Trauma

Question 1

When is a massive blood transfusion indicated?

Answer 1

Indicated in trauma with an ABC score 2+, and EBTN >5 and patients 12+ years old.

Question 2

Steps to blood transfusion

Answer 2

1. Group and screen (if able)
2. Consider TXA
3. Mitigate hypothermia
4. Consult with EPOS
5. Administer blood products
6. Consider Ca+ after 4 units given

Question 3

Risks of blood transfusion …and how to mitigate them

Answer 3

• Coagulopathy: administer 2 units of plasma first
• Hypothermia: use blood warmer. A 1 degree celsius drop in temperature increases blood loss by 16%
• Hypocalcemia: 1g Ca++ after 4 units of blood product. Monitor labs to maintain Ca++ over 1 mmol/L
• TACO: support respiration, may require ventilation assistance

Question 4

Blast injury categories

Answer 4

• Primary is from the initial shockwave. Shear stress forces, tympanic, ocular and lung injuries.
• Secondary fragment impact: penetrations, lacerations, amputations
• Tertiary body into objects: blunt trauma, crush injuries
• Quarternary environmental contamination: burns, inhalation injury, toxins
• Quinary bodily absorption of device additives (i.e. radiation): hypermetabolic state

Question 5

Intraperitoneal vs. Retroperitoneal

Answer 5

Intraperitoneal organs are surorunded by visceral peritoneum in peritoneal cavity. Retroperitoneal organs are behind peritoneum and relatively fixed in place.

• IP: stomach, liver, spleen, jejunum, ileum and transverse colon
• RP: kidneys & ureters, adrenal glands, aorta, esophagus, pancreas, parts of duodenum, colon & rectum

Question 6

Major Burns criteria

Answer 6

• > 20% partial or full between 11 and 50 years old, otherwise >10% partial or full if younger or older
• hands, feet or joints
• > 5% full thickness
• electrical
• chemical
• inhalation
• in presence of major trauma

Question 7

What is the Brooke-Parkland formula?

Answer 7

Used to estimate amount of fluid (ringer’s lactate preferred) needed to resuscitate and prevent burn shock when >15% in children or 20% in adults.
* Volume = 2-4mL x %BSA x weight (kg)
* Deliver first 1/2 in first 8 hours
* Deliver 2nd half in following 16 hours

Titrate to urine output 30-50cc/hr in adults and 1cc/kg/hr in kids.

Question 8

Hydroxycobalamine: MOA, considerations

Answer 8

Antidote for cyanide poisoning - common in structure fires. It’s a precursor to B12 acting as a coenzyme for metabolic functions. Can bind to cyanide ions for excretion in the urine.

May cause transient hypertension and bradycardia. Does cause red in urine lasting up to 6 weeks (can interfere with lab tests and hemodialysis)

Question 9

How is Hydroxycobalamine dosed?

Answer 9

5g IV in 200mL n/s over 15 minutes
Duration is 26-31 hours

Question 10

ABC Score

Answer 10

1 point each for:
* SBP equal to or less than 90mmHg
* HR equal to or more than 120bpm
* positive FAST
* penetrating mechanism

Used for pt’s over 12 yo. 2 points indicate need for blood in setting of trauma.

Question 11

EBTN Score

Answer 11

Used for pt’s over 12yo. Score over 5 indicated need for blood transfusion.

Question 12

Describe hemorrhagic shock Class 3

Answer 12

This is where things “crump”.

Blood loss is 1500-2000mL or 30-40%
HR >120
Hypotensive with decreased pulse pressure
Cap refill 3-4 seconds
RR 30 - 40
Urine output 5-10mL
LOC agitated/confused