Trauma II

Question 1

TBI Goals

Answer 1

Traumatic brain injury

Prevent 2° brain damage resulting from intracranial bleeding, edema, ↑ICP, hypoxia, & shock

Question 2

TBI Classifications

Answer 2

Mild GCS 13-15
- Resolves w/ minimal deficits
- Observation 24hrs
Moderate GCS 9-12
- Early CT
- High deterioration potential requires early intubation & mechanical ventilation
- Manifested as intracranial lesions that require surgical evacuation
Severe GCS < 8 
- Intubate 
- Carries significant mortality rate
- Direct care at cerebral perfusion

Question 3

What ideal CPP should be maintained in patients w/ severe TBI?

Answer 3

CPP 60-70mmHg

Question 4

CPP Formula

Answer 4

MAP - ICP

Question 5

What inhalational anesthetics should be avoided in TBI anesthetic management?

Answer 5

Nitrous oxide → pneumoencephalogram

Question 6

SCI

Answer 6

Spinal cord injury

Most often occurs at lower cervical spine level C4-7

Question 7

SCI Deficits

Answer 7

Sensory
Motor
Sensory & motor

Question 8

What 3 factors do SCI patient outcomes depend on?

Answer 8

1. Acute injury severity
2. Exacerbation prevention during rescue, transport, & hospitalization
3. Avoid hypoxia & hypotension*

Question 9

Early SCI Treatment Focus

Answer 9

Adequate perfusion to prevent 2° injury

Question 10

What complication develops in 85% SCI patients w/ complete injury above T5?

Answer 10

Autonomic hyperreflexia

Question 11

SCI Goal MAPs

Answer 11

> 85mmHg

Question 12

Neurogenic Shock

Answer 12

Unopposed PSNS tone

Loss cardioaccelerator fibers → bradycardia

Question 13

C-Spine Evaluation

Answer 13

Requires all 7 cervical vertebrae to clear

Patients need to be awake - no sedation, ETOH, drug intoxication, or CNS impairment

Question 14

SCI Intubation

Answer 14

Simple chin lift w/ manual in-line stabilization
Avoid extension, flexion, & rotation w/ direct laryngoscopy
Consider video laryngoscopy

Gold standard = awake fiberoptic intubation*
*Requires cooperative patient

Question 15

What fractures are at high risk for DVT?

Answer 15

Long bone fractures

Fix or reduce w/in 1st 24hrs ↓pneumonia, ARDS, or fat emboli risk

Question 16

Dislocated Hip Considerations

Answer 16

Femoral head avascular necrosis = EMERGENCY

Requires paralysis → GETA

Question 17

Fractured Pelvis Considerations

Answer 17

Pelvic binder
Expect high blood loss
- Type & cross 4 units
- Notify blood bank to remain at least 2 units ahead

Question 18

Crush Injury Considerations

Answer 18

Muscle damage → myoglobinurea
Administer fluids to flush myoglobin through kidneys & prevent renal tubal clogging
Consider Mannitol & Bicarbonate to treat

Question 19

Open Fracture Considerations

Answer 19

OR w/in 1st 12hrs to debride

Question 20

Compartment Syndrome Considerations

Answer 20

Check pulses distal to the fracture

Treatment = fasciotomy

Question 21

Orthopedic Trauma

Anesthetic Management

Answer 21

Emergency trauma = full stomach → general anesthesia
Controlled hypotension MAP < 20mmHg baseline to prevent bleeding or w/in 20%
Administering inotropes before bleeding controlled → excessive blood loss

Question 22

Traumatic Aortic Injury

Diagnosis

Answer 22

CXR
Angiography
CT scan
TEE

Requires surgery to repair d/t rupture risk in hours to days

Question 23

The most common injury resulting from blunt chest trauma: _____ ______

Answer 23

Flail chest

Question 24

Flail Chest

Answer 24

Comminuted fractures at least 3 ribs
Characterized by paradoxical respirations
Consider pain management - epidural placement to maintain ventilation/perfusion or regional techniques (intercostal or TAP blocks)
CPAP or BiPap support

Question 25

Beck's Triad

Answer 25

Hypotension Jugular venous distension Muffled heart sounds

Question 26

Cardiac Tamponade Presentation

Answer 26

Beck's triad Narrow pulse pressure Tachycardia

Question 27

Blunt Cardiac Trauma →

Answer 27

Bruising or contusion → hypotension and/or arrhythmias Presents similar to MI (functionally indistinguishable) Treatment - manage as ischemic cardiac injury

Question 28

Cardiac Bruising or Contusion | Treatment

Answer 28

Volume control Vasodilators Monitor & treat rhythm disturbances Cardiology consult as necessary

Question 29

OB & Pregnancy | Trauma

Answer 29

High incidence spontaneous abortion, pre-term labor, or premature delivery OB consult for immediate management & follow-up Requires rapid & complete resuscitation 1° focus = mother L lateral uterine displacement Rh¯ mother admin Rhogam U/S fetus, assess gestational age, consider viability & delivery Spontaneous abortion requires surgical D&C

Question 30

Extubation Criteria

Answer 30

Mental status - not intoxicated, able to follow commands, non-combative, & pain adequately controlled Airway anatomy & reflexes - appropriate cough & gag, able to protect airway from aspiration, & no excessive airway edema or instability Respiratory mechanics - adequate tidal volume & RR, normal motor strength, FiO2 requirements < 50% Systemic stability - adequately resuscitated, repeat surgeries not required in short-term, normovolemic w/o S/S sepsis

Question 31

Risk factors r/t developing ARDS after trauma:

Answer 31

``` Elderly Pre-existing physiologic impairment or co-morbidities Direct pulmonary or chest wall injury Aspiration blood or stomach contents Prolonged mechanical ventilation Severe TBI SCI w/ quadriplegia Massive transfusion Hemorrhagic shock Occult hypoperfusion Wound or body cavity infection ```

Question 32

Appropriate Ventilator Settings

Answer 32

``` Vt 6-8mL/kg PEEP 10-15cmH2O Limit peek pressures < 40cmH20 Adjust I:E ratio as necessary Wean FiO2 to obtain PaO2 80-100 w/ SpO2 93-97% ```

Question 33

Postoperative Complications

Answer 33

``` Infection/sepsis Thromboembolism Abdominal compartment syndrome ARDS Volume status ```