Article Trauma-Damage Control Resus Early Coag Of Trauma

Front 1

EXAM QUESTION
The lethal triad in severely injured casualties consists of?

Back 1

1) hypothermia
2) acidosis
3) coagulopathy

Front 2

Conventional resuscitation practice for damage control currently focuses on?

Back 2

rapid reversal of acidosis and prevention of hypothermia

Front 3

Conventional surgical techniques for damage control currently focus on?

Back 3

controlling hemorrhage and contamination

Front 4

Why has direct treatment of coagulopathy been relatively neglected

Back 4

viewed as byproduct of resuscitation, hemodilution, and hypothermia
Delayed by blood banking logistics

Front 5

For the 10% of casualties (most seriously injured) in shock and coagulopathic what is optimal resuscitation fluid?

Back 5

liquid plasma

Front 6

critical to optimal coagulation function, what does acidosis significantly impair?

Back 6

thrombin generation rates

Front 7

What are the goals of controlling acidosis with volume loading of blood components once hemostasis is obtained?

Back 7

restoration of normal lactate, base deficit, or pH

Front 8

Damage control as a structured intervention begins when?

Back 8

immediately after rapid initial assessment in the ED progressing through the OR into the ICU.

Front 9

Why is resuscitation limited to keep blood pressure at about 90 mm Hg?

Back 9

prevent renewed bleeding from recently clotted vessels

Front 10

EXAM QUESTION

How does one accomplish intravascular volume restoration in damage control resuscitation of the severely injured?

Back 10

thawed plasma as a primary resuscitation fluid in at least a 1:1 or 1:2 ratio with PRBC's.

Front 11

EXAM QUESTION

Discuss use of crystalloid in damage control resuscitation

Back 11

use is minimized and serves mainly as a drug carrier and to keep lines open between the units of blood products

Front 12

What is the leading cause of early death in both civilian trauma and military combat casualty care?

Back 12

Hemorrhage

Front 13

Is there a US FDA indication for Factor VIIa for traumatic shock?

Back 13

Not currently.
Factor VIIa is available according to hospital-specific criteria and after consultation with an on-call hematologist.

Front 14

According to the articles, MT (massive transfusion) protocol is to emphasize what?

Back 14

Early FFP use in a FFP: PRBC ratio of 1:1.

Front 15

Factor VII is in which coagulation pathway?

Back 15

Extrinsic pathway.
III (tissue thromboplastin)-->F VIIa --> X

Front 16

Cryoprecipitate can rapidly increase the concentrations of what coagulation factors?

Back 16

Fibrinogen and VonWillebrand-facto/VIII complex

Front 17

What was cryoprecipitate initially developed and used for?

Back 17

Treatment of hemophilia A and von Willebrand disease
(since replaced by specific preparations)

Front 18

List what is contained in cryoprecipitate

Back 18

fibrinogen
von Willebrand-factor/VIII complex
fibrin stabilizing factor XIII

Front 19

Initially, what was the main indication for cryoprecipitate

Back 19

restoration of plasma labile factor VIII

Front 20

Initially deficit of what factor was thought to be one of the vital defects caused by massive whole blood transfusion?

Back 20

plasma labile factor-VIII

Front 21

In massive transfusions, generally how long can you delay giving platelets?

Back 21

until 10-20 units of RBC have been given.
less urgent situations guided by platelet counts or evidence of coagulopathic bleeding

Front 22

Cohort data suggest improved survival in massive transfusion when administering a standard 6 pack platelets for how many units of RBC's?

Back 22

7-8 units of RBC

Front 23

Cryoprecipitate is given in what increments?

Back 23

10 U increments
rapidly raise concentration of fibrinogen
(Benefits unknown)

Front 24

Thawed plasma can be kept for how many days?

Back 24

5 days

Front 25

How long does it take for a unit of FFP to thaw?

Back 25

20-30 minutes
(each one is a 250g block of ice in a plastic bag at -30 to -80 celcius)

Front 26

How is cryoprecipitate stored?

Back 26

Frozen- so it must be thawed

Front 27

How are platelets stored?

Back 27

in the blood bank because they have stringent storage requirements (20-24 degrees C on a shaker or rotator)
and SHORT outdate

Front 28

One unit of FFP contains approximately how much fibrinogen?

Back 28

0.5 g of fibrinogen and all other pro-and anticoagulant proteins in balanced proportions

Front 29

One unit of cryoprecipitate contains how much fibrinogen?

Back 29

0.25 g of fibrinogen, but in 4% of the volume of a unit of FFP
10ml compared with 250 ml respectively.

Front 30

is routine prophylactic cryoprecipitate supplementation harmful?

Back 30

not harmful but may not be routinely necessary since FFP can most likely ensure hemostatic concentrations of all coagulation factors INCLUDING FIBRINOGEN

Front 31

clinical approach to administering plasma, platelets, and cryoprecipitate for bleeding control are:

Back 31

1) 95% of all injured patients do not need any of these components
2) 1 in 20 of the remaining 5% are coagulopathic at onset of resuscitation (result of drugs or acquired disease)needing immediate treatment and oxygen carrying capacity

Front 32

A clinical approach to the problems of administering plasma, platelets, and cryoprecipitate for the control of bleeding needs to take into account four facts. Name 2 of these. (the other 2 are in a different question)

Back 32

3) Resuscitation progresses to massive transfusion- hemodilution is inevitable d/t composition of banked blood components
4) massively bleeding patients have low blood volume and ongoing vigorous resuscitation with crystalloids and colloids.

Front 33

What is the second leading cause of death in combat casualties?

Back 33

Hemorrhage

Front 34

Hypovolemic patients lead to deficient coagulation profile sooner than anticipated d/t what?

Back 34

dilution in the field and the ER with crystalloids to replace volume without any definitive treatment plan.

Front 35

A PT above what % generally ensures normal coagulation with a safe margin?

Back 35

30-40%

Front 36

Factor VII hooks up with tissue factor where?

Back 36

In vessel endothelium and starts a cascade and formation of clot

Front 37

what other 2 factors does one need for clot formation?

Back 37

Platelets and calcium

Front 38

About how much calcium is given during massive transfusion and how often?

Back 38

1 amp of calcium given every 4-5 units of blood given

Front 39

EXAM QUESTION

Define shock

Back 39

inadequate oxygen utilization at the cellular level and the ramifications of such inability to repay accumulated oxygen debt

Front 40

after losing 2 blood volumes, most patients approach the critical platelet count of?

Back 40

50,000

Front 41

True/false
Earlier supplementation of FFP to avoid coagulopathy is the main theme of these articles?

Back 41

true

Front 42

nonviable platelets are sequesterd into which organ?

Back 42

spleen

Front 43

What slow test can suggest problems not evident from PT and platelet count?

Back 43

Thromboelastography (TEG)

Front 44

the recovery rate of five-day old platelets after transfusion is ?%

Back 44

50%

Front 45

Mild hypothermia, core temp above 33C, affect platelet adhesion more/less than coagulation enzymes?

Back 45

MORE
At temps under 33C both platelet adhesion and coagulation enzyme activities are reduced.

Front 46

what organ produces alot of fibrinogen?

Back 46

The liver

Front 47

Allow permissive hypotension which is to keep the MAP between _____and _______ to prevent renewed bleeding

Back 47

50-55. don't want to aggrevate ongoing blood loss. Keep perfusion to major organs; keep them oxygenated

Front 48

Coagulation bomb is composed of what?

Back 48

Cryoprecipitate
Factor VII
Platelets

Front 49

Some reasons platelets don't work include

Back 49

patient is acidotic
patient is cold

they sequester in the spleen

Front 50

What are the protocols to give Factor VII?

Back 50

lactate less than 13
no pressors on board
fibrinogen >100
not a futile effort (it's expensive)
PT<21 I think PTT>34

Front 51

At what temperature do platelets stop working?

Back 51

35 C

Major issues at 33C

Front 52

Trends are _________

Back 52

Friends

Front 53

Anaerobic metabolism is energy costly. ?___ ATP produced? What happens to lactate levels?

Back 53

Increased lactate
2 ATP produced
Energy costly
Cell takes on water...interstitial fluid...cell next to it swells..capillary between pinches off..reperfusion injury

Front 54

What is spinal shock?

Back 54

T6 injury
complete sympathectomy
lose all autonomic function below level of injury including the reflex arc

Front 55

When is spinal shock resolved?

Back 55

When reflexes return
(few days-week after injury)

Front 56

Trauma
#1 killer is___________
#2 killer is__________

Back 56

#1- Traumatic brain injury
#2-Hemorrhage

Front 57

Neurogenic Shock is

Back 57

complete sympathectomy below level of injury
vasodilation

Front 58

When do you get autonomic dysreflexia? What is it?

Back 58

get it after spinal shock is resolved.
HTN below level of injury...have sympathectomy..
massive reaction to noxious stimuli (ex..full bladder). Nerve signal can't get to brain d/t lesion. Heart senses the HTN and sends signal to brain. Brain tells heart to slow down (Bradycardia) and dilate out the blood vessels (Hypotension) but the signal doesn't go below the level of the spinal cord lesion. So get HTN below level of injury and bradycardia/hypotension above the level of injury. Wicked. Relieve the noxious stimuli and the HTN goes away...usually.

Front 59

Where are the 5 places trauma victims lose blood?

Back 59

1) Chest
2) Abdomen
3) Long bones (thigh 2-3 liters)
4) Street
5) Retroperitoneum

Front 60

Goals in hemorrhagic shock

Back 60

1) stop bleeding
2) do resuscitation
a) FFP-no O2 carry capacity
b) PRBC's- +O2 carry capacity

Front 61

Triad of death consists of?

Back 61

1) Acidosis
2) Hypothermia
3) Coagulopathy

Front 62

What type of blood do you give a female of childbearing age?

Back 62

0 negative

Front 63

What are the risks of transfusion for the following?
O+ uncrossmatched________%
Type specific_________%
Type and crossmatched_______%

Back 63

O+ uncrossmatched 1%
Type specific 0.01%
Type and crossmatched 0.001%

Front 64

Describe reperfusion injury

Back 64

impaired microcirculation
shunting of blood away from more perfused areas
anaerobic metabolic process

Front 65

What are the top 3 mechanisms of trauma injury?

Back 65

1) accidents
2) falls
3) industrial disease

Front 66

What does PARC stand for?

Is this a level one trauma center?

Back 66

Primary
Adult
Resource
Center

Not a level 1 trauma center

Front 67

Old thoughts on FFP is that it is simply what?

Back 67

it is NOT a volume expander

Front 68

New thoughts on FFP are

Back 68

It is a good volume expander in certain categories where it becomes the volume expander of choice (massive transfusion)

Front 69

Give an example of the following types of wounds.
1) penetrating
2) Blunt
3) Burns
4) Mixed
5) Biological
6) Environmental

Back 69

1) penetrating stab wound
2) blunt car accident/falls
3) burns-thermal injury/fires
4) Mixed-fence post thru chest
5) Biological-Sarin gas
6) Environmental-cold/heat/snake bites

Front 70

Blunt trauma-
first thing to think about is?

Back 70

Tension pneumothorax

first sign is increased peak inspiratory pressures
2nd is hypotension

Front 71

How do you treat tension pneumothorax?

Back 71

14 ga angiocath placed midclavicular at level of 2nd intercostal

Front 72

#1 reason patients die in trauma deaths is from what injury that is difficult to treat?

Back 72

TBI- traumatic brain injury

Front 73

#2 reason patients die in trauma deaths is from what injury that is easier to treat if you get to it early?

Back 73

Hemorrhage. 40% trauma deaths dut to hemorrhage.
10% of these die from MODS

Front 74

How many units of blood would define a massive transfusion?

Back 74

10 units

Front 75

At what GCS do you intubate?

Back 75

8

Front 76

What are the 3 stages of shock?

Back 76

1) compensated
2) uncompensated
3) irreversible

Front 77

list some risks of colloidal transfusions

Back 77

coagulopathy dilution, allergic reaction, dilutional electrolyte disturbances, hypothermia, febrile, reperfusion injury

Front 78

List some risks of crystalloid transfusions

Back 78

dilutional, hypothermia, acidosis, 3rd spacing (abdominal compartment syndrome), reperfusion injury

Front 79

Are vasopressors contraindicated in hemorrhagic shock?

Back 79

Yes unless there is a neurogenic component when you can't overcome the hypotension with just volume

Front 80

List some etiologies of shock

Back 80

Hypovolemia-hemorrhagic
Cardiogenic-pump problem
Neurogenic-SCI
Distributive- sepsis/anaphylac
Obstructive-impedes Right heart return/preload
Traumatic- combo hemorrhagic and (neuro/cardio)

Front 81

Define autonomic hyperreflexia

Back 81

syndrome of sympathetic imbalance that may occur after the phase of spinal shock unique to patients after SCI at T-5 level and above. Irritating stimulus introduced to body below level of SCI, stimulus sends a nerve impulse to SC where it travels upward unti they are blocked by lesion at level of injury. Impulses can't reach the brain, a reflex is activated that increases activity of the sympathetic portion of the ANS, results in spasms and narrowing of blood vessels causing HTN. Nerve receptors in heart and blood vessels sense this HTN and send a message to brain- brain sends message to the heart causing bradycardia and vessels above level of injury to dilate. Brain can't send signals to dilate to vessels below level of injury (d/t the lesion) and so BP can't be regulated.

Hint 81

Treatment is to give nitrates.

Front 82

How do you know when enough is enough during a resuscitation?

Back 82

trends are friends
repaid oxygen debt
perfusion to all cells
labs are normal
(rare to see this in the OR)

Front 83

What is the most difficult trauma patient to anesthetize?

Back 83

Hypovolemic (hemorrhagic shock) with a TBI
want to give volume but it will increase the ICP
walk a fine line with what you do
get to the OR quick
open skull
relieve pressure
start resuscitation