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130 Cards in this Set

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In trauma, what are signs that airway is clear?
gag reflex, ability to talk
what are signs of airway compromise?
stridor, hoarseness, respiratory retractions (between ribs), accessory muscle use
What is the initial evaluation of a trauma patient?
ABCDE
Airway
Breathing
Circulation
Disability
Environment
What kind of history do you need to take on a trauma pt?
AMPLE
Allergies
Meds
Previous illnesses
Last Meal
Events surrounding injury
What are indications for intubation?
inadequate resp effort, severely depressed MS, GCS of 8 or less, compromised resp mechanics like broken ribs
What are 3 Criteria for GCS?
Eye Opening Response (4)
Verbal Response (5)
Motor Response (6)
When a trauma pt is stable, what's the first thing to do?
CXR, pulse ox
What do you do if you see a "sucking" chest wound?
seal it with occlusive dressing
What to do if a chest tube is not fully inflating the lung?
assuming that the chest tube is working, it may be in wrong location, like subQ, clotted off. Replace or reposition. Maybe put another one in.
If you insert a chest tube but large amounts of air continue to leak into it, what is probably going on?
Major airway injury with disruption of bronchus or trachea. May need partial lung resection
When is it ok to not do anything about a small pneumo?
Not enlarging, no free fluid in pleural space, asymptomatic, no other injuries esp chest injuries
If there's a small pneumo and the pt may go to surgery, is it ok to leave it alone?
No, because intubation and assisted ventilation puts the tracheobronchial tree at a pressure of 20-40mmHg, which increases risk of making pneumo bigger and dev into tension pneumo
What are sxs of a pneumo?
Absent breath sounds, hypotension, distended neck veins. Chest tube immediately or at least needle aspiration
What direction does the mediastinum deviate in pneumo?
Away from side of pneumo
What do you suspect if you have distended neck veins and hypotension but with intact breath sounds?
Cardiac tamponade
Beck's triad for cardiac tamponade? Other signs of tamponade?
1. Hypotension
2. JVD
3. Distant heart sounds
Other: pulsus paradoxus, Kussmaul's sign: increase in CVP during inspiration
Best procedure for tamponade?
1. open using subxyphoid approach
2. Neddle aspiration using US
3. eventually should get pericardial window and find source of bleeding
What do you do for normal neck veins, normal breath sounds, and hypotension?
2 large bore IVs, 1-2L of NS, quick search for bleeding site, major arterial sites, long bone fractures
What happens when you lose 15-30% of blood volume?
mild changes, tachy, increased pulse pressure
What happens when you lose 30-40% of blood volume?
more severe changes, tachy, hypotension, decrease mentation
How to evaluate adequacy of resuscitation?
BP, HR, Urine output, Mental status
What to do when someone is hypotensive despite resiscitation?
Do a central line if you can do it quickly, it helps for monitoring CVP and resuscitation, but do it on the same side that you may suspect pneumo. Also search for underlying cause: laparotomy or thoracotomy
Would you expect a closed head injury to cause hypotension?
No, because of Cushing Reflex due to ischemia and swelling of brain leads to vasoconstriction and bradycardia to maintain BP
Hemodynamic effects of pregnancy?
Increase in HR, hypotension because of uterine compression of vena cava, increase in plasma vol, decrease in hematocrit such that normal is 31-35%
Should you advance a foley into bloody urethral meatus?
No. Could be prostate or urethral injury and worsen it. Put suprapubic catheter instead
What is cervical spine precautions and assessment?
Neck immobilization, palpating for tenderness or deformity, test motor and sensory function, cervical spine XR. Careful not to extend neck with intubation!
What do you give to cervical spine injury to minimize damage from edema?
Steroids
What are signs of fresh spinal cord injury?
Priapism, loss of anal sphincter tone, loss of vasomotor tone, bradycardia, intestinal ileus
How much blood do you need out of a chest tube to warrant thorax exploration?
>1500ml OR
>200ml for 3 hours
Strucutres that can get damaged in stab would below clavicle?
SCM, Omohyoid muscle, Pec minor, anterior scalene, External Jugular vein, Transverse cervical vein, Anterior jugular vein, Subclavian A and V, Thyrocervical trunk
What should you do if subclavicular stab would pt is stable?
angiogram
What to do for suspected diaphragmatic injury?
Explore abdomen/thorax
What to do for gunshots?
Mark entrance and exit wounds, do radiography to locate bullet, surgically explore
What are radiographic findings on aortic transection?
1. Obliteration of aortic knob/aortic-pulmonary window
2. Deviation of trachea to right
3. Pleural cap filled with pleural fluid or blood
4. Dev of esophagus to right
5. Depression of L main bronchus or Elevation of R main bronchus
6. widened mediastinum on PA chest
How to diagnose damaged aorta?
CT/aortic angiography
What are 3 categories of trauma that require further eval based on mech of injury?
1. Unprotected trauma
2. High energy trauma
3. Minor trauma to those with limited reserve to tolerate injury (elderly, chronic dz, immunocompromised)
If a car accident pt is stable with no swelling or abdominal pain or lesions, do you explore? what do you do?
When exploration not necessary or if you need a quick diag, do imaging (CT or FAST) and Diagnostic Peritoneal Lavage
How do you do a Diagnostic Peritoneal Lavage? Pros and cons?
1. empty bladder
2. midline incision
3. fluid lavage
4. If no blood, place 1L saline and then remove for analysis
Pros: fast, low false neg, cheap
Cons: misses retroperitoneal injury if there is no communication
Except for abdominal fluid/blood, what else can FAST diagnose?
Pericardial effusion
Why should CT be avoided in unstable pts?
Requires them to be away from resuscitation unit
What to do for suspected pelvic injury?
1. FAST
2. pelvic angio if no blood seen where they can do an embolization of a branch of internal iliac is bleeding
3. reduction and internal fixation
Branches of internal iliac from top to bottom?
1. Iliolumbar
2. Superior gluteal
3. Lateral sacral
4. Inferior gluteal
5. Internal Pudendal
6. Obturator
7. Middle hemorrhoidal
8. Vesical
Branches of external iliac that could get damaged with pelvic fracture?
1. Deep circumflex iliac
2. Superior hemorrhoidal
3. Superficial external pudendal
What grade spleen injury warrants exploration?
Stage IV
What should splnectomy pts always get?
Vaccines for diplococcus, Meningococcus, Haemophilus (encapsulated organisms)
What determines whether or not liver lesions get explored or not?
Stable or unstable
What imaging do you get before going in to remove a kidney?
IV pyelorogram to make sure they've got 2
What to do for partial transection of pancreas?
Exploration, debriedement and drainage, repair, for severe cases duodenal diverticularization to divert fluids away from pancrease to allow for healing
When should you explore a duodenal hematoma?
After 5-7 days of observation and NPO
3 zones of the retroperitoneum and significance?
1. Central, usually surgically explored
2. Flank: can be observed in stable
3. pelvic: observed in stable, angiogram and embolization with bleeds
Why does exploration of pelvis worsen bleeding?
B/c it's being tamponaded by intact peritoneum
How do you stop a liver bleed?
Pack it with gauze
What does a rapid neuro exam consist of?
1. pupillary response
2. LOC/GCS
3. CNs
4. Motor and sensory
What are some sxs of a basal skull fracture?
Loss of consciousness, blood in ear, orbits, Battle's sign (ecchymosis in mastoid region), ecchymosis around the eyes, CSF from the ear or nose
What's the very least that warrants a head CT?
Loss of consciouness, change in MS
When should someone with loss of consciousness stay overnight?
If the episode was longer than 5 min
How do you minimize brain edema?
Elevate head to 30 deg, hyperventilate to 26-28 PCO2 (should promote vasoconstriction) with impending brain herniation like a blown pupil. Slow Mannitol. Phenytoin for 1 wk for seizure prophylaxis. Limit fluids.
What kind of injury usually happens after a coma-producing head injury?
Diffuse axonal injury
What are signs of a large neuro focal lesion?
Lateralizing motor deficits, unequal pupils
Signs of epidural hematoma?
Loss of consciousness, lucid interval, second loss of consiousness, dilated fixed pupil on same side as lesion
What do eccymosis in the mastoid region mean?
Battle's sign: basal skull fracture
What's safer than an NG tube in the presence of a CSF leak?
Orogastric tube an endotracheal tube so that Cribriform plate doesnt get punctured
Why do brain injuries get hyponatremic?
b/c brain injury can cause SIADH from direct response of hypothalamic osmoreceptors
What are sxs of SIADH?
High urine Na, expanded fluid volume, can cause cerebral edema. Can lead to restlessness, irritability, confusion, convulsions, coma
Treatment of SIADH?
Water restriction, 3%NaCl solution 200-300 given over 3-4 hours
How much of the Na deficit should be correct the first day?
Only half of the Na deficit should be corrected in first 24h to avoid central pontine myelinosis
Why can brain injuries get hypernatremic?
b/c brain injury can also lead to DI and dehydration without access to water or loss of consciousness
How to treat DI?
Vasopressin or Desmopressin, access to free water
Why is hypothermia concerning in trauma pts?
It leads to coagulopathies from platelet dysfunction and prolongation of PT and PTT, also predictor of poor outcome
How to treat hypothermia?
rewarm however possible. Correct persistent coagulopathies with FFP
What do you do if someone's platelets gets too low?
Could be DIC, give platelets to keep count above 60,000
What can cause metabolic acidosis in trauma pts?
hypothermia, hypovolemia, subsequent tissue hypoperfusion
How do you get abdominal compartment syndrome?
Continued hemorrhage from liver which causes decrease renal blood flow due to a tense abdomen, elevated diaphragm, difficulty breathing
How do you manage postop blood loss?
Give same amount of blood ml for ml, or 3ml NS for every ml lost
What's the target urine output postop?
.5-1 ml/kg/hr
When should we be really careful with fluid replacement?
Lung contusion, because damaged lung is more susceptible to pulmonary edema
What's going on if you're fluid resuscitating but vitals are not responding?
Probably has third space losses. Need to look at CVP: tells you RA pressure. IF CVP is normal (normally 3-8) and vitals still not responding, it could mean that they need more fluids, have low CO from abnormal heart, or CVP is not reflecting L heart filling pressures
What does a Swan Ganz tell you?
CO, RA, PA, PCWP (LA) pressures and SVR, and temp
What do a low or high PCWP tell you?
Low or high L heart preload= volume status
When do you get arrhythmias when placing a Swan Ganz?
When cath is in RV. advance or withdraw.
What is normal SVR? PA? PCWP? CO?
SVR: 800-1400 dynes-sec/cm^5
PA: Systolic 15-30 Diastolic 4-12
PCWP: 2-15
CO: 4-8 L/min
What can cause increased SVR?
Cardiogenic shock, hypovolemic shock, HTN, vasoconstrictors
What causes reduction in SVR?
Septic shock, neurogenic shock, vasodilators
What's the picture when PCWP is low, CO is low, and SVR is high?
Hypovolemia
What's the picture then PCWP are normal, CO is high, and SVR is low?
High output septic shock after fluid resuscitation. usually comes later in sepsis. in early or decompensated sepsis the CO is low
What's the picture when PCWP is high, CO is low, and SVR is high?
Cardiogenic shock: SVR increased because of high sympathetic impulses
What are the hemodynamic parameters of neurogenic shock? what type of trauma usually causes it?
Low PCWP, low CO, low SVR.
Can be caused by spinal cord injury
How do you treat neurogenic shock?
fluids. Vasoconstrictors and cardiac drugs to increase HR is usually not necessary
What kind of heart failure do you get from a traumatic AV fistula?
High output cardiac failure
How to diagnose AV fistula?
Palpable thrill and audible bruit, if you put pressure on it and the HR drops by 10 or more, that's Branham's sign. due to baroreflex activation
When can you treat an AV fistula?
After cardiac status is stable
What are hemodynamic parameters of traumatic AV fistula?
High PCWP, high CO, low SVR
What other types of fistulas can be problematic?
Hemodialysis fistulas, abdominal aneurysms that fistulize with IVC
What's the danger of severe rib pain?
Compromised breathing which leads to atelectasis, hypoxia, increase risk for pna. Give analgesics
What do you do for moderate respiatory distress?
Check airway, get ABG, place on O2, check the chest tube, get a CXR to confirm. are they chest splinting? pain?
How do you get a flail chest?
Multiple rib fractures leave a segment of chest wall unstable causing paradoxical movement of that segment
What kind of analgesics appropriate for chest wall pain?
thoracic epidural cath with bupivicaine and morphine
What to do for severe resp distress?
intubate, mechanical vent, CXR, ABG
How do you correct a high or low PCO2?
adjust vent rate
What can cause hypoxia even with intubation?
worsening ARDS, mucous plus, incorrect positioning of endotracheal tube. Reposition and suction
How do you correct a low PO2?
Increase FIO2, maybe give a little PEEP to help keep alveoli patent
What to do if mechanical ventilation is failng?
Jack up the FIO2 to 100%, add 10cmH2O of PEEP, perform arterial line for monitoring BP and getting easy ABGs, CXR
What hemodynamic effect does PEEP have?
Causes CO to drop by impairing venous return to heart, thus lowers urine output
What to do for tension pneumo and failure to ventilate?
Could be tension pneumo. Listen for lung sounds. If no breath sounds on one side: needle thoracostomy with angiocath in 2nd intercostal space midclavicular. Then chest tube in fifth intercostal space midaxillary then get CXR
What are borders of zones of the neck area?
Zone 1: Up to the cricoid
Zone 2: Cricoid to angle of mandible
Zone 3: Angle of mandible and up
What is significance of zones of the neck?
Trauma to zone 1 and 3 if stable should get angiogram if evidence of vascular injury.
Trauma to zone 2 should be explored if evidence of vascular injury
What does subq emphysema in neck mean?
airway injury, must explore
What can blunt trauma to the neck cause?
Damage to carotids. Tx for it is controversial, from anticoag alone to thrombectomy
First thing to do on burn patient?
Remove clothes, put on dry sheets, determine if airway burn is likely: black sputum, facial burn, hoarseness, low O2sat, dyspnea
Assessment of burns?
1. depth
2. type: flame, contact, scald with liquid, steam
3. percentage body surface area (BSA)
What is rule of 9s?
In adults: Head and upper extremities are 9% each
Lower extremities and anterior and posterior trunk are 18 each
Neck/Hand is 1 each
Describe degrees of burns?
First deg: superficial layer of epidermis
Second: through epidermis into dermis "partial thickness burns", blistering
Third: full thickness down to subq tissue, white waxy appearance, no sensation or capillary refill, req skin grafting
Indications for transfer to burn center?
1. Full thickness burn >5%BSA
2. Parital thickness burn >20% BSA
3. Age <5 or >50
4. Burns of face, hands, genitalia, perineum, major joints, feet
5. Inhalation injury
6. Cicumferential burns of chest or extremities
7. Chemical or electrical burns
What is Parkland's formula?q
Used for estimating fluids for first 24 hours after burn
TotalVol of LR=(%BSA)(kg)(4ml/kg)
give half in first 8 hours and second half over next 16 hours
What other solutions do you need to give burn pts in addition to LR?
D5W for evaporative water loss, keep an eye on serum Na and give .5ml plasma/%BSA over 8 hours to maintain colloid oncotic pressure
Why no colloids in first 24 hours?
capillaries are too leaky
What are some abx for topical tx of burns?
Silver sulfadiazine, Mafenide, Povidone-Iodine. no prophylactic systemic abx
How often do you change burn dressings?
2x daily
How to manage third degree burn?
Regular debridement until split thickness skin graft can be put into place
What to do for dark urine after a burn?
It's myoglobinuria: risk for ATN, fluids to ensure urine output at least 2-3x normal, alkalinization of urine (sodium bicarb) and osmotic diuretics (Mannitol) can also be used in extreme cases
How do you diagnose CO poisoning?
CarboxyHg of 5% in nonsmokers and 10% in smokers indicates it. Give 100% O2 until normalized. Hyperbaric chambers also used.
How to diagnose methemoglobinemia?
Chocolate brown appearance of blood, central cyanosis, seizures, pulse ox canNOT diff b/w met and normal Hg, so do an ABG!. Specific tx for MetHg is Methylene blue. Reduces MetHg at low doses
What's the danger of a circumferential burn of the thorax?
Can rapidly become thickened and limit motion and impairs ventilation. Do escharotomy.
What to do for electrical burns?
EKG, cardiac enzymes
What is the protein requirement for nondepleted, depleted, and hypermetabolic patients?
1g/kg/d nondepleted
2.5-3 g/kg/d hypermetabolic

depleted is somewhere in between
How do you calculated caloric needs?
Weir Formula for Resting energy expenditure and Harris-Benedict Eq for Basal energy expenditure
How many calories does average male need on a daily basis?
2100kcal
What's a severe complication of long term TPN?
Metabolic coma from Hyperglycemia Hyperosmolar Nonketotic coma secondary to dehydration due to excessive diuresis due to hyperglyemia. d/c TPN and give insulin, monitor glucose and lytes
What happens to liver on TPN?
LEFTs can be abnormal in 30% of TPN pts. Reduce rate of infusion. TPN can also cause fatty liver and structural damage and cirrhosis over years.
Why would you get dry scaly skin on TPN?
FFA def. Give lipids