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AS - N934 Advanced Principles II > Trauma I > Flashcards

Trauma I Flashcards

1
Q

Rapid Overview

A

Initial impression
Few seconds
Stable vs. unstable

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2
Q

Inability to oxygenate → brain injury & death w/in _____ minutes

A

5-10

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3
Q

Primary Survey

A 
Identify & address life-threatening injuries
Airway patency
Breathing
Circulation
Disability (neuro/mental status)
Exposure
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4
Q

What are the most common trauma causes in patients < 45yo?

A

MVA
Falls
Suicide
Homicide

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5
Q

Secondary Survey

A

Detailed & systematic evaluation
Head to toe assessment
Continued resuscitation as needed

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6
Q

GCS

A 
Glasgow coma score
- Eye opening response
- Verbal response
- Motor response
Normal 15/15
< 8 → intubate
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7
Q

Airway

A

Keep ‘em breathing

100% oxygen

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8
Q

Airway Obstructions

A 
Edema or direct injury
Cervical deformity or hematoma
Foreign body
Dyspnea, hoarseness, stridor, dysphonia
Subcutaneous emphysema & crepitus
Hemoptysis and/or oral bleeding
Copious secretions
Tracheal deviation = tension pneumothorax EMERGENCY ↓CO → cardio-respiratory arrest
Jugular venous distension
Hemodynamic condition (internal bleeding)
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9
Q

Trauma Airway Management Considerations

A
  • 100% oxygen admin
  • Jaw thrust > chin lift (avoid neck manipulation)
  • Full stomach d/t SNS response
  • Oral and/or nasal airway
  • Cervical spine immobilization
  • Ventilation inadequate → tracheal intubation
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10
Q

Basilar Skull Fracture S/S

A

Battle sign - bruising behind ears
Raccoon eyes
Ears and/or nose bleeding or CSF leak

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11
Q

When to perform ETT intubation?

A

Cardiac or respiratory arrest
Respiratory insufficiency or deteriorating condition
Airway protection
Pain control - deep sedation or analgesia
GCS < 8
Carbon monoxide treatment 100% FiO2 delivery
Facilitate work-up in uncooperative (anoxic) or intoxicated patient
Transient hyperventilation TBI required

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12
Q

Tracheostomy

A

Longer to perform as compared to cricothyroidotomy

Requires neck extension (contraindicated when neck trauma or cervical injury present)

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13
Q

Surgical Cricothyroidotomy

A 
Emergency placement up to 72 hours
Vertical incision to prevent RLN injury
Complications:
1. Esophageal perforation
2. SQ emphysema
3. Bleeding or hemorrhage
Contraindicated in patients < 12yo (potential laryngeal damage)
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14
Q

Needle Cricothryoidotomy

A

Less effective ventilation
Smaller diameter ↑resistance
Pediatrics

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15
Q

RSI Indications

A

All traumas = full stomach
SNS response diverts blood flow away from GI tract
Cricoid pressure at C6

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16
Q

Trauma & Depolarizing NMBs (Succinylcholine administration)

A

Okay 1st 24 hours after burns or spinal cord injury
After 1st 24 hours → nAChR UPregulation
Excessive K+ release → hyperkalemia

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17
Q

Induction Agents

A

Etomidate 0.2-0.3mg/kg IV (cardiac stable)

Ketamine 2-4mg/kg IV or 4-10mg/kg IM (direct myocardial depression typically masked by SNS stimulation)

Propofol 2mg/kg IV

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18
Q

NMBs

Succinylcholine

A 
Dose 1-1.5mg/kg IV
Onset 30 seconds
Fasciculations
DOA 5-12 minutes
De-fasciculating dose Rocuronium 5mg
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19
Q

NMBs

Rocuronium

A

Dose 1.2mg/kg IV
Onset 30-60 seconds
Modified RSI + mask ventilation
DOA 60-90 minutes

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20
Q

Cervical Spine Clearance

A

Maintain stabilization until x-ray clearance C1-C7
Ensure patient not obtunded, sedated, or ETOH intoxication
Patient needs to be able to communicate any pain or paresthesias present

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21
Q

What keeps the diaphragm alive?

A

C4-C5

INTUBATE

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22
Q

C6-C7

A

Unable to clear secretions or cough

Intubate

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23
Q

Hemothorax S/S

A

Blood present in pleural cavity

  • Hypotension
  • Hypoxemia
  • Tachycardia
  • ↑CVP
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24
Q

Hemothorax Treatment

A

Chest tube
Possible PRBC transfusion
Single lumen ETT to secure airway → double lumen ETT

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25
Pneumothorax | Definition/Types/Treatment
Gas present w/in pleural spaces disrupts parietal or visceral pleura 1. Simple 2. Communicating 3. Tension Treatment = chest tube when > 20% lung collapsed
26
Tension Pneumothorax S/S
Occurs w/ rib fractures & barotrauma d/t mechanical ventilation ``` Hypotension Hypoxemia Tachycardia ↑CVP Diminished breath sounds on affected side Tracheal deviation → cardiac arrest ```
27
Tension Pneumothorax Treatment
NEEDLE DECOMPRESSION Anterior approach 2nd/3rd ICS midclavicular line Lateral 4th/5th intercostal space
28
Flail Chest
At least 2 ribs fractured Costochondral separation Sternal fracture Paradoxical rib/chest wall movement retract on inhalation & outward on exhalation Respiratory insufficiency & hypoxemia over several hours w/ deterioration on CXR & ABG
29
Flail Chest Treatment
``` 1° supportive Pain management - Epidural - Intercostal blocks Oxygen administration - FiO2 - Incentive spirometry - CPAP/BiPAP Decompensation → intubate ```
30
What's the most common cause traumatic hypotension & shock in trauma patients?
Hemorrhage | Active internal or external bleeding
31
Circulatory failure leads to _____
Inadequate vital organ perfusion & oxygen delivery
32
Physiological Response to Shock
Vasoconstriction & catecholamine release Preserve cardiac, brain, & renal blood flow Inadequate organ perfusion → lactic acid & metabolic acidosis Ischemic cells produce inflammatory factors - leukotrienes, interleukins, etc. Multiple organ dysfunction/failure
33
Shock Types
Hemorrhagic* Cardiogenic Distributive Neurogenic
34
Where do inflammatory byproducts accumulate?
LUNGS Pulmonary capillary beds → results in ARDS Sentinel organ to develop MODS
35
What patients are at increased risk to experience cardiac ischemic injury in response to shock?
Elderly CAD Patients w/ minimal cardiac reserve
36
What organ experiences the earliest effects r/t hypo-perfusion in response to shock?
Gut/intestines | Higher risk to trigger MODS
37
What triggers protein C?
Hypotension & tissue injury → inflammatory response → endothelial activation protein C (APC)
38
Protein C
Unable to form clots efficiently | Early diagnosis & treatment ROTEM/TEG
39
Base Deficit
``` Determines shock severity Oxygen debt O2 delivery changes Fluid resuscitation adequacy Multi organ dysfunction/failure likelihood ```
40
MILD Shock
Base deficit 2-5mmol/L
41
MODERATE Shock
Base deficit 6-14mmol/L
42
SEVERE Shock
Base deficit > 14mmol/L
43
What correlates with increased mortality r/t base deficit?
Admission base deficit 5-8mmol/L
44
Blood Lactate Levels
LESS specific than base deficit Used to determine resuscitation end point ↑lactate correlate w/ hypo-perfusion
45
Normal Plasma Lactate | & Half-Life
0.5-1.5mmol/L > 5mmol/L indicates significant lactic acidosis 3 hours
46
What correlates w/ increased mortality r/t blood lactate levels?
Failure to clear lactate w/in 24 hours after shock reversal
47
Systemic Perfusion Assessment
``` Vital signs UOP - potentially inaccurate d/t diuretic therapy, intoxication, or renal injury Acid-base status Lactate clearance CO Mixed-venous oxygenation ``` Gastric tonometry Tissue specific oxygenation SVV (stroke volume variation) Acoustic blood flow
48
Shock S/S
``` Pale & diaphoretic Agitated or obtunded (altered neuro status) Hypotension Tachycardia Prolonged capillary refill ↓UOP Narrowed pulse pressure ```
49
IV Access Sites & Advantages
AC PIV Subclavian - easiest to place & does not require neck manipulation (cervical neck injuries) Femoral - access above the diaphragm ideal especially w/ abdominal injuries Internal jugular IO only 2-3 days
50
EARLY Resuscitation Goals
``` Maintain SBP 80-100mmHg Hct 25-30% PTT/PT w/in normal range Platelet count > 50,000 Normal serum iCal Core temperature > 35°C Maintain Pox function - consider alternative site (ear lobe or nose) Prevent ↑serum lactate & worsening acidosis Adequate anesthesia/analgesia ```
51
LATE Resuscitation Goals
Maintain SBP > 100mmHg Individualized Hct goals (CAD ↑Hct oxygen-carrying capacity) Normalize coagulation status, electrolyte balance, & body temperature (warming) Restore UOP Maximize CO w/ invasive or non-invasive monitoring Reverse systemic acidosis Document serial lactates
52
Overall Resuscitation Goals
Oxygenate & ventilate | Restore organ perfusion
53
Overall Resuscitation Goals
``` Oxygenate & ventilate Restore organ perfusion & homeostasis Repay oxygen debt Treat coagulopathies Restore the circulating volume Continuously monitor response ```
54
Resuscitation End-Point
Serum lactate < 2mmol Base deficit < 3mmol/L Gastric intramucosal pH > 7.33
55
Hemorrhagic Shock Management
Control/STOP the bleeding Begin fluid resuscitation - isotonic, hypertonic, colloids, PRBCs, plasma Consider rapid infusing system 400-1,500mL/min
56
Isotonic Crsytalloids
NS Lactated ringer's Plasmalyte
57
Hypertonic Saline
TBI | Osmotic agent to put fluid into the vascular space & therefore ↓ICP
58
Colloids
Rapid plasma volume expansion | NO oxygen carrying capacity
59
PRBCs
Provide adequate oxygen carrying capacity
60
Blood Loss Replacement
Crystalloid 3:1 PRBCs 1:1 Rh¯ blood preferable when crossmatch not complete (ABO & Rh) *Especially in women childbearing age
61
FFP
Replace 2 units FFP w/ every 4 units PRBCs when massive transfusion anticipated or ongoing to replace clotting factors
62
Massive Transfusion Protocol
Damage control Set blood & hemostatic products to mimic whole blood Limit crystalloid Prevent over-resuscitation early on as too much fluid will potentially dislodge clots & lead to ↑bleeding
63
Goal-Direct Hemostatic Resuscitation
Utilizes POC viscoelastic monitoring TEG/ROTEM to direct therapy
64
Hemostatic Agents
TXA anti-fibrinolytic beneficial when instituted w/in 1 hour admission Recombinant activated human coagulation factor VII (rFVIIa)
65
Rapid Infuser
Fluid administration rates up to 1,500mL/min Crystalloid, colloid, PRBCs, washed blood, & plasma compatible Reserve allows product mixing to prepare for rapid blood loss Controlled temperature 38-40°C Able to pump simultaneously through multiple IV lines Accurately records fluid volume administration Portable & able to travel w/ patient b/w units
66
Lethal Triad
Acidosis Hypothermia Coagulopathy Acidosis & hypothermia are factors that induce coagulopathy - fluid & PRBC resuscitation w/o hemostasis properties dilute already dysfunctional platelets
67
Hypothermia impacts the following:
Acid-base disorders Coagulopathy - impairs platelet & clotting enzyme function Myocardial function Shifts oxy-hemoglobin curve to the left ↓tissue oxygenation ↓lactate, citrate, & anesthetic drug metabolism Vasoconstriction ↑BP
68
Trauma Patient Coagulopathy
Clotting cascade activation causes clotting factors consumption Blood loss → clotting factors loss Massive transfusion → hemodilution further dilutes clotting factors Hypercoagulable state → DIC
69
Platelets & PTT/PT at 29°C
PTT/PT ↑50% Platelets ↓40% → BLEEDING
70
Coagulopathy Treatment
``` Avoid and/or reverse the lethal triad: - Control hemorrhage - Avoid/correct hypothermia - Actively re-warm Avoid hemodilution TEG/ROTEM ```

AS - N934 Advanced Principles II (18 decks)

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