Trauma And Remote Locations

Front 1

What are the four characteristic hormonal changes in response to trauma?

Back 1

1. Increased cortisol
2. Increased glucagon
3. Increased catecholamines
4. Decreased insulin

Front 2

With a stress, which six endocrine organs respond to provide the endocrine components of the "stress response"?

Back 2

1. Hypothalamus
2. Anterior pituitary
3. Posterior pituitary
4. Adrenal cortex
5. Pancreas
6. Adrenal medulla

Front 3

The trauma pt has suffered massive blood loss and is unconscious. You should begin resuscitation with what fluid or blood product? What fluid should be avoided?

Back 3

1. For hemorrhagic shock, use normal saline or lactated ringers.
2. Avoid dextrose containing solutions.

Front 4

Define cardiogenic shock. Identify 3 common causes of cardiogenic shock.

Back 4

Cardiogenic shock is an advanced form of CHF in which cardiac output is insufficient to maintain adequate perfusion of the kidneys and other vital organs.

3 common causes:
1. MI
2. CHF
3. Secondary mechanisms such as pericardial tamponade.

Front 5

How do pulmonary artery occlusion pressure, cardiac index, and systemic vascular resistance reflect cardiogenic shock?

Back 5

1. Increased PAOP
2. Low CI
3. Increased SVR

Front 6

A pt with facial injury develops subcutaneous emphysema. What is the cause? What is the potential problem

Back 6

The cause is laryngeal or tracheal trauma. The potential problem is respiratory collapse.

Front 7

A pt has a farm accident and is unconscious. He is taken to the ER and awakens and then loses consciousness. What is this a sign of?

Back 7

This is a classic sign of "walk and drop" epidural hematoma, which results from an arterial bleed between the skull and dura associated w skull fracture.

Front 8

Is immediate surgical intervention for the pt with sign of epidural hematoma necessary?

Back 8

Yes - to prevent uncal herniation and death.

Front 9

A trauma pt presents for intubation with cervical neck fracture with rhinorrhea and clear fluid exudate from ears. Should you attempt a nasal intubation? Why or why not?

Back 9

Nasal intubation must be avoided in pts with obvious or suspected maxillofacial injury. Any pt w suspected head injury may have an anterior fossa basilar skull fracture. Evidence of basal skull fracture is a contraindication to nasal intubation.

Front 10

What are the potential complications of nasal intubation in the trauma pt with an anterior fossa basilar skull fracture?

Back 10

1. Inadvertent placement of the tube through the cribriform plate into the brain.
2. Introduction of nasal bacteria through the skull fracture into the cranial vault, possibly leading to meningitis.
3. Bacteremia due to nasal mucosal abrasion or transfer of nasal bacteria into the trachea and later complications of maxillary sinusitis.
4. Otitis media

Front 11

Is meningitis a potential complication of nasal intubation in the trauma pt with an anterior fossa basilar skull fracture?

Back 11

Yes.

Front 12

Under what condition is nasal intubation and/or NG tube placement contraindicated?

Back 12

When the pt has a basilar skull fracture.

Front 13

What are signs of a basilar skull fracture?

Back 13

1. Blood behind an ear drum
2. LeFort III skull fracture
3. Otorrhea
4. CSF exudate from ears
5. CSF rhinorrhea

Front 14

What is the most likely cause of hematuria after trauma?

Back 14

Injury to the kidneys or lower urinary tract.

Front 15

What is the common cause of death in electrical burns? What is a less common cause?

Back 15

Most common cause:
1. V-fib
2. Asystole
3. Other fatal cardiac arrhythmias

Less common cause:
1. Direct insult to brainstem causing respiratory arrest.

Front 16

When should PRBCs be used to treat hypovolemic shock in the trauma pt?

Back 16

When life-threatening blood loss cannot be adequately replaced with other fluids.

Front 17

What type blood could be transfused to the moribound pt requiring immediate blood transfusion who has not been typed and crossmatched?

Back 17

O-negative

Front 18

Which clotting factor deficiencies develop with massive transfusions?

Back 18

1. Factor VIII can decrease by 50% after two days of storage.
2. Dilutional thrombocytopenia quickly develops due to massive transfusion.

Front 19

A trauma pt who had surgery with massive blood transfusions two days ago must return to the OR within the next few hours for urgent exploratory laparotomy. The pt is bleeding intra-abdominally. What will be your initial treatment for the bleeding?

Back 19

Administration of platelets and FFP.

Front 20

What is the primary goal of MAC? What monitoring guidelines generally apply during MAC?

Back 20

The primary goal is to provide pt safety and comfort during procedures performed under local anesthesia or no anesthesia at all. ASA standards for Basic Intraoperative Monitoring apply during MAC.

Front 21

During MAC, which is superior for administration of sedative-hypnotics: continuous infusions or intermittent bolus dosing:

Back 21

Continuous infusions.

Front 22

What intravenous agents may be used for the technique of MAC?

Back 22

1. Propofol
2. Midazolam
3. Fentanyl or Alfentanyl

Front 23

What intravenous agent is best suited for solo administration for a MAC case? Why?

Back 23

Propofol. It is an easily titratable drug with an excellent recovery profile. This combined with the low incidence of nausea and vomiting make it a good choice for conscious sedation.

Front 24

How shall ventilation of the awake but sedated pt be evaluated?

Back 24

By continual observation of things such as chest excursions or skin color.

Front 25

Describe how the respiratory status of the pt during regional anesthesia or MAC is assessed initially.

Back 25

Ventilatory monitoring must begin with clinical observation of the respiratory pattern, respiratory rate, and tidal volume. Careful observation of thoracic and abdominal movements with ventilatory efforts, timing of the respiratory rate, detection of air movement at the nose and mouth, and/or observation of cyclical condensation of exhaled water vapor on the inner wall of the face mask are basic.

Front 26

In addition to observing the pt, list three quantitative ways the respiratory status of the pt can be monitored during MAC. State which of these is the monitor of choice.

Back 26

1. Precordial, paralaryngeal, or pretracheal stethescope
2. Pulse oximeter
3. CO2 monitoring

A stethoscope is the monitor of choice.

Front 27

What has been the most common cause of brain damage or death during MAC?

Back 27

Respiratory mishaps - mostly due to inadequate ventilation.

Front 28

What is the greatest danger during MAC?

Back 28

A lack of vigilence.

Front 29

How long does full recovery of psychomotor function require following conscious sedation?

Back 29

24-72 hours

Front 30

What hemodynamic changes occur in the pt with cardiac tamponade?

Back 30

1. Decreased preload
2. Decreased stroke volume
3. Decreased cardiac output
4. Decreased arterial blood pressure
5. Increased heart rate

Front 31

What are the first signs of cardiac tamponade?

Back 31

Hypotension with reflex tachycardia.

Front 32

What happens to arterial blood pressure during inspiration in the pt with cardiac tamponade? What is this called and why?

Back 32

There is a prominent decrease in SBP with inspiration. This is called pulsus paradoxus.

Front 33

List three temporary measures that can be taken to maintain stroke volume in the pt with cardiac tamponade.

Back 33

1. Fluids
2. Positive inotrope
3. Correct metabolic acidosis

Front 34

Which cardiac pressures equalize in cardiac tamponade?

Back 34

Right and left atrial pressures and right ventricular end-diastolic pressure equalize at 20mmHg.

Front 35

What is the treatment for cardiac tamponade?

Back 35

Pericardiocentesis

Front 36

If the pt with cardiac tamponade needs to be induced, what agent should be selected?

Back 36

Ketamine and 100% O2 after decompression of the pericardial space.

Front 37

List three anesthetic concerns for the pt with cardiac tamponade.

Back 37

1. Large bore IV access
2. Anesthesia technique that maintains high sympathetic tone until the tamponade is relieved.
3. Fluids

Front 38

What should be the goals for the pt with pericardial tamponade?

Back 38

Avoid vasodilation or cardiac depression.

Front 39

What drugs should be avoided during anesthesia for the pt with cardiac tamponade?

Back 39

Avoid drugs or manipulations that decrease:

1. Venous return
2. HR
3. Arterial blood pressure
4. Ventricular contractility