Trauma Surgery Flashcards
(113 cards)
1
Q
What differentiates traumatic injury from other diseases?
A
Unlike diseases with a biological basis, traumatic injury results from an external force disrupting the body’s normal structure and function.
2
Q
What are the common causes of traumatic injury?
A
Traumatic injury is typically attributed to circumstance and misfortune, rather than genetics or environmental exposure, and is considered a disease of human behavior.
3
Q
How significant is the impact of traumatic injury in terms of mortality?
A
Traumatic injury remains the leading cause of death for Americans aged 1 to 44, resulting in 214,000 deaths in the United States alone – approximately one death every 3 minutes.
4
Q
What efforts have contributed to the reduction of traumatic injuries from motor vehicle collisions (MVCs)?
A
Improvements in automobile safety and the development of public policy have successfully reduced annual traumatic injuries from MVCs, falls, and firearms by nearly one-third.
5
Q
What services does a Level I trauma center provide?
A
A Level I trauma center provides a full spectrum of trauma care and offers immediate access to specialized services.
6
Q
What are the capabilities of a Level II trauma center?
A
A Level II trauma center has a 24-hour in-house general surgeon and specialty access available to support and initiate definitive care.
7
Q
What defines a Level III trauma center?
A
A Level III trauma center maintains a 24-hour in-house emergency room physician and specialty access for general surgery/anesthesia. It has transfer agreements with higher-level centers and provides stabilizing care.
8
Q
What is the role of a Level IV trauma center?
A
A Level IV trauma center offers basic emergency department capabilities, provides ATLS (Advanced Trauma Life Support) support, and can transfer patients to higher-level trauma centers for further care.
9
Q
What is the purpose of the ATLS course developed by the ACS?
A
The ATLS course provides a structured framework for the initial management and evaluation of trauma patients from prehospital to hospital settings.
10
Q
What are the primary goals in the prehospital management of trauma patients?
A
The primary goals include ensuring a patent airway, adequate ventilation, and control of external bleeding.
11
Q
What is the primary survey and its components in the ATLS guidelines?
A
The primary survey, referred to as the ABCDEs of trauma care, aims to identify and manage life-threatening conditions. The components are Airway, Breathing, Circulation, Disability, and Environment.
12
Q
When does the secondary survey occur and what is its purpose?
A
The secondary survey is a thorough head-to-toe assessment, including a neurologic examination, conducted after the primary survey and initial stabilization. It identifies any injuries missed in the primary survey.
13
Q
What are the immediate causes of death in trauma patients?
A
- Brain injury
- severe hemorrhage.
Primarily
14
Q
What are the late causes of death following a traumatic injury?
A
- Infection
- Multisystem organ failure
- Further brain injury
- Hemorrhage.
15
Q
What are the common causes of death after discharge in trauma patients?
A
- Cardiovascular event
- second major traumatic injury
- neurologic injury
- malignancy.
16
Q
What mechanisms contribute to blunt trauma in patients?
A
Blunt trauma can result from direct impact, deceleration, continuous pressure, shearing, and rotary forces, often associated with high-energy impacts like high-speed collisions and substantial falls.
17
Q
How does Newton’s first law relate to traumatic injuries?
A
Newton’s first law explains that an object in motion remains in motion until acted upon by an external force; thus, abrupt deceleration can result in negative gravitational forces causing internal injuries.
18
Q
Why do internal organs suffer damage in cases of blunt trauma?
A
In blunt trauma, the body’s exterior decelerates abruptly while internal organs continue moving forward at the original velocity, leading to injuries from rotary and shearing forces tearing them from their attachments.
19
Q
What damages can rotary and shearing forces cause in blunt trauma?
A
- Can lead to the disruption of connective tissue, blood vessels, and nerves.
20
Q
What are the clinical presentations of Beck’s Triad Trauma?
A
- Hypotension
- Jugular venous distention
- Distant heart sounds
21
Q
Mention examples of Blunt Trauma:
A
- Motor Vehicle Collision Trauma
- Thoracic Trauma
- Tension pneumothorax
- Pericardial tamponade (Becks triad)
- Massive hemothorax
- Cardiac rupture
- Traumatic aortic rupture
- Tracheal injuries
22
Q
What is the range of severity for penetrating injuries?
A
Penetrating injuries can vary widely in severity, from minor like a simple pinprick to significant such as a high-velocity projectile injury.
23
Q
What factors determine the extent of damage in a penetrating injury?
A
- Type of wounding instrument
- the projectile’s velocity at impact
- the characteristics of the tissue it passes through.
24
Q
What are examples of wounding instruments that can cause penetrating injuries?
A
- knives
- projectiles like bullets or shrapnel.
25
How does the velocity of a projectile affect the resulting injury?
* Higher velocities can cause more significant damage as the energy transfer to tissues is greater.
26
Why do the characteristics of tissue matter in penetrating injuries?
The impact and damage of a penetrating injury are influenced by the type of tissue involved; for instance, bone, muscle, fat, blood vessels, nervous tissue, and organs all respond differently to trauma.
27
What are the key elements of Damage Control Resuscitation?
1. Warming the patient
2. Early correction of coagulopathies
3. Minimizing crystalloid use
4. Permissive hypotension
5. Reversing metabolic acidosis
6. Implementing massive transfusion protocols
7. Using antifibrinolytics like tranexamic acid
28
Why is warming the patient a critical step in DCR?
Warming helps prevent hypothermia, one part of the lethal triad, which can exacerbate coagulopathy and acidosis.
29
How does correcting coagulopathies fit into the DCR approach?
* To prevent excessive bleeding
* To stabilize the patient's condition as part of the DCR strategy.
## Footnote
**DCR = Damage control resucitation**
30
What is the DCR stance on crystalloid administration?
* Advocates for the avoidance of large amounts of crystalloid
* To prevent dilutional coagulopathy and fluid overload.
## Footnote
**DCR = Damage control resucitation**
31
How is permissive hypotension used in DCR?
* Involves tolerating lower blood pressure until bleeding control is achieved
* To reduce blood loss and improve clot formation.
## Footnote
**DCR = Damage control resucitation**
32
What is the approach to reversing metabolic acidosis in DCR?
Reversing metabolic acidosis is an early and integral part of DCR to improve coagulation function and overall patient stability.
## Footnote
**DCR = Damage control resucitation**
33
What is the significance of massive transfusion protocols in DCR?
Implementing early massive transfusion protocols with balanced ratios (1:1:1) of blood products is a key component of DCR to manage hemorrhage and coagulopathy
34
How are antifibrinolytics utilized in DCR?
Antifibrinolytics, particularly tranexamic acid, are used in DCR to stabilize clots and reduce the breakdown of fibrin, thereby aiding in the control of bleeding.
35
What is the clinical presentation of Trauma Triad?
1. Hypothermia
2. Acidosis
3. Coagulopathy
36
Describe the ATLS Curriculum in Trauma Management
- ATLS provides a structured framework for managing traumatic injury,
- It is applicable across various disciplines, not specific to any one field.
37
Verbalize the ABCDs of Trauma Anesthesia - Overview
- Discusses the implications of the ABCDs in trauma anesthesia
- Outlines an approach for clinical management.
38
What is the Primary Goal of the Anesthesia Team in Trauma?
1. To facilitate rapid surgical management
2. ensuring swift transition of the patient to the operating room.
39
What is the Nature of Trauma Anesthesia and Surgery?
- Often an emergency situation
- Necessitating quick patient movement to the operating room for surgical correction of traumatic injuries.
40
What is the Third most common respiratory-related event in a trauma patient?
- Difficult tracheal intubation.
- Leads to death and brain damage
41
What can be a factor that lead to difficult tracheal intubation?
1. Anesthetist not able to perform a thorough airway examination.
42
What are the consequences of Difficult Tracheal Intubation?
1. Death
2. Brain damage
43
What are the most common indications for endotracheal intubation?
1. Inadequate oxygenation/ventilation
2. Loss of airway reflexes
3. Decreased level of consciousness GCS < 8
4. Occasionally the need for pain management and ability to safely provide deep sedation during painful procedures
44
Challenges in Airway Examination and Management in Trauma
- Urgency often prevents thorough airway examination.
- Complications include facial injuries, airway foreign bodies, neck injuries, hypoventilation with hypoxemia, and apnea.
45
Rapid Sequence Intubation (RSI) - Purpose
- RSI aims to quickly control a patient’s airway
- minimize the risk of gastric aspiration.
46
Components of Rapid Sequence Intubation
1) Preoxygenation
2) Cricoid pressure
3) Induction/Muscle relaxation
4) Apneic ventilation
5) Direct laryngoscopy.
47
Preoxygenation in RSI
- High-flow oxygen (10–15 L) is critical to reduce hypoxia risk during airway management
Using:
- nonrebreather facemask,
- bag-valve facemask, or
- anesthesia circuit.
48
Challenges in Preoxygenation for RSI
In patients unable to follow commands or perform vital capacity breaths, controlled positive pressure mask ventilation is used, keeping inspiratory pressure below 20 cm H2O to prevent gastric distention.
49
Cricoid Pressure in RSI
- applied during RSI, helps prevent gastric insufflation during bag-valve-mask ventilation and passive reflux of gastric contents
- It has been determined that 30 newtons (∼3 kg or 10 lb of
pressure) adequately occludes the esophagus
50
What is the role and appropriate pressure of cricoid pressure in Rapid Sequence Intubation (RSI)?
* Cricoid pressure is maintained throughout RSI and is not released until Endotracheal Tube (ETT) placement is confirmed.
* The appropriate pressure is 30 newtons (∼3 kg or 10 lb) to adequately occlude the esophagus.
51
What are the options for anesthetic induction in RSI and is there a superior agent?
Anesthetic induction can be achieved using various agents with no evidence supporting the superiority of one over another.
52
What is the suggested induction dose of propofol for hemodynamically unstable patients in RSI?
For hemodynamically unstable patients, the suggested dose is one-tenth to one-half of the normal induction dose of propofol.
53
Why consider Ketamine or Etomidate for RSI in trauma patients, especially if hemodynamically unstable?
Ketamine or Etomidate are considered for RSI in trauma patients due to their minimal impact on causing significant hypotension, with Etomidate often used as the primary induction agent for its ability to minimize significant hypotension in hemodynamically unstable trauma patients.
54
What is the role of Succinylcholine in Rapid Sequence Intubation, and what is the preferred dosage?
Succinylcholine, at a dose of 1.5 mg/kg, is generally preferred for RSI due to its rapid and favorable muscle relaxation unless contraindications exist.
55
How does Rocuronium compare to Succinylcholine in RSI, and what is the recommended dose?
Rocuronium, at a dose of 1.2 mg/kg, can be used for RSI. Its onset time is similar to that of Succinylcholine, with only a slight delay in achieving complete muscle relaxation.
56
What are the risks associated with Succinylcholine in patients with spinal cord injuries or crush injuries?
Succinylcholine may cause lethal hyperkalemia in patients with spinal cord injuries or massive crush injuries, typically emerging 24 to 48 hours after the injury.
57
What are the laryngoscopy options for RSI in trauma patients, and is there an optimal choice?
Both direct and video laryngoscopy can be used in trauma patients for RSI. There is no evidence suggesting an optimal laryngoscope blade or size. Video laryngoscopy is becoming more common as it allows for both direct and video-assisted views with a video screen for team viewing.
58
Why is cervical spine injury a significant concern in the airway management of trauma patients?
Cervical spine injury should always be assumed in trauma patients until proven otherwise due to its significant impact on airway management.
59
What are the two approaches to managing a cervical spine injury in airway management?
Cervical spine injury management can be 'emergent,' involving inline stabilization and Rapid Sequence Intubation (RSI), or 'controlled,' involving an awake flexible intubating technique.
60
Logical Management algorithm
61
When is an alternate airway plan indicated, and what are the options?
An alternate airway plan, including a laryngeal mask airway, laryngeal tube airway, or a surgical airway, is indicated if tracheal intubation is not possible.
62
What are the specific indications for performing a surgical airway?
* Edema of the glottis
* fracture of the larynx
* severe oropharyngeal hemorrhage
* obstructing the airway
* failure to place an endotracheal tube through the vocal cords.
63
Why is a surgical cricothyroidotomy often preferred over a tracheostomy in emergency situations?
Surgical cricothyroidotomy is preferred because it is easier to perform, associated with less bleeding, and requires less time than an emergency tracheostomy.
64
How is a surgical cricothyroidotomy performed?
Perform a surgical cricothyroidotomy by making a skin incision through the cricothyroid membrane, using a curved hemostat or scalpel handle to dilate the opening, and then inserting a small endotracheal or tracheostomy tube.
65
Identify the structure on the image below:
1. Thyroid cartilage
2. Crycothyroid membrane
3. Cricoid cartilage
4. Trachea
66
What is the expected Pao2 and Sao2 in a healthy patient breathing room air and when placed on 100% oxygen?
* In-room air (21% oxygen), a healthy patient typically has a Pao2 of ~100 mm Hg and Sao2 of 100%.
* On a high-flow, nonrebreather mask with 100% oxygen, Pao2 could reach ~500 mm Hg, while Sao2 remains at 100%.
67
What is the prevalence and progression of pulmonary contusions in blunt thoracic trauma?
Pulmonary contusions are the most common lung injury in blunt thoracic trauma, affecting up to 70% of patients. They can develop over time and may progress to acute respiratory distress syndrome (ARDS).
68
What is the targeted oxygen saturation in ARDS, and what are the preferred ventilation techniques?
In ARDS, a target oxygen saturation of 90% to 94% is allowed to avoid oxygen toxicity. Reduced tidal volume ventilation is preferred, and Positive End-Expiratory Pressure (PEEP) is used to recruit collapsed alveoli and improve ventilation.
69
What happens to vascular tone and systemic vascular resistance (SVR) when blood volume is reduced?
Reductions in blood volume cause an immediate change in vascular tone and increase in SVR. Blood is shunted from ischemia-tolerant areas (like skin and bone) to highly metabolic tissues (brain, heart, gut) to maintain cellular perfusion and aerobic respiration.
70
How does vascular shunting change as blood loss worsens, and what happens during decompensated shock?
As blood loss worsens, vascular shunting increases, leading from compensated to decompensated shock. In decompensated shock, blood is redirected from lower metabolic organs (kidneys, gut) to higher metabolic structures to maintain perfusion.
71
What changes occur in systemic vascular resistance and cardiac function during decompensated shock?
In decompensated shock, changes to SVR are less effective in maintaining perfusion. The body compensates for decreased stroke volume and cardiac output by increasing heart rate and contractility.
72
ATLS Classification of Schock
73
What is the significance of IV access in treating hemorrhagic shock, and what is Poiseuille’s law's relevance?
Appropriate IV access is crucial for hemorrhagic shock management. The speed of IV fluid administration is related to the catheter's radial diameter, as explained by Poiseuille’s law. Central venous access should be considered early in trauma management.
74
What are the ATLS resuscitation guidelines for fluid infusion in hemorrhagic shock?
ATLS guidelines suggest brisk isotonic crystalloid infusion (up to 2 L) for limited injuries with minimal bleeding and component therapy for larger resuscitations with more significant blood loss.
75
What is the role of colloids in the treatment of hemorrhagic shock, and what are their potential risks?
Colloids can rapidly restore intravascular volume but may contribute to pulmonary edema and increased bleeding if hemostasis has not been achieved.
76
How should blood be replaced in trauma center settings for patients with hemorrhagic shock?
At trauma centers, RBCs should be replaced to maintain adequate oxygen-carrying capacity. Ideally, lost blood is replaced with a 1:1:1 volume ratio of packed RBCs, plasma, and platelets.
77
What is the recommendation regarding the use of dextrose-containing solutions in initial resuscitation for hypovolemic hemorrhagic shock?
Dextrose-containing solutions are generally undesirable for initial resuscitation fluid administration in hypovolemic hemorrhagic shock
78
What causes stress-induced hyperglycemia in trauma and critical illness?
Stress-induced hyperglycemia in trauma is linked to increased levels of cortisol, catecholamines, glucagon, growth hormone, and enhanced gluconeogenesis and glycogenolysis.
79
What is the role of antifibrinolytic agents, specifically tranexamic acid (TXA), in trauma patients with severe hemorrhage?
Early use of an antifibrinolytic agent, particularly tranexamic acid (TXA), is supported by evidence for trauma patients with severe hemorrhage
80
What are the common blood pressure targets in the treatment of hemorrhagic shock, and why?
Most clinicians target a Systolic Blood Pressure (SBP) of ≥ 85 to 90 mm Hg while limiting fluid administration. This approach reduces bleeding and improves surgical exposure for vascular injury repair.
81
What is the impact of each unit of Packed Red Blood Cells (PRBC) on Hematocrit (HCT)?
Each unit of PRBC (200 mL of red cells) increases HCT by approximately 3% in the absence of ongoing bleeding.
82
How does replacing 500 mL of blood loss affect coagulation factors?
For every 500 mL of blood loss replaced, there is a 10% decrease in the concentration of coagulation factors.
83
What happens to coagulation proteins when 8-10 units of PRBC are transfused?
At 8-10 units of PRBC transfusion, coagulation proteins fall to about 25% of normal levels.
84
What is the effect on platelet count after transfusing 10-12 units of PRBC?
At 10-12 units of PRBC transfusion, the platelet count drops to 50% of normal levels.
85
What should be remembered about dilutional coagulopathy in massive transfusion protocols?
It's important to remember that dilutional coagulopathy does occur during massive transfusion and should be actively prevented.
86
What are the primary causes of trauma-induced coagulopathy?
he primary causes are dilution of factors, hypothermia/acidosis, severe Traumatic Brain Injury (TBI), and hypovolemic hemorrhagic shock.
87
What does the ASA recommend for managing coagulopathy in trauma patients?
The ASA recommends administering procoagulant products like Prothrombin to maintain an INR of 1.5 or less and a platelet count above 50,000. Viscoelastic assays (TEG, ROTEM) along with a platelet count are recommended when coagulopathy is suspected.
88
What should be done if viscoelastic assays are not available for evaluating coagulopathy?
If viscoelastic assays are unavailable, standard coagulation tests like INR, activated partial thromboplastin time (aPTT), fibrinogen concentration, and platelet count should be obtained.
89
How does hypothermia contribute to coagulopathy in trauma patients?
Hypothermia can cause significant coagulopathy due to radiant heat loss from patient-environment temperature gradients. It affects platelet function and reduces fibrin enzyme kinetics.
90
What is the most effective management approach for hypothermia and acidosis in trauma patients?
The best management is rewarming the patient and focusing on restoring optimal perfusion to correct acidosis. Warming fluids during administration and controlling the ambient temperature in the resuscitation unit/operating room are crucial steps.
91
What does the initial neurologic assessment of a trauma patient involve?
Neurologic assessment begins upon hospital entry, focusing on patient mentation, behavior, and response to stimuli. A Glasgow Coma Scale (GCS) score is assigned during the primary or secondary survey and is continually reassessed
92
What is the focus of care for patients with primary TBI?
The goal is to prevent secondary brain damage due to intracranial complications like intracranial bleeding, edema, and increased Intracranial Pressure (ICP).
93
What are the recommended Mean Arterial Pressure (MAP) and Cerebral Perfusion Pressure (CPP) targets for TBI patients with increased ICP?
It is recommended to maintain a MAP greater than 80 mm Hg to ensure a CPP of greater than 60 mm Hg in TBI patients with increased ICP. ICP monitoring is often indicated in moderate and severe brain injuries.
94
What are the methods for temporary reduction of ICP in TBI patients?
* Incremental doses of propofol
* Moderate hyperventilation (short term)
* Mannitol and/or furosemide for diuresis
* Elevation of the patient's head relative to the heart.
95
What are the most common causes of Spinal Cord Injury (SCI) in the United States?
* Motor Vehicle Crashes (MVCs) at 31.5%
* Falls at 25.3%
* gunshot wounds at 10.4%.
96
What are the key factors that influence the outcome after an acute SCI?
* The outcome depends on the severity of the acute injury
* avoiding exacerbation during rescue, transport, and hospitalization
* preventing hypoxia and systemic hypotension that can further impair neural function.
97
What are the common locations and types of SCI?
Most SCIs involve the craniocervical junction (33%).
Over 50% of traumatic SCIs occur in the cervical region, resulting in:
* incomplete tetraplegia (31%)
* complete paraplegia (25%)
* complete tetraplegia (20%)
* incomplete paraplegia (19%)
98
Review the Spinal cord injury table
99
Signs and symptoms of Spinal cord injury table.
100
How do hypoxia and hypercarbia affect spinal cord injuries?
Hypoxia and hypercarbia can exacerbate the damage in spinal cord injuries, worsening the overall impact
101
What is the consequence of spinal cord injuries at the C1 or C2 level?
Injuries at the C1 or C2 level can result in complete respiratory paralysis. Without immediate airway support and assisted ventilation, death can occur within minutes.
102
What is crucial in the evaluation of spinal cord injuries?
A thorough evaluation of all seven cervical vertebrae is essential; C7 is the most common site of injury.
103
Why might Succinylcholine be problematic in patients with spinal cord injuries?
Succinylcholine may cause cardiac arrest in patients with massive muscle injury or denervation, common in SCIs, severe crush injuries, or burns.
104
What is a safer alternative to Succinylcholine for patients with SCI?
For patients with SCI, a conservative approach involves using a non-depolarizing neuromuscular blocker like rocuronium or avoiding paralysis altogether during airway management.
105
Spinal Shock Vs. Hemorrhagic Schock
106
What are the common symptoms observed in spinal shock?
A triad of hypotension, bradycardia, and hypothermia often occurs due to a relative sympathectomy in SCI patients.
107
How does the location of the SCI affect the severity of spinal shock?
The severity of spinal shock increases with higher-level SCIs. SCIs at or above the T6 level result in severely impaired Central Nervous System (CNS) function.
108
What are the cardiovascular effects of spinal shock?
loss of sympathetically mediated cardioaccelerator responses and loss of sympathetic tone leads to:
* significant bradycardia
* vasodilation
* pooling of peripheral circulation
* decreased venous return
* reduced cardiac output
* hypotension.
109
How does spinal shock affect temperature regulation?
Spinal shock disrupts sympathetic pathways from the hypothalamus to peripheral blood vessels, impairing the patient's ability to regulate temperature by constricting or dilating blood vessels or shivering.
110
What is the likelihood of high paraplegic or quadriplegic patients experiencing autonomic dysreflexia post-SCI?
Up to 98% of high paraplegic or quadriplegic patients may experience autonomic dysreflexia from several weeks to 6 months post-SCI, especially following a painful injury below the level of the spinal lesion.
111
What characterizes autonomic dysreflexia in SCI patients?
Autonomic dysreflexia, potentially fatal, occurs in patients with SCI above T6. It's marked by sudden sympathetic activation due to noxious stimuli, often triggered by surgery, or colorectal, or bladder distention.
112
What are the symptoms and potential consequences of autonomic dysreflexia?
Autonomic dysreflexia presents with severe hypertension and can lead to seizures, pulmonary edema, myocardial infarction, acute renal injury, and intracranial hemorrhage.
113
How is an acute autonomic dysreflexia attack managed?
Management includes identifying and correcting the noxious stimuli. Bladder catheterization, checking for urinary tract infections, and rectal disimpaction are essential, as bladder distention and fecal impaction are common triggers.
