and hyperbaric oxygen

255
Q

Dalton’s law

A

total pressure exerted by a mixture of gases is equal to the sum of the pressure of each gas (the whole is equal to the sum of the parts)

100% O2 in hyperbaric oxygen therapy

256
Q

Boyle’s Law

A

volume of gas is inversely proportional to the pressure and the density is directly proportional to the pressure

In Hyperbaric oxygen, as the pressure increases, the alveolar volume decreases and concentrates the oxygen molecules

257
Q

Graham’s Law

A

oxygen and carbon dioxide move independently from an area of high pressure to an area of lower pressure

In hyperbaric oxygen therapy, concentrated oxygen in alveolus moves into blood stream and from blood stream into damaged tissue

Principle's D (2 decks)

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