Trauma N Burns

Question 1

1. Q1. What is the first priority after securing the airway in a burn patient?

Answer 1

1. A1. Managing life-threatening injuries and aggressively resuscitating with large volumes of intravenous fluids.

Question 2

2. Q2. Why is fluid administration critical in burn patients?

Answer 2

2. A2. It is crucial for patient survival and preventing renal failure.

Question 3

3. Q3. What type of shock is caused by burns and what changes are observed?

Answer 3

3. A3. Hypovolemic shock, characterized by loss of circulating plasma volume, hemoconcentration, massive edema formation, decreased urine output, and depressed cardiovascular function.

Question 4

When are fluid losses greatest after a burn injury?

Answer 4

In the first 12 hours after burn injury, stabilizing after 24 hours.

Question 5

1. What are the components of the primary survey in trauma care?

Answer 5

1. The primary survey in trauma care involves assessing Airway, Breathing, Circulation, Disability (neurologic status), and Environment/exposure.

Question 6

2. Describe the goal of the primary survey in trauma care.

Answer 6

2. The goal of the primary survey is to rapidly identify and manage life-threatening conditions or injuries.

Question 7

3. What does the secondary survey involve?

Answer 7

3. The secondary survey is a comprehensive head-to-toe assessment that includes a neurologic examination, performed after stabilization efforts from the primary survey.

Question 8

4. Explain the difference between blunt and penetrating trauma.

Answer 8

4. Blunt trauma results from high-energy impacts such as MVCs and falls, causing injuries due to deceleration, shearing, and other forces. Penetrating trauma involves direct entry of objects into tissues.

Question 9

5. What are the types of motor vehicle collision (MVC) traumas?

Answer 9

5. MVC traumas include head-on, rear impact, side impact, rotational impact, and rollover, causing injuries above and below the waist.

Question 10

What injuries are associated with blunt thoracic trauma?

Answer 10

Blunt thoracic trauma commonly affects the chest wall, lungs, heart, pericardium, and airways, often leading to significant morbidity and mortality.

Question 11

What is tension pneumothorax?

Answer 11

Tension pneumothorax occurs when air enters the pleural space and cannot escape, leading to progressive collapse of the affected lung and displacement of mediastinal structures.

Question 12

What are the symptoms of tension pneumothorax?

Answer 12

Symptoms of tension pneumothorax include hypotension, decreased breath sounds on one side, hyperresonance on percussion, and tracheal deviation.

Question 13

9. How is tension pneumothorax managed emergently?

Answer 13

9. Emergent management of tension pneumothorax includes needle decompression followed by chest tube thoracostomy.

Question 14

10. What is pericardial tamponade and how is it managed?

Answer 14

10. Pericardial tamponade restricts cardiac filling, leading to low cardiac output and hemodynamic instability. Management involves pericardiocentesis to relieve pressure on the heart.

Question 15

1. What are the anesthetic considerations for massive hemothorax?

Answer 15

1. Massive hemothorax requires adequate fluid and blood resuscitation before chest tube placement to prevent hypotension and further bleeding complications.

Question 16

How should anesthesia be managed in patients with cardiac rupture?

Answer 16

Patients with cardiac rupture require rapid prehospital transport and immediate surgical intervention due to high mortality rates in the prehospital setting.

Question 17

3. What are the hemodynamic goals in the management of traumatic aortic rupture?

Answer 17

3. Hemodynamic management in traumatic aortic rupture aims for a systolic blood pressure (SBP) less than 100-120 mm Hg and a heart rate less than 100 bpm to minimize the risk of extending the aortic injury.

Question 18

4. How are tracheal injuries typically managed in the acute setting?

Answer 18

4. Tracheal injuries may be managed with intubation to bridge the transected tracheal parts or surgical correction. Total transection requires rapid surgical retrieval of the distal segment for lifesaving mechanical ventilation.

Question 19

5. What are the preferred pharmacological agents used to achieve hemodynamic control in traumatic aortic rupture?

Answer 19

5. Short-acting β-blockers, calcium channel blockers, and/or vasodilators like nitroprusside are used to achieve hemodynamic control in traumatic aortic rupture, aiming to stabilize blood pressure and heart rate to prevent further aortic damage.

Question 20

Q1:** What is the primary goal during the primary survey of trauma care?

Answer 20

A1:** Identifying and rapidly managing life-threatening conditions or injuries.

Question 21

Q2: What imaging techniques are utilized during the primary survey to assess injuries?

Answer 21

A2: Ultrasound and radiography.

Question 22

Q3: Why is coordination between surgical and anesthesia teams essential during the primary survey?

Answer 22

A3: To ensure efficient management and preparation for potential surgical intervention.

Question 23

Q4: When does the secondary survey begin in trauma care?

Answer 23

A4: After the primary survey and the initiation of resuscitative and stabilization efforts.

Question 24

Q5: What does the secondary survey focus on?

Answer 24

A5: A more complete head-to-toe assessment, including a neurologic examination.

Question 25

**Q6:** What causes blunt trauma?

Answer 25

**A6:** Direct impact, deceleration, continuous pressure, shearing, and rotary forces.

Question 26

**Q7:** How should all blunt trauma victims be treated regarding their cervical spine?

Answer 26

**A7:** They should be suspected of having an unstable cervical spine.

Question 27

**Q8:** What is the third most common type of blunt injury?

Answer 27

**A8:** Blunt chest trauma.

Question 28

**Q9:** What percentage of trauma-related deaths is chest trauma a major contributor to?

Answer 28

**A9:** 50% of trauma-related deaths.

Question 29

**Q10:** What is a common complication of blunt thoracic trauma?

Answer 29

**A10:** Pneumothoraces, present in as many as 40% of all blunt thoracic injuries.

Question 30

What significant sign indicates a developing pneumothorax during surgery?

Answer 30

Reduced tidal volumes and decreased oxygen saturation.

Question 31

**Q12:** Why should nitrous oxide be avoided in patients with suspected thoracic trauma?

Answer 31

**A12:** It can increase the size of a pneumothorax during positive pressure ventilation.

Question 32

**Q13:** What determines the extent of damage in penetrating trauma?

Answer 32

**A13:** The type of wounding instrument, the velocity of the projectile, and the tissue characteristics it passes through.

Question 33

What is negative imbibition pressure and how does it affect fluid loss in burn injuries?

Answer 33

Negative imbibition pressure is a strong negative interstitial pressure within injured tissue causing fluid absorption. It results in large fluid losses and demands during resuscitation. The magnitude of burn injury increases this negative pressure, leading to early hypovolemia despite fluid therapy.

Question 34

Q: What do current guidelines for fluid resuscitation not fully account for, and what happens to fluid volume after a burn injury?

Answer 34

Current fluid resuscitation guidelines, especially those based on crystalloids, do not fully account for early fluid loss, leading to a controlled hypovolemic state in the first 12-16 hours post-burn. Tissue edema peaks between 24-48 hours, and fluid is gradually returned to circulation and excreted over 7-14 days, potentially causing lung dysfunction due to hypervolemia.

Question 35

Q: What are the characteristics and hemodynamic alterations of severe burn shock?

Answer 35

Severe burn shock is both distributive and hypovolemic in nature, with increased systemic vascular resistance (SVR) due to the release of catecholamines, antidiuretic hormone, and hemoconcentration, which compounds the adverse effects of the shock phase.

Question 36

What state develops 48 to 72 hours after a burn injury and what are its characteristics?

Answer 36

A hyperkinetic and hypermetabolic state develops 48 to 72 hours after burn injury, characterized by decreased vascular permeability, increased heart rate, and decreased systemic vascular resistance (SVR), resulting in increased cardiac output.

Question 37

What heart rate is considered normal in a burn patient?

Answer 37

100-120

Question 38

What fluid resuscitation formula is most commonly used in the burn patient?

Answer 38

Parkland formula= 4ml/kg crystalloids for every% TBS burned. Given over 24hours half of which is given in the first 8 hours.

Question 39

What percentage of TBSA can burns be managed with oral intake or 1.5 times hourly fluid requirement?

Answer 39

<15%

Question 40

Fluid resuscitation formulas in the burn patient call for a target urine output of what?

Answer 40

0.5ml/kg/hr in adults (or 30-50ml/hr) and 1ml/kg/hr in children

Question 41

What are the signs of resuscitation failure in the burn patient?

Answer 41

low urine output, repeated episodes of hypotension or need for vasopressors, worsening of base deficit, or fluid infu- sion in excess of predicted resuscitation needs in the first 24 hours

Question 42

In regards to fluid resuscitation, when does the risk for abdominal compartment syndrome increase?

Answer 42

When administered fluid volumes exceed 250ml/kg/day

Question 43

After what administered volume should you check cardiac function in the burn patient?

Answer 43

6ml/kg/%TBA

Question 44

What are the normal abdominal pressures and which necessitate intervention?

Answer 44

Normal: 5-10mmhg Intervention: >25mmhg

Question 45

What defines ACS?

Answer 45

Abdominal pressure exceeding 25mmhg with new onset organ disfunction (oliguria, decreased lung compliance)

Question 46

Patients with high voltage injuries should be assessed for what?

Answer 46

Rhabdo, compartment syndrome, vertebral fractures

Question 47

Before initiating frostbite warming, what temperature should the body be heated to?

Answer 47

35 degrees celcius

Question 48

Significant difference between children and adult patients in burns?

Answer 48

Children have higher surface area to volume ratio, thinner skin, greater fluid requirements and fluid loss to evaporation, higher incidence of hypothermia

Question 49

Besides TBSA burned, what is the most important morbidity factor?

Answer 49

Age

Question 50

General metabolic factors in the burn patient?

Answer 50

increased resting energy expenditures, increased myocardial oxygen consumption, marked tachy- cardia, increased body temperature, glycolysis, proteolysis, lipolysis, and futile substrate cycling.

Question 51

Nutritional needs of the burn patient are increased by what percent?

Answer 51

200% increase in basal energy requirement

Question 52

In the preop assessment of the burn patient, special attention should be paid to what?

Answer 52

time and extent of burn injury, airway evaluation, presence of inhala- tion injury, quantity of fluid received, current resuscitation regimen and the patient’s response, vascular access/sites, and tolerance of enteral feeding and NPO status

Question 53

In regards to the burn patients airway, what can be said regarding the musculature?

Answer 53

Patients masseter and neck muscles can be stiff/contracted, making displacement to the submandibular area difficult

Question 54

During the acute phase of burn injury (first 24-48hours) what can be said about CO? How does this effect pharmicokinetics?

Answer 54

Decreased CO and intravascular volume decreasing metabolism and clearance of drugs.

Question 55

After resuscitation of the burn patient, they go into the hyperdynamic phase. What does this entail pharmacologically?

Answer 55

Drugs dependent on organ blood flow (propofol, fentanyl) will have faster clearance and may require increased dosing.

Question 56

What happens to plasma proteins in the burn patient?

Answer 56

Albumin decreases, while AAG increases twofold.

Question 57

What happens to phase I and II reactions in the burn patient?

Answer 57

Decreased phase I reactions (oxidation, reduction, hydroxylation, demethylation), phase II is unaffected (conjugation, glucuronidation, and sulfation).

Question 58

What are the effects of burns on NMBA?

Answer 58

Succs generally avoided after 24-48 hours of burn due to severe Hyperkalemia. NDNMBA require increased dosages due to up regulation of ACH and fetal (neuronal) ach receptors, increased AAG levels, and increased clearance by liver and kidneys

Question 59

What is the dose of rocuronium in the burn patient?

Answer 59

1.2mg/kg-1.5mg/kg

Question 60

What is the onset time of ROC in the burned patient compared to the unburned?

Answer 60

90 seconds in the burned patient compared to 60 in the unburned.

Question 61

Why do patients with extensive burns have difficulty thermorefulating (neurologically)

Answer 61

The inflammatory response to large burns causes an increase in the hypothalamic core temperature set point and the metabolic rate is increased to maintain this increased temperature.

Question 62

What can be given to persistent post operative pain that is resistant to opiates?

Answer 62

0.25mg/kg of ketamine IV.

Question 63

Mild shock base deficit

Answer 63

2-5 mmol/L

Question 64

Moderate shock base deficit?

Answer 64

6-14 mmol/L

Question 65

Severe shock base deficit

Answer 65

>14mmol/L