Trauma - ICU and ward management Flashcards
(112 cards)
1
Q
A
2
Q
What is the primary goal in the management of a shocked patient in ICU?
A
Establish adequate oxygen delivery
Supranormal resuscitation has been shown to lead to poorer outcomes; now the approach is goal-directed.
3
Q
What are the indications for intubation?
A
- Airway obstruction or inability to protect airway (inadequate gag reflex)
- Inability to breathe (e.g., paralysis, high spinal injury, tidal volume <5ml/kg)
- Poor ventilation leading to respiratory failure (Poor PaO2 + PaCO2)
- Systolic pressure <75mmHg despite adequate resuscitation
- GCS <8/15
- Temperature <32°C
4
Q
What is the target range for PaCO2 during ventilatory support?
A
35-40mmHg
Avoiding respiratory alkalosis is important due to its effects on the haemoglobin dissociation curve and cerebral vasoconstriction.
5
Q
What is the target range for PaO2 during ventilatory support?
A
80-100mmHg with the lowest possible inspired O2 concentration
6
Q
Which pharmacological agent is preferred for acute trauma in ICU management?
A
Noradrenaline
It has potent inotropic effects and activates myocardial β-adrenergic and vascular α-adrenergic receptors.
7
Q
What are the primary effects of adrenaline in ICU management?
A
- Peripheral vasoconstriction
- Increased systemic vascular resistance
- Increased systolic and diastolic BP
- Increased myocardial electrical activity
- Increased coronary and cerebral blood flow
- Increased myocardial contraction strength
- Increased myocardial oxygen requirement
8
Q
What is the role of dopamine in ICU management?
A
- Stimulates dopaminergic and adrenergic receptors in a dose-dependent manner
- Low dose causes vasodilation and increased urinary output
- Higher doses cause increased systemic vascular resistance and preload
9
Q
What are the effects of dobutamine?
A
- Potent inotropic effects through β1 and α1-adrenergic receptor stimulation
- Increases cardiac output
- Reduces peripheral resistance
- Less likely to induce tachycardia compared to adrenaline
10
Q
What is the effect of isoproterenol/isoprenaline?
A
Strong chronotropic effect
It has largely been superseded by dobutamine in clinical use.
11
Q
What is the primary function of nitroprusside?
A
Potent peripheral vasodilator with balanced effects on systemic and pulmonary circulation
12
Q
What is the limitation of digoxin in shock management?
A
Significant time to act limits its usefulness; usually used to treat atrial fibrillation or supraventricular tachycardia.
13
Q
Fill in the blank: The indication for intubation includes a GCS of _____ or less.
A
8/15
14
Q
True or False: Supranormal resuscitation is now the recommended approach for managing shocked patients.
A
False
15
Q
α1-receptors
- list three α1-receptor agonists and summarise their effect
A
Noradrenaline>adrenaline»isoprenaline
Smooth muscle contraction, mydriasis, vasoconstriction in skin, mucosa, abdominal organs, sphincter contration in GI tract and bladder
16
Q
α2-receptors
- list 3 α2-receptor agonists and summarise their effect
A
Adrenaline=noradrenaline»isoprenaline
act on smooth muscle
17
Q
β1-receptors
List 3 β1-receptor agonists and summarise their effect
A
Isoprenaline>noradrenaline>adrenaline
Positive chronotropic, inotropic effects
18
Q
β2-receptor
-list three β2-receptor agonists and summarise their effects
A
Isoprenaline>adrenaline>noradrenaline
Smooth muscle relaxation (bronchodilation)
19
Q
β3-receptor
- list β3-receptor agonists and summarise their effects
A
Isoprenaline >noradrenaline=adrenaline
Enhanced lipolysis, bladder relaxation
20
Q
What is a potential complication of trauma related to hypothermia?
A
Risk factor for cardiac arrest
Hypothermia can lead to various complications, including the risk of cardiac arrest due to impaired physiological responses.
21
Q
What is the neuroprotective aspect of hypothermia?
A
Hypothermic patients are neuroprotective
Hypothermia can provide protection to the brain during periods of reduced blood flow or oxygen supply.
22
Q
When can a hypothermic patient be declared dead?
A
Cannot be declared dead until near-normal body temperature reached
This is important to prevent misdiagnosis of death in hypothermic patients.
23
Q
What should be done if a hypothermic patient’s temperature is below 29.5°C?
A
Rapidly re-warm
Immediate re-warming is critical to prevent further complications and improve patient outcomes.
24
Q
What is the recommended action for a hypothermic patient with a temperature between 30-32°C?
A
Use passive re-warming, but often active core warming
Active methods may be necessary to ensure effective re-warming.
25
Name 5 external methods of re-warming a hypothermic patient.
* Removal of wet clothing
* Drying patient
* Radiant heat
* Electrical warming blankets
* Warm air heating blankets
## Footnote
These methods help restore normal body temperature effectively.
26
What are 6 internal methods of re-warming a hypothermic patient?
* Heated, humidified respiratory gas to 42 degrees
* IV fluids warmed to 37
* Gastric lavage warmed to 42 degrees
* Continuous bladder lavage at 42 degrees
* Peritoneal lavage – potassium free dialysate at 42 degrees
- ECMO
## Footnote
Internal methods can provide more direct warming of the core body temperature.
27
What does ECMO stand for?
Extracorporeal Membrane Oxygenation
## Footnote
ECMO is a technique used in critical care to provide prolonged cardiac and respiratory support.
28
True or False: A hypothermic patient is resistant to chemical and electrical cardioversion.
True
## Footnote
This resistance emphasizes the need for continued CPR in such patients.
29
Define SIRS
Systemic inflammatory response syndrome
3 or more of:
Temp <36 or >38
Pulse >90
RR >20
PaCO2 <32
WCC >12 or <4
30
What is multiorgan dysfunction syndrome?
Progressive failure of multiple and interdependent organs
31
What happens to organ function in multiorgan dysfunction syndrome?
Organ function is no longer able to maintain homeostasis
32
Which organs are primarily affected in multiorgan dysfunction syndrome?
Lungs, liver and kidneys
33
What are the main inciting factors of multiorgan dysfunction syndrome?
Hypovolaemic shock and infection
34
What triggers the uncontrolled or inappropriate systemic inflammatory response in multiorgan dysfunction syndrome?
Innate immune response with subsequent uncontrolled or inappropriate systemic inflammatory response
35
What is the one hit model in the context of multiorgan dysfunction syndrome?
Single insult initiates a SIRS that can result in progressive MODS
36
What does the two hit model suggest about the progression to MODS?
Sequential insults lead to MODS
37
What is the specific therapy for multiorgan dysfunction syndrome?
Limited, other than adequate and full resuscitation, treatment of infection and ICU supportive cares
38
What metabolic derangements interfere with clotting mechanisms in multiorgan dysfunction syndrome?
Acidosis
39
What is a common cause of early mortality in blunt trauma?
Head injury
## Footnote
Early mortality in blunt trauma is often linked to head injuries.
40
What condition can contribute to secondary head injury?
Raised ICP
## Footnote
Raised intracranial pressure (ICP) can lead to further damage following an initial injury.
41
What should be monitored and controlled in patients with head trauma?
ICP
## Footnote
Monitoring and controlling intracranial pressure is crucial in managing head trauma cases.
42
List five physiological states that can negatively affect ICP
Hypoxia
Hypotension
Hyperglycaemia
Hyperthermia
Hypercarbia
43
List five considerations when evaluating and managing acute renal failure
Nephrotoxic contrast/dyes and drugs where possible
Hypovolaemia
Rhabdomyolysis
Abdominal compartment syndrome
Obstructive uropathy
44
What two parameters need to be taken into account when considering metabolic disturbance in ICU patients?
1. Acid base disorders
2. Electrolyte disturbance
45
What five electrolytes need review in the consideration of electrolyte disturbance?
Hypokalaemia
Hyperkalaemia
Hypocalcaemia
Hypomagnesaemia
Hypophosphataemia
46
List 8 delivery techniques for parentaral administration of analgesia
Bolus opiates
IV morphine or fentanyl titrated
PCA
Epidural
Intrapleural analgesia
Extrapleural analgesia
Intercostal blocks
Catheter techniques for peripheral nerve blocks
47
48
What are six negative outcomes of inadequately managed pain in the ICU patient?
Increased oxygen consumption
Increased minute volume demand
Psychic stress
Sleep deprivation
Impaired lung mechanics with associated pulmonary complication
49
What modes of feeding are available for patients unable to eat?
NG
NJ
PEG
Jejeunostomy/PEJ
TPN
50
Which four types of trauma patients are at high risk of malnutrition/inadequate nutrition?
Major trauma
Traumatic Brain Injury
Burns
Sepsis
51
What is the nutritional state of trauma patients?
Trauma patients are hypermetabolic and have increased nutritional needs
## Footnote
Hypermetabolism in trauma patients leads to a higher requirement for calories and nutrients.
52
What is the benefit of early enteral feeding in trauma patients?
Early enteral feeding reduces post-op septic morbidity
## Footnote
This approach helps prevent infections and supports recovery.
53
Who should receive enteral nutrition in the ICU?
All ICU patients who are not expected to be on full oral intake in 3 days should be on enteral nutrition
## Footnote
This ensures adequate nutrition is provided during recovery.
54
What should be done if a patient cannot receive enteral nutrition and shows signs of malnutrition?
If patient cannot be given enteral nutrition and has evidence of protein-calorie malnutrition, then give TPN
## Footnote
TPN (Total Parenteral Nutrition) is used when enteral feeding is not feasible.
55
Is there a significant difference in outcomes between enteral nutrition and TPN?
No significant difference in outcomes between enteral and TPN
## Footnote
Both methods can be effective in providing nutrition.
56
What has contributed to the decrease in incidence of stress ulcers?
Improved resuscitation and widespread PPI use
## Footnote
PPI stands for proton pump inhibitors, which reduce stomach acid production.
57
What is the DVT rate in trauma patients?
12-32%
## Footnote
DVT stands for deep vein thrombosis.
58
What is required for all trauma patients other than those with haemorrhagic TBI and spinal cord epidural haematoma?
They should be on LMWH
## Footnote
LMWH stands for low molecular weight heparin.
59
When should graded pneumatic compression devices be used?
Unless extremity injury precludes use
## Footnote
These devices help prevent DVT.
60
What should all patients with open wounds and without recent immunisation receive?
Tetanus immune globulin
## Footnote
This is to prevent tetanus infection.
61
What immunisations should be considered for splenectomy patients?
H. influenza, meningococcus, and pneumococcus
## Footnote
Splenectomy increases the risk of infections.
62
What is the protocol for managing traumatic wounds?
Adequate debridement and irrigation to remove all non-viable tissue
## Footnote
If unable to close primarily, use wet dressings changed twice daily.
63
What should be done if a traumatic wound cannot be closed primarily?
Debridement, irrigation, then Initially wet dressings changed twice daily until grafts or flaps can be applied
## Footnote
This is done once the health of the wound is assured.
64
What is the first step in tracheostomy care?
Full respiratory assessment first; have pulse oximetry on, auscultate
## Footnote
This step is crucial to ensure the patient's respiratory status is monitored before proceeding with care.
65
How often should tracheostomy care be performed?
Once per shift or prn
## Footnote
'prn' stands for 'as needed'.
66
What solution is used to clean the inner cannula of the tracheostomy tube?
Half strength peroxide, further diluted with NS
## Footnote
NS refers to normal saline.
67
What motion is used to remove the inner cannula of the tracheostomy tube?
Counter clockwise motion
## Footnote
This ensures safe removal of the cannula.
68
What should be done after removing the inner cannula?
Replace oxygen source & place in solution
## Footnote
This prevents hypoxia during the cleaning process.
69
How should the lumen and outside of the inner cannula be cleaned?
With a brush
## Footnote
This helps to effectively remove secretions.
70
What should be used to rinse the inner cannula after cleaning?
Saline
## Footnote
Rinsing is essential to remove any cleaning solution.
71
What is the purpose of drying the inner cannula?
To ensure no moisture remains before reinsertion
## Footnote
Moisture can cause airway obstruction if not dried properly.
72
How should the inner cannula be replaced?
At 9 o'clock position and turn until hear click
## Footnote
Proper positioning ensures secure placement.
73
What should be done with the drain sponge around the tracheostomy?
Remove and clean around ostomy & plate with cotton buds
## Footnote
Keeping the area clean prevents infection.
74
What is the proper way to change ties on a tracheostomy?
Leave old ties on until new ties secure; tie double knot away from carotid
## Footnote
This technique ensures safety during the tie change.
75
What should be done after changing the ties?
Replace drain sponge
## Footnote
This helps maintain cleanliness around the tracheostomy site.
76
What is the final step after completing tracheostomy care?
Repeat respiratory assessment
## Footnote
This ensures that the patient's respiratory status is stable after care.
77
What is the frequency for re-stitching in wound drain care?
Weekly
78
What should be protected in wound drain care?
Skin
79
What is an indication for chest drain insertion related to hemothorax?
Hemothorax on chest x-ray
## Footnote
Chest drains are indicated when a hemothorax is identified on imaging.
80
What constitutes a significant pneumothorax requiring chest drain?
Significant pneumothorax (>20% loss of diameter on chest x-ray)
## Footnote
A pneumothorax is considered significant if there is a greater than 20% loss of diameter on imaging.
81
In what scenarios other than haemothorax on CXR and significant pneumothorax, is a chest drain indicated?
severe lung injury or any pneumothorax or surgical emphysema in a patient who is to be transported by ground or air or who is to undergo GA or positive pressure ventilation
## Footnote
This is necessary to prevent complications during procedures requiring general anesthesia.
82
When is a chest drain used as a diagnostic procedure?
In the unstable multi-trauma patient with suspected internal hemorrhage into the chest
## Footnote
This helps to assess and manage suspected internal bleeding.
83
What procedure is being phased out in favor of chest drains?
Needle thoracentesis
## Footnote
Needle thoracentesis is being replaced by more effective drainage methods.
84
What gauge needle is used for needle thoracentesis?
14 gauge needle
## Footnote
This gauge is recommended for effective drainage.
85
Where is the 14 gauge needle inserted during needle thoracentesis?
2nd intercostal space, mid-clavicular line
## Footnote
This location is chosen for optimal access to the pleural space.
86
What is the safe triangle for chest drain insertion?
Nipple (5th IC space), anterior to mid-axillary line
## Footnote
The safe triangle is defined by specific anatomical landmarks.
87
What anatomical structures define the safe triangle for chest drain insertion?
* Anterior border of latissimus dorsi
* Lateral border of pectoralis major
* Horizontal line through anatomical position of ipsilateral nipple
## Footnote
These structures help avoid injury to vital structures during insertion.
88
What preparation is needed before chest drain insertion?
LA (local anesthesia), pulse oximetry, BP monitoring, secure IV
## Footnote
Proper preparation is crucial for patient safety and comfort.
89
What incision is made during chest drain insertion?
2-3cm horizontal incision
## Footnote
This incision allows access to the pleural space for tube placement.
90
What technique is used to access the pleural space after incision?
Blunt dissect to top of rib
## Footnote
Care must be taken to avoid the neurovascular bundle located under the rib.
91
What is the purpose of puncturing the parietal pleura?
To facilitate drainage of air or fluid from the pleural space
## Footnote
This step is essential for effective chest drain placement.
92
What should be replaced with a gloved finger after puncturing the pleura?
Roberts needle
## Footnote
This allows for the insertion of the drainage tube.
93
What size tube is typically placed during chest drain insertion?
28-32F tube
## Footnote
The size ensures adequate drainage of fluid or air.
94
What should be looked for after tube insertion?
Fogging
## Footnote
Fogging indicates that the tube is correctly positioned in the pleural space.
95
What type of drain is connected to the chest drain?
Underwater sealed drain (UWSD)
## Footnote
This type of drain uses water as a one-way valve to prevent air from re-entering the pleural space.
96
Why must the underwater sealed drain be kept upright and on the floor?
To maintain hydrostatic pressure of the fluid column counterbalancing the negative pleural pressure
## Footnote
Proper positioning is crucial for effective drainage.
97
What happens to air or fluid in the pleural space during breathing, when a chest drain with UWSD is in situ??
It is pushed out of the pleural space with each breath, causing air to bubble up through the seal reservoir
## Footnote
This mechanism helps in maintaining pleural pressure and preventing collapse.
98
What are the components of the Modern UWSD?
* Drainage bottle (bottle 1 - yellow)
* Pressure relief valve (blue)
* Underwater seal (bottle 2 - red)
* Suction controller (bottle 3 - teal)
## Footnote
Each component serves a specific function in the drainage system.
99
What should bottles 2 and 3 be topped up with?
Water
100
True or False: The bottles in the Modern UWSD can be topped up with saline.
False
101
What happens if the system is designed as one chamber?
The fluid that comes out of the chest would add to the hydrostatic pressure of the fluid column.
102
What is a benefit of the Modern UWSD regarding suction?
Don’t need suction
103
What indicates that the drain is patent and in continuity with the pleural space?
Fluid in drain tubing swings
104
What happens in bottle 2 until the air in the pleural space is gone?
Bubbles in bottle 2
105
What does bottle 3 show when suction is applied?
Bubbles in bottle 3
106
What is the function of the pressure that corresponds to the level in bottle 3?
It must exceed the pressure to create bubbles.
107
What type of system is the Modern UWSD?
Three chamber system
108
What is essential to understand regarding the physiology of chest tubes?
Have a good answer for physiology of chest tubes
109
List early complications of chest tubes (x5)
damage to the intercostal artery/vein (causing a heamopneumothorax)
damage to the intercostal nerve (causing neuralgia)
incorrect tube position
laceration/puncture of thoracic or abdominal organs
s/c emphysema (usually at the tube site)
110
Give five late complications of chest tubes
introduction of infection (eg thoracic empyema)
chest tube kinking / blocking / dislodging / disconnecting
Persistent pneumothorax (from a pleural or tubing leak)
lung fails to expand due to plugged bronchus; bronchoscopy required
recurrence of pneumothorax on removal of chest tube – seal of thoracostomy wound not immediate
111
When can you remove a chest drain?
Depend on reason for putting it in
Pneumothorax - No air leak for 24 hours
Hemothorax – No bleeding for 24 hours
Effusion - <200ml/day
Empyema – clinically & radiologically resolved
112
List the steps for removing a chest drain
Aseptic
LA
Place purse string suture around drain
Undo suture holding drain
Assistant forms loose knot in purse string
Patient – deep breath & mild Valsalva
Pull drain out at held full inspiration (or held full expiration but harder for patients to do) one quick motion
Tie knot
Cover with occlusive dressing
?routine CXR in 4- 6 hours
