Lecture Takeaways Flashcards
(149 cards)
1
Q
Phases of TCCC:
A
Care Under Fire (CUF)
Tactical Field Care (TFC)
Tactical Evacuation Care (TACEVAC)
2
Q
Damage Control Resus GOAL:
A
AVOID Lethal Triad:
hypothermia, acidosis and coagulapathy
3
Q
Primary Care in Care Under Fire (CUF):
A
#1 Tourniquet
STOP life-threatening hemorrhage
4
Q
Primary Care in Tactical Field Care (TFC):
A
Focused on MARCH acronym:
M: Massive Bleeding - direct pressure first if have time, tourn, hemostatic and pressure drsg
A: Airway - adjuncts, reposition, consider neck trauma b4 LMA a go
R: Respiration/Breathing - aggressive needle D, TBI, O’s >90%, seal chest wound
C: Circulation - IV/IO, BB, limit crystaloids–reassess tourn’s, apply pelvic binder
H: Head injury/Hypothermia - Assume TBI, ICP of 20, HOB >30 deg,
AVOID HypoT and hypothermia
5
Q
MARCH purpose for CCATT:
A
Use MARCH on initial assessment of TACEVAC handoff
– TCCC used in TACEVAC with “fresh” pt (not BAF to LRMC)
6
Q
Lethal triad components affect each other:
A
With blood loss–
Hypothermia combined with coagulopathy = stops the coag cascade
Coagulopathy combined with Metabolic Acidosis = lactic acid production
Metabolic Acidosis combined with Hypothermia = decreased myocardial performance
7
Q
Tenets of DCR:
A
– Balance resus approach - 1:1:1 (PRBC/FFP/Plts/Cryo)
– Prevent acidosis → decent circulation/BP
– Empiric use of TXA - 1st dose w/in 3 hrs–1gm over 10 min - followed by 1gm over next 8 hrs (may not have to if Hgb normalized)
– Prevent hypothermia
– Prevent hypocalcemia - Ca 1gm per 1-2 units of administered blood
– Minimize/avoid coagulopathy
8
Q
Calcium administration affects BP by how much?
A
Calcium 1gm = 5pt BP increase
9
Q
First choice in TACEVAC blood product:
A
Whole Blood
10
Q
Balanced Volume Resus:
A
1st Choice (always)- whole blood
2nd choice - Bld products at 1:1:1 ratio
3rd choice - PRBC’s and Plasma 1:1
4th choice - Plasma with or without RBC’s
5th choice - PRBC’s alone
6th choice - Crystalloid (LAST resort = induces coagulopathy/worsens outcome)
11
Q
INR goal for volume resus:
A
INR 1.3
12
Q
INR over 1.3 = ________
A
TRALI risk with too much FFP administration
13
Q
Blood Admin through TLC preference:
A
Brown Port = #16
(other two = #18)
14
Q
Can you give Ca replacement and blood product in the same line?
A
Preferably no. Give through a different line.
15
Q
Mass Transfusion Predictors:
A
3 of 4 = 70% MT risk
– SBP <100 (most useful)
– HR >100
– Hct <32%
– pH <7.25 - can indicate low volume - other parts of the body producing lactic acid to compensate f/blood to head and heart as a priority
16
Q
Mass Transfusion Other predictors:
A
– AKA, multi-amputation
– penetrating torso injury
– + FAST US >2 sites
– INR >1.5
– BD >6
– Lactate >2.5
17
Q
Mass Transfusion = ______ units of blood
A
>10 units
18
Q
Why avoid crystalloid resus?
A
pH of NS is 5.0
= drives up the chlorine resulting in hyperchloremic acidosis
19
Q
How to minimize/avoid coagulapathy:
A
– Prevent hypothermia
– use a balanced resus
– do not use crystalloid, albumin or hextand = dilutional coagulopathy
– Prevent hypocalcemia - co-factor in coag cascade
– TXA to prevent fibrinolysis
20
Q
TXA administration:
A
Give within 3 hrs
First dose: 1gm over 10 min
Second dose: 1gm over 8 hrs
(Vial = 1,000mg/10ml = 100mg/1ml)
21
Q
iCal levels with blood administration:
A
iCal g = >1.2
Citrate present in all blood product components as an anticoagulant
– 90% of citrate is in FFP and Plts, not PRBC
– give additional Ca for every 2-4 units of blood
– CaChl = 3x more Calcium molecules then CaGluconate
(Check CL vs PIV as okay)
22
Q
How to lower INR level:
A
FFP administration
23
Q
Hemmorhagic Shock Hgb goal
A
Hgb >7
24
Q
Good non-invasive shock signs to monitor:
A
AMS and UO
25
What differentials falsely lowers HR?
– Nuerogenic shock
– Severe TBI that causes _Cushing's reflex_
– Meds: Betablockers, CCB's, _Precedex_
– Athlete warriors - baseline, usually younger in age
26
FAST exam locations:
--Spleen
– Liver
– Pelvis
– Heart
27
A GCS of \<9 = SBP goal of \_\_\_\_\_\_\_
GCS \<9 indicates TBI soooo SBP g=\>110
28
Pulse Pressure
Narrow = anything that decreases LV (the CO) -→ no longer filling and ejecting
ie tamponade, tPTX, PE, obstruction from RV.
**PP = useful in diagnosing hypovolemia early**
Pulse pressure _more_ sensitive than BP
BUT
it is useful but no longer an absolute
29
In general, if your HR is _____ than your SBP = Bad
In general, if your HR is _greater_ than your SBP = Bad
30
Shock index (SI)
Normal ratio of SI is HR/SBP = 0.7
Trauma pt's – SI of 0.9 indicates higher mortality rate
31
What is THE most important clinical parameter
that is not monitored electronically?
**UOP**
32
Five lab values used as resus endpoints:
(Lactate and BD - strongly related on initial resus only)
– **Lactate - BEST end-point** use lab
– BD = how far away f/7.4 is acid away from the norm
– Bicarb
– Anion Gap norm = 812 mmol/L -→ \>12 = inc mortality
– pH = POOR endpoint of resus as easily affected by MV
33
Can CVP alone be used to assess fluid responsiveness?
No.
There is no relationship b/t CVP and fluid responsiveness
– Do not use CVP in isolation.
= Use US to evaluate IVC (collapsable? extended?)
34
What does the FAST exam NOT pick up?
Retroperitoneal bleeds
35
What does the wavering line indicate observed on the A-line tracing?
fluid volume receptiveness
36
Needle D for tPTX:
Needle lentgh - 2.5 inches
ideal location- 4-5th ICS midaxillary (used also as the CT insertion site)
– also used is 2 ICS MCL = high miss rate
37
tPTX hemodynamic instability:
– Inc HR
– Dec SpO2
– Dec BP
38
tPTX physical exam:
– Resp distress (asymmetrical chest wall mvmt)
– distended neck veins
– tracheal deviation
– dec breath sounds
– hyperresonance
39
What happens if a sucking chest wound is not covered?
air will be pulled into the hole,
air becomes trapped
and
will cause a tPTX
40
Sucking chest wound temporizing measure:
3-sided chest seal
| (semi-occlusive dressing)
41
Physical Exam noted Pericardial Tamponade Dx:
– JVD
– Hemodynamic instability - inc HR, dec BP
– Tachypnea
– Dyspnea
– Muffled heart tones
42
Why do you monitor Calcium during/after a blood transfusion?
Citrate is added to the product.
– It is a major anticoagulant for product and storage
– Citrate binds to the free calcium and it prevents it from interacting with the coag system.
43
MOST important way of preventing a secondary brain injury:
**AVOID**
**_hypoxia_** – SaO2 (93%, PaO2 \<80
and
**_hypotension_**
44
Possible effects effects of TBI to monitor for:
– Increased ICP
– Vasospasms
– Seizures
– Waxing/waning mental status
45
What is the most important score of the GCS components?
MOTOR score = the _most consistent_ predictive component
46
How to prevent a secondary TBI injury:
– Avoid hypoxia
– Maintain CPP
– Treat intracranial hypertension
47
Indications for ICP monitoring:
– GCS \<8 AND abnormal CT scan
– GCS \<8 AND normal CT scan with 2 or more of:
+ Age \> 40
+ SBP \< 90
+ Motor posturing
(per CPG, neuro can put in ventric per these criteria to fly)
* * *
48
Cerebral Perfusion Pressure goal:
60-70 mmHg
49
CPP \> 70 by using pressors can lead to:
a 5-fold increase in ARDS risk
– vasoconstrict and vasospasm -→ loose regulation
50
CPP \< 60 = \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
associated with poor outcomes
51
MAP - ICP =\_\_\_\_\_\_\_\_
CPP
52
Basic TBI Care: (X10)
1. Avoid hypotension - -→ no monitor keep SBP \>110, with monitor SBP \> 90 and CPP \> 60
2. Avoid hypoxia –\> g = \> 93%
3. Maintain euglycemia -→ BS g = 80-180
4. Maintain normothermia -→ Temp \< 99 deg F (IV Tylenol, exposure, ice, buddy light)
5. Maintain hyperosmolar euvolemia -→ Na g = 150-160, 3% IV admin
6. Maintain PaCO2 35-45 -→ “hypo-norm”
7. Correct coagulopathy -→ INR g = 1.4-1.5 (FFP)
8. Elevate HOB -→ head first, mechanical
9. Avoid jugular venous compression -→ C-collar loosen, Reverse-T
10. Seizure -trophy→ Keppra, Phosphenytoin
53
3% Administration
Bolus 250 cc's,
then 50cc's/hr.
54
Tools to help assess volume status:
1. CVP
2. US
3. Base deficit (if no HCO3)
4. PPV/SVV
5. UOP (without DI)
55
What fluid do you use for euvolemia maintenance in a TBI?
Normal Saline
– fluid resus with albumin was associated with higher mortality rates
vs resus with saline
56
In a TBI, use _________ \_\_\_\_\_\_\_\_\_ over __________ to maintain euvolemia.
In a TBI, use blood products over Albumin to maintain euvolemia.
– fluid resus with albumin was associated with higher mortality rates
vs resus with saline
57
TBI PaCO2 Normoventilation:
PaCO2 35-40 (allows for brain perfusion)
(hypercapnia/inc CO2 = dilatation)
58
In head pt's, hyperventilation/hypocapnia induces \_\_\_\_\_\_\_\_\_.
Vasoconstriction - thus decreases cerebral blood flow (CBF)
59
TBI and coagulopathy = \_\_\_\_\_\_\_\_.
**BAD**
INR g = 1.4-1.5 acceptable without a TEG.
(technical goal = 1.3 but this is easier to get to using a TEG)
60
Pt's with a TBI, which pt's are at high risk for Sz's:
– Depressed Skull Fracture
– Intracranial Bleed
– Penetrating TBI
– GCS \<9
61
What is the recommended per CPG for Sz prohy?
– Keppra 500mg PO/IV BID (common)
– Phenytoin or Phosphenytoin
***Only effective for _EARLY_ seizures in 1st seven days***
62
What are the physical signs of elevated ICP?
– Cushing's Triad
– Deteriorating Nuero Exam ( worsening GCS & dilated pupil)
63
Cushing triad components:
– Bradycardia
– Hypertension
– Irregular Respirations
64
Treatment for increased ICP:
– hyperventilate (?) thought this was a last ditch effort recently
– Paralyze
– Mannitol 1gm/kg
= last ditch d/t bad for aggressive diurese as it shrinks brain quick and well)
65
Prefered analgesia and sedation for increased ICP?
Fentanyl and Propofol
66
Treatment for increased ICP:
1. Elevate HOB/no neck compression
2. Sedate and Analgesic
3. Drain EVD per MD orders (if present)
4. Hyper osmolar therapy (3% IV)
1. Temporizing hyperventilation consideration ONLY if associated with clinical deterioration to pCO2 goal of 30-35.
67
When can you use Vecuronium in a pt with increased ICP?
LAST DITCH
Vecuronium to paralyze
– monitor for Hypotension
– must be given in conjunction w/sedatives
68
Hypertonic Saline Mechanism:
– Decreases ICP by osmotic effect
– augments intravascular volume and cardiac output
69
Mannitol Hyperosmolar Therapy MOA
1. Decreases ICP by osmotic effects
2. Augments CBF
**3. Rebound ICP elevations**
4. Causes diuresis and hypovolemia
4a. *AVOID using in under-resuscitated casualties*
4b. Most commonly used in isolated TBI pt's with intracranial hypertension
70
Mannitol Dosing
Clarify this:
1g/kg rapid push
then 0.25g/kg rapid push q4 hrs
(CCATT PEARL - d/t bottle crystalization, ask pharm b4 take off for a bag of it)
71
CPP Low Treatment \<60 mmHg
_High ICP_
Increase sedation
Hyperosmolar therapy
Drain EVD per NRSG recs
_Low MAP_
Volume resus - blood for suspected bleeding, NS or 3%
Pressors if euvolemic - Vaso, Phenylepherine
72
High CPP Treatment
High BP:
1. Analgesia and sedation increased (Fent and Prop)
2. Reduce pressors
1. Only lower with vasoactive meds if very severe HTN (SBP\>160 increases mortality)
73
Ketamine use in TBI
When Ketamine was used in TBI pt's,
vasopressors were used less often to maintain CPP.
74
Ketamine MOA's
**Sedation, amnesia, anxiolytic and sympathomimetic**
– rapid onset, short half-life
– increases cardiovascular and CBF
– protective airway reflexes left intact
75
TBI pt's have a high risk of suspicion of:
– DI (most common early on)
– Sz's
– Consider benzodiazepine **if** sedation/anes fails- Versed/Ativan/Valium
76
What is absolute contraindicated in TBI pt's?
STEROIDS
77
Goal HCT for Catastrophic Head Injury
30
78
CHI SBP and MAP goals = \_\_\_\_\_\_\_\_\_.
SBP \>100
MAP \>65
(if goals not met with fluids/blood - use pressors)
79
When do you initiate T4 protocol?
– More than one pressor required to maintain pressure goals OR Levo \> 15 mcg/min
– Evidence of Diabetes Insipidus - large amt's of pale urine
(caused by hypothalamus or pituitary gland injury)
80
How to treat Diabetes Insipidus?
DDAVP or vasopressin
– Remember - volume resus and urine replacement.
81
What physiologic effects go hand in hand in pain?
Tachycardia and HTN
82
For purposes of sedation, what two meds are recommended over the use of Benzo's?
Propofol and Precedex
| (also decreases VAP incidences)
83
What‘s the current recommended hand placement
for direct manual pressure?
Apply hands directly on top of the bleeding wound
and
push down as hard as you can.
84
If able, prolonged tourniquet time to off preferred at __________ hours.
Prolonged use \>2 hours…..MAX 4 hours.
At the 6 hr mark, will have a 50/50 chance of lose vs keep limb option
85
6 P’s of Acute Compartment Syndrome
1. PAIN out of proportion
2. Pallor
3. Pulselessness
4. Parathesias
5. Paralysis
1. Poikilothermia - the inability to regulate core body temp (ie sweating to cool off and next putting on clothes to warm up)
86
Is compartment syndrome with open fractures possible?
Yes
87
Who is likely to get extremity compartment syndrome?
Burns and runners
88
What induction agents does CCATT have in their allowance
and preferred line of administration?
— Ketamine - 1st line
— Etomidate - 2nd line
— Propfol
89
What two paralytic agents are in the allowance std?
Succ and Vec
90
What’s a benefit of using a Cook Catheter?
You can give breaths thru it
91
Hemodynamic instability (X3) observed
with a Tension Pneumothorax.
— Increase HR
— Decreased SpO2
– Decreased BP (late sign)
92
Tension Pneumothorax Needle D location:
— preferred 5th Intercostal, mid-axillary line (place CT in after)
— 2nd ICS MCL (high miss rate)
Needle length = 2.5 in
93
What indicates surgical intervention in a Hemothorax?
CT output of:
— 1500 cc initial output
— 200 cc/hr in 4 hours
94
Sucking chest wound intervention:
3 sided chest seal (semi-occlusive dressing)
95
What is the potential injury that occurs with a sucking chest wound?
Without a seal -
air is pulled into the chest cavity,
air becomes trapped
= cause a T-Ptx
96
What indicates a flail chest?
= 2 or more rib fractures
— paradoxical breathing
97
Besides airway/breathing, what is the most important intervention
to stay on top of with rib fractures?
PAIN Control
98
Beck‘s Triad indicates \_\_\_\_\_\_\_\_\_\_\_.
What are the sign/six’s of Beck’s Triad?
Belk’s Triad = Pericadial Tamponade
— Decreased BP
— JVD
— Muffled Heart sounds
99
Which diagnosis is ARDS most commonly seen
in approx 72 hours post injury/event?
— Pulmonary contusion
— Multiple transfusions
— Inhalational injury
— PNA
— Gastric aspiration
— Fat emboli
— Septic Shock
100
What are initial DCS goals?
— Stop the bleed
and
— Washout contaminatin
101
DCS Resusitation goals:
= End organ perfusion
— HR, BP, mentation
— UOP!!!
102
Who requires a SplenECTOMY?
Grade IV-V splenic injury
103
Who requires a SplenOTOMY?
Grade III and TBI
104
Septic Shock Criteria:
— persistent hypotension requiring pressers to keep MAP \>65
– serum lactate \>2 mmol despite adequate vol resus
105
SIRS criteria:
— HR \>90
– RR\>20 or PCO2 \<32
– Temp \>100.4
– WBC \>12K or \<4K
106
qSOFA Sepsis criteria:
— SBP \<100
— RR\>22
– AMS
Outside the ICU: 2 or more criteria point to poor outcome in septic patients
107
TRansfusion Associated Lung Injury (TRALI) criteria:
— transfusion ARDS
— \<6hrs to onset
— Resp Distress (intubation)
– Hypotension (inotropes/pressers)
108
Transfusion Associated Circulatory Overload (TACO) criteria:
— excessive blood products
— \<6 hrs onset
— resp distress ( intubation)
— HYPERtension (Lasix - feels weird b/c ie 4hrs ago was actively bleeding)
109
ACS is a clinical syndrome of:
Myocardial ischemia arising from an
## Footnote
**imbalance of oxygen supply and demand**
110
How much can shivering increased metabolic demand?
400%
111
What is no longer a part of MONA for ACS pain?
Morphine - Has been shown to increase mortality and interfere with Plavix
112
Tamponade Treatment:
— maintain euvolemia (a pre-load dependent condition)
— maintain spontaneous vent/avoid intubation )a pre-load defendant condition)
— Inotropic support
— Pericardiocentesis (prepare for if you this is a possibility)
113
What are some arrythmias that may be seen post MI?
— AIVR
— VT
— A-fib
— New LBBB
— AV node - 1st, 2nd, 3rd deg blocks
**Place pads on pt as your transport monitor**\*
114
Ventricular Tachycardia characteristics
— WCT
— rate \>120
115
Vent Tachycardia electrolyte optimization:
— K\>4
— Mag \>2
116
VT that requires intervention:
— frequent non-sustained VT
— sustained VT\>30’s
— VT that requires defibrillation
117
Ventricular Tachycardia Treatment - Stable:
1st line - BB— Metoprolol 25-50mg PO BID (5mg IV QID)
2nd line - Amiodarone 150 mg over 10 min, then 1mg/min X6 hrs, then 0.5mg/hr next 18 hrs
3rd line (if Amio not work) - Lidocaine 1.5 mg/kg X1, may repeat X1 after 5 min, Max 300 mg total, then 1-4 mg/min Gtt
118
A-FIB Treatment - Stable vs Unstable:
Stable :
— EF \>40% - BBlockers, CCB’s
— EF \<40% - Amiodarone
Unstable:
— IMMEDIATE Cardioversion
119
Desired HR for aortic dissection:
HR 60-70
120
First line IV medication even if pt is NOT hypertensive:
BBlocker - Esmolol or labetalol
121
BP control in aortic dissection—second line? Ask melissa
— Target BP: \<110 mmHg
— start vasodilator 2nd line: nicardipine, nitroglycerin
122
What medication class do you avoid with Aortic Dissection?
Anti-platelets
123
Which layer of burn is NOT counted towards the TBSA %?
Superficial - only involves the epidermal layer
aka a sunburn
124
At what percent requires fluid resuscitation?
TBSA 20%
125
At \_\_\_\_\_\_\_% do you intubate the pt and why?
TBSA 40%
b/c 40% systemic effect is significant enough to result in airway edema—\> regardless of airway involvement from the initial burn
126
What fluid do you use for a burn resuscitation?
LR
127
Rule of 10’s
10ml an hour for every % TBSA burn of \>40kg and \<80kg pts
for each kg over 80kg, add 100 ml per 10 kg over.
ie. 90Kg 30% = 10 x 30 = 300ml/hr + 100 ml (for 90 kg) = 400ml/hr
128
What are the endpoints for burn resuscitation?
UOP (30-50ml) and MAP ( \>55mmHg)
(CVP the tiebreaker or a climbing lactate)
129
If you have early anemia and hypotension in the burn resus protocol,
look for sources of \_\_\_\_\_\_\_\_.
Bleeding
130
CVP end point of burn resus :
Consider the CVP a TIEBREAKER:
— CVP g = 6-8 mmHg
— If CVP low - increase IVF rate
— If CVP at goal but MAP \<55mmHg:
——— use first line = Vasopressin 0.04unit/min
——- second line = norepi 2-20 mcg/min (or phenylepherine) —look up CPG on phenyl
131
Three end goals for burn resus:
— UOP 30-50 hr
— MAP \> 55 mmHg
— CVP 6-8 mmHg
132
If you need to give blood during the initial burn resus, does it count towards your total volume?
YES!
133
When can you administer Albumin to a burn pt?
At the 8-12 hour mark
IF the hourly fluid rate exceeds 1500 ml/hr
OR
the projected 24 hr total fluid volume approaches 250ml/kg
134
Is there an Albumin administration chart for burn guidance?
Yes, located in the ERCC under burns.
135
If you are transporting a pt with an inhalation burn, what two additional medication would you take?
Albuterol and Heparin
Dose: Aerosolized unfractionated heparin 5000 u per ETT q4 hrs - since heparin can induce a bronchospasm when mixed with albuterol
136
When to consider an ETT for a burn pt:
— comatose pt
— symptomatic inhalation injury
— deep facial burn
— TBSA \> 40%
137
What size ETT or greater for a burn pt?
ETT 8.0 or greater
138
What is a burn pt at HIGH risk for?
HYPOTHERMIA
139
Massive fluid replacement is a risk factor for _______ \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_.
Abdominal Compartment Syndrome
140
Do you give a burn pt abx in the absence of a fever?
No. They are not indicated in the absence of a fever Per CPG.
141
Per CPG, administer ________ for burn pt’s \> 20% for potential for stress ulceration.
Proton Pump inihibitors
142
All burn pt’s should receive _________ prohylaxis unless contraindicated.
DVT prophy - SCD + UFH or LMWH
| (DVT incidence is higher in burn pts)
143
An _____________ is normally perfomed in the setting of a circumferential full thickness burn per CPG.
Escharotomy (the skin vs a fasciotomy - the compartment)
If to escharotomy early, may avoid a later fasciotomy
144
When to consider chest escharotomies?
— Circumferential 2 deg or 3 deg truncal burns
— Decreasing thoracic compliance
— increasing PaCO2 and airway pressures
145
Why are electrical injuries difficult to calculate a TBSA percentage?
Surface assessment of TBSA does not correlate with actual damage
146
TACEVAC Handoff:
M - Mechanism
I - Injuries
S - Vitals, Lines/Tubes
T - Procedures/operations performed, Last dose of Meds: Abx, TXA, anes, sedation
147
What is the preferred vascular method for blood administration?
PIV large bore (over a central line)
148
What's the best practice regarding amputations and TQ's in flight?
Preposition the TQ on the amp extremity -
“SOFT TQ” placement so able to tighten should the pt begin to hemorrhage
149
What is most likely missed when setting up chest tubes for flight?
Attach CT's to suction!!!!
