TRAUMA Flashcards
(96 cards)
The most commonly accepted definition of massive transfusion is
more than 10 units in a 24 hour period.
This approximates one total blood volume exchange.
Indications of massive transfusion include
multiple (usually >3) units of uncrossmatched blood given with anticipated ongoing need,
or
a severely injured patients in extremis with no response to 2 units of blood.
massive transfusion protocol would include
repeatedly sending pRBCs, FFP and platelets every 20 minutes until the team requests it be stopped.
Ratios are kept as close to 1:1:1 as possible.
after 2 packs of massive transfusion, one should consider additionally requesting
cryoprecipitate (fibrinogen, factor 8, VWF)
or
fibrinogen
labs followed in massive transfusion and what are rough endpoints
CBC, PT/PTT, fibrinogen, ABG, calcium and BMP should be serially checked. There are no specific guidelines on when to discontinue massive transfusion. In general, control of bleeding with a Hb >8, INR 100,000 are appropriate goals.
Some of the major indications for damage control are:
Core temperature 95 F or 35 C SBP 14 mmol/L
INR or PTT > 50% normal Blood Loss > 4L Blood transfusion >10 units Fluid replacement >10L Persistent non-surgical bleeding
physiologic capture
describes there resussutation to be acheieved before attempting definitive repaire of inuries differed in damage control
has take place.
what injuries are managed even when doing damage control
Complex injuries to the duodenum may be treated with debridement and primary repair or pyloric exclusion.
Pancreatic injuries are treated with drainage alone or with resection and drainage.
CBD injuries are primarily repaired if less than 50% circumfrence.
Gallbladder is resected
Goals of resuscitation with damage control
basically a normal preop patient!!
temperature to 37 C (98.6 F)
Packed red blood cells, fresh frozen plasma and platelets should be administered in a 1:1:1 ratio for maximum benefit.
Goals of resuscitation should be:
PT < 15 or INR < 1.2
(using FFP, vitamin K, calcium)
Fibrinogen >100 mg/dL
(using cryoprecipitate or fibrinogen concentrate)
-remember cryo has fibrinogen, VWF, 8-
Platelets >100,000/mm^3 using packed platelets
NO pulse goal
function of fibrinogen and normal level
Fibrinogen is broken down to fibrin by the enzyme thrombin to form clots. ( if you’re fibrinogen level is low then you’re using it all up trying to make clots)
greater than 100
epidural hematoma
blood in the space between the skull and dura.
traumatic arterial injury.
lucid interval
biconvex (lenticular) mass that does not cross cranial suture lines
Acute subdural hematomas
tearing of bridging veins.
Blood between the arachnoid and dura mater and appears as a bright colored crescent-shaped mass which may cross suture lines but not the midline secondary to the presence of the falx
tracheoinnominate fistula
90% mortality associated with and an initial bleed in or around the tracheostomy tube may be the only indication of subsequent occurrence.
The first step should be overinflation of the tracheostomy / endotracheal tube cuff (choice A) for attempted tamponade.
If unsuccessful, digital compression of the artery against the sternum should be the next step
Pressure should be maintained on the artery during transport to the operating room.
An oral endotracheal tube should be inserted after successful arterial compression.
Diagnosis may require bronchoscopy and wound exploration if found early
Primary repair
should not be attempted due to high risk for failure and associated
mortality.
Those that develop and biloma tx algorrhthm
usually treatable with percutaneous drainage alone
less than 300 mL/day will usually close spontaneously.
more than 300 mL drains daily, the injury should be localized with fistulogram, ERCP, radionucleotide scan or transhepatic cholangiogram.
Sphincterotomy may help close biliary leaks.
Major ductal injuries may be stented or require operative repair.
Persistence of drainage more than 50 mL/day beyond 2 weeks indicates development of a biliary fistula. These often resolve without further intervention. (CAREFUL just because turns into “fistula” and has been 2 wk - does not mean you do anything but watch it resolve with drainage!)
If the Pringle maneuver is effective, hepatic artery ligation may be considered. what are potential complicaitons
increase the risk for hepatic abscess
or
biloma
(CAREFUL, increase risk of hepatic necrosis is listed as a not fully correct answer compared to above)
Injuries to the bladder (choice D) following blunt trauma most commonly what type, associated with what injuries and are managed how
extraperitoneal and associated with pelvic fractures. Extraperitoneal injuries can be managed non-operatively with foley catheter drainage.
Urethral injuries should be suspected if
inability to void, high riding prostate, blood at the urethral meatus, palpable bladder butterfly perineal hematoma.
pubic symphysis fractures,
Pubic diastasis and inferior pubic rami fractures are termed “straddle fracture” and correlate highly with urethral injuries.
associated bladder injury
pelvic hematomas.
Diagnosis of urethral injuries is made by
retrograde urethrogram.
immunologic function after embolization
Multiple studies have demonstrated preserved immunologic function after embolization.
Indications embolization for splenic injury
active extravasation, traumatic pseudoaneurysm, grade III injury with large hemoperitoneum or grade IV injuries.
Nonoperative management of blunt splenic injury is successful in what percent of peds patients versus adults
what time period are failures seen by percent
90% of pediatric patients
60-80% of adults.
The majority of failures (61%) occur within the first 24 hours,
90% within the first 72 hours.
Failure is most commonly associated with grade of injury, with grade V having a 75% failure rate.
Grade IV liver injuries have a 33% chance of failure.
Flank stab wounds are located where
those between the anterior and posterior axillary lines and between the tip of the scapular and the iliac crest.
The recommended modality of evaluation Flank stab wounds
hemodynamically stable patient
CT with triple contrast.
oral, IV and rectal contrast.
When performed this way, the sensitivity for injury is 89% and specificity 98%.
Rectal contrast is given to improve detection of colonic injuries, which is a partially retroperitoneal organ.
In the hemodynamically unstable patient, or those with peritoneal signs, evisceration or findings on other diagnostic modalities (free air on CXR, positive FAST),
laparotomy is
indicated.
The Eastern Association for the Surgery of Trauma (EAST) practice management guidelines have tried to delineate the appropriate evaluation for BCI
Recommendations are as follows:
1.) An admission ECG and another at 8 hours should be performed in any patient suspected of having BCI (choice A.) 2.)
If the admission ECG results are normal then pursuit of the diagnosis can be terminated.
However, if they are abnormal then the patient should be admitted for cardiac monitoring for 24-48 hours
- ) If the patient is hemodynamically UNstable then an imaging study such as an echocardiogram should be obtained
- ) The presence of a sternal fracture does NOT predict the presence of BCI and thus does not mandate continuous monitoring in the face of a normal ECG
- ) Neither CPK-MB nor troponin T are useful in predicting which patients will have BCI
Echocardiogram is not mandated unless the patient is hemodynamically unstable.
