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39 Cards in this Set
- Front
- Back
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what should be administered to children prior to RSI
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As heart rate is the primary determinant of cardiac output in children and because children have a more pronounced vagal response to intubation than adults, atropine should be administered to children prior to RSI
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The indications for a definitive airway (a cuffed tube in the trachea)
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nclude apnea, inability to maintain an airway, need for airway protection, coma, or inability to maintain adequate oxygenation with a face mask
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Once the tube is in the trachea and the cuff inflated, proper location of the tube must be confirmed. The first step is to
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listen for breath sounds bilaterally, both anteriorly and in the axillae to confirm tracheal intubation. The finding of epigastric gurgling may diagnose esophageal intubation; however, auscultation alone is not adequate to determine proper or improper placement of the tube.14 Rapid resolution of hypoxia to normal saturation levels is a good indicator of proper placement of the tube. A more rapid indicator is the use of colorimetric carbon dioxide (CO2) detectors to confirm proper intubation, but these do not provide absolute assurance of tracheal intubation. CO2 will be detected with intubation of one mainstem bronchus and, occasionally, CO2 will be detected in gas aspirated from the stomach (but will clear with a half dozen breaths). It is important to remember that CO2 may not be detectable in patients following cardiac arrest, even with proper tube placement.
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Two of the factors that affect reliability of the pulse oximeter readings are
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anemia less than 5 g% and hypothermia less than 30°C (86°F).
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Injuries of the chest that should be detected during the primary survey include:
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tension pneumothorax, flail chest with pulmonary contusion, open pneumothorax, and massive hemothorax. Massive hemothorax causes derangement of both breathing (hypoventilation) and circulation (hypovolemic shock).
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describe what happens in a tension pneumothorax and what are the possible consequences
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develops when air continuously enters the pleural space from the lung, bronchi, trachea, or through the chest wall, cannot escape, and causes the lung to collapse. Eventually, this air under pressure will cause a shift of the mediastinum toward the opposite side, compression of the superior vena cava and inferior vena cava, decreased venous return to the heart, and hypotension.
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clinically what are the findings of a tension pneumothorax?
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Clinically, a sense of impending death, marked respiratory distress ("air hunger"), deviated trachea, distended neck veins, unilateral absence of breath sounds, cyanosis, and hypotension may be seen. A deviated trachea at the base of the neck is difficult to see or feel and may not be a prominent finding. Distended neck veins may also be undetectable, particularly if hypovolemia from other injuries is present. Because hypotension and distended neck veins are seen in tension pneumothorax and cardiac tamponade, they are sometimes difficult to differentiate. Cardiac tamponade is less common and does not cause mediastinal shift, and breath sounds are usually symmetric.
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what is the treatment of a tension pneumothorax?
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The diagnosis of tension pneumothorax is a clinical one and requires emergent chest decompression with a needle (14-gauge 3 inch catheter-over-needle inserted into the second intercostal space in the midclavicular line). Again, tension pneumothorax is a clinical diagnosis that should never wait for chest X-ray confirmation as this will delay life-saving decompression of the chest. A rush of air escaping through the catheter confirms the diagnosis. This converts the tension pneumothorax into a simple pneumothorax. The absence of a rush of air suggests misdiagnosis or insertion of the needle into the wrong hemothorax. Occasionally, the respiratory distress is so profound that breath sounds are diminished on both sides. If the diagnosis of tension pneumothorax still seems likely, the catheter is left in place and the opposite hemithorax is punctured. If no rush of air occurs, the wrong diagnosis is likely, and cardiac tamponade should be considered. Whether or not the needle confirms the presence of a tension pneumothorax, tube thoracostomy should follow.
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The diagnosis of tension pneumothorax is a clinical one and requires emergent chest decompression with a needle (14-gauge 3 inch catheter-over-needle inserted into the second intercostal space in the midclavicular line).
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The diagnosis of tension pneumothorax is a clinical one and requires emergent chest decompression with a needle (14-gauge 3 inch catheter-over-needle inserted into the second intercostal space in the midclavicular line).
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A flail chest consists of
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segmental fractures of three or more adjacent ribs, one or more rib fractures with an associated costochondral separation, or fracture of the sternum.
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A flail chest consists of segmental fractures of three or more adjacent ribs, one or more rib fractures with an associated costochondral separation, or fracture of the sternum. This causes an
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unstable or "floating" segment of the chest wall that moves paradoxically during respiration. A force of injury strong enough to cause a flail chest usually causes an underlying pulmonary contusion. A pneumothorax or hemothorax may be present, as well. An injury to the chest wall of this magnitude is associated with significant pain, and respiratory efficiency is reduced.
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the treatment of a flail chest is
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directed toward reversing the hypoventilation (caused by pain) and hypoxia (caused by an associated pulmonary contusion).27 Careful monitoring of ventilation and oxygenation is required, and intubation and ventilatory support may be indicated in 20 to 40% of patients. An associated hemopneumothorax is treated by insertion of a thoracostomy tube. Control of pain from multiple rib fractures using regional anesthetic techniques such as repeated intercostal nerve blocks or insertion of an epidural catheter is important to improve the respiratory mechanics. Over-resuscitation should be avoided in patients with a pulmonary contusion.
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An open pneumothorax or "sucking chest wound" results when
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a defect in the chest wall exceeds two-thirds the diameter of the trachea. Inspiration draws air into the chest through the chest wound (and into the pleural cavity) rather than into the lungs via the trachea, and hypoxia ensues.
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An open pneumothorax or "sucking chest wound" results when
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a defect in the chest wall exceeds two-thirds the diameter of the trachea. Inspiration draws air into the chest through the chest wound (and into the pleural cavity) rather than into the lungs via the trachea, and hypoxia ensues.
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Tx a open/sucking chest wound via
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prompt closure of the defect with a sterile occlusive dressing will improve ventilation. Three sides of the dressing should be taped to the skin and the fourth side allowed to remain open to create a one-way valve for escape of trapped air. This will prevent conversion to a tension pneumothorax. A chest tube should be placed as soon as it is clinically safe to do so. Intubation and assisted ventilation should be instituted if these methods fail to alleviate the respiratory distress and hypoxia persists (arterial partial pressure of oxygen, po2 <60 mmHg). All defects in the chest wall resulting in an open pneumothorax require surgical closure, usually in the operating room.
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A massive hemothorax, defined as
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>1500 mL of blood in the chest acutely, may be caused by penetrating or blunt trauma.28 The ipsilateral lung is compressed with diminished or absent breath sounds. Massive hemothorax may also cause hypovolemic shock and (or shifting of the mediastinum. Distention of the neck veins is usually absent because of the massive blood loss.
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assumed to be hemorrhagic shock until proven otherwise
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in the trauma patient, tachycardia is always suggestive of hypovolemic shock. A heart rate greater than 120 in adults and 160 in preschool children is assumed to be hemorrhagic shock until proven otherwise
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assumed to be hemorrhagic shock until proven otherwise
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in the trauma patient, tachycardia is always suggestive of hypovolemic shock. A heart rate greater than 120 in adults and 160 in preschool children is assumed to be hemorrhagic shock until proven otherwise
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why is BP misleading in the evaluation of shock?
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Up to 30% of the blood volume may be lost before a significant decrease in blood pressure can be measured because of vasoconstriction as compensation for the lost volume. The pulse pressure (the numeric difference between systolic and diastolic pressures) is more sensitive. A decrease in pulse pressure is noted when as little as a 15% blood loss has occurred. When the systolic blood pressure is below 90 mmHg, a shock state exists in most adolescents and adults.
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why is BP misleading in the evaluation of shock?
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Up to 30% of the blood volume may be lost before a significant decrease in blood pressure can be measured because of vasoconstriction as compensation for the lost volume. The pulse pressure (the numeric difference between systolic and diastolic pressures) is more sensitive. A decrease in pulse pressure is noted when as little as a 15% blood loss has occurred. When the systolic blood pressure is below 90 mmHg, a shock state exists in most adolescents and adults.
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pericardiocentesis in tamponade is via
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A needle pericardiocentesis, using a long 16- or 18-gauge needle via the subxiphoid route to aspirate even small amounts of blood, can temporarily relieve the tamponade, but definitive operation is almost always necessary to treat the underlying injury. If the tamponade is unrelieved by pericardiocentesis and the patient is dying, immediate left anterolateral thoracotomy, pericardiotomy, and cardiac repair in the emergency department are appropriate
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pericardiocentesis in tamponade is via
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A needle pericardiocentesis, using a long 16- or 18-gauge needle via the subxiphoid route to aspirate even small amounts of blood, can temporarily relieve the tamponade, but definitive operation is almost always necessary to treat the underlying injury. If the tamponade is unrelieved by pericardiocentesis and the patient is dying, immediate left anterolateral thoracotomy, pericardiotomy, and cardiac repair in the emergency department are appropriate
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Neurogenic shock is caused by injury to the spinal cord and is not associated with injuries to the
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brain.
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Neurogenic shock is caused by injury to the spinal cord and is not associated with injuries to the
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brain.
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describe neurogenic shock
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Neurogenic shock due to injury of the spinal cord is associated with the loss of sympathetic tone, vasodilation, and absence of an increased pulse rate.
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describe neurogenic shock
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Neurogenic shock due to injury of the spinal cord is associated with the loss of sympathetic tone, vasodilation, and absence of an increased pulse rate.
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what type of IVs should be used in shock
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Two large-bore intravenous catheters should be placed into peripheral veins in all patients with suspected or confirmed serious injuries. Because the diameter and length of the catheter determine flow rate, short large-bore catheters are ideal. In the adult, 14- and 16-gauge plastic cannulas are ideal.
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what type of IVs should be used in shock
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Two large-bore intravenous catheters should be placed into peripheral veins in all patients with suspected or confirmed serious injuries. Because the diameter and length of the catheter determine flow rate, short large-bore catheters are ideal. In the adult, 14- and 16-gauge plastic cannulas are ideal.
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Patients with hypovolemic shock are not treated acutely with
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vasopressors, steroids, or sodium bicarbonate.
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hypovolemic shock treatment
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The use of a warmed balanced salt solution such as Ringer's lactate is considered safe and effective. A bolus of 2 L is given to the adult patient with hypotension, and 20 mL/kg to the child. If a hemodynamically normal state is restored, crystalloids can be continued. If the patient remains unstable, a second bolus is utilized while blood is being obtained. If the patient's vital signs have not returned to normal after two boluses, blood should be administered. If the need is urgent, type-specific blood may be used. When this is not immediately available, low-titer type O-positive blood for men or O-negative blood for women is acceptable. The patient who requires uncrossmatched blood usually needs to be in the operating room.
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hypovolemic shock treatment
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The use of a warmed balanced salt solution such as Ringer's lactate is considered safe and effective. A bolus of 2 L is given to the adult patient with hypotension, and 20 mL/kg to the child. If a hemodynamically normal state is restored, crystalloids can be continued. If the patient remains unstable, a second bolus is utilized while blood is being obtained. If the patient's vital signs have not returned to normal after two boluses, blood should be administered. If the need is urgent, type-specific blood may be used. When this is not immediately available, low-titer type O-positive blood for men or O-negative blood for women is acceptable. The patient who requires uncrossmatched blood usually needs to be in the operating room.
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hypovolemic shock treatment
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The use of a warmed balanced salt solution such as Ringer's lactate is considered safe and effective. A bolus of 2 L is given to the adult patient with hypotension, and 20 mL/kg to the child. If a hemodynamically normal state is restored, crystalloids can be continued. If the patient remains unstable, a second bolus is utilized while blood is being obtained. If the patient's vital signs have not returned to normal after two boluses, blood should be administered. If the need is urgent, type-specific blood may be used. When this is not immediately available, low-titer type O-positive blood for men or O-negative blood for women is acceptable. The patient who requires uncrossmatched blood usually needs to be in the operating room.
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particularly sensitive to gastric dilatation, and decompression frequently improves their vital signs.
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Children are particularly sensitive to gastric dilatation, and decompression frequently improves their vital signs. Because insertion of the gastric tube may induce vomiting, the resuscitation team must be prepared to rapidly logroll the patient should emesis occur.
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particularly sensitive to gastric dilatation, and decompression frequently improves their vital signs.
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Children are particularly sensitive to gastric dilatation, and decompression frequently improves their vital signs. Because insertion of the gastric tube may induce vomiting, the resuscitation team must be prepared to rapidly logroll the patient should emesis occur.
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Patients who have bleeding from the nose, ears, or mouth should be suspected of having a fracture of
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the cribriform plate, base of the skull, mastoid process, and(or a leak of cerebrospinal fluid. Orogastric intubation is safer in these patients to avoid insertion of an (attempted) nasogastric tube into the brain, a potentially fatal injury.39 Blood aspirated from a gastric tube is often swallowed blood, but can be from gastroduodenal injury.
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Patients who have bleeding from the nose, ears, or mouth should be suspected of having a fracture of
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the cribriform plate, base of the skull, mastoid process, and(or a leak of cerebrospinal fluid. Orogastric intubation is safer in these patients to avoid insertion of an (attempted) nasogastric tube into the brain, a potentially fatal injury.39 Blood aspirated from a gastric tube is often swallowed blood, but can be from gastroduodenal injury.
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Patients who have bleeding from the nose, ears, or mouth should be suspected of having a fracture of
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the cribriform plate, base of the skull, mastoid process, and(or a leak of cerebrospinal fluid. Orogastric intubation is safer in these patients to avoid insertion of an (attempted) nasogastric tube into the brain, a potentially fatal injury.39 Blood aspirated from a gastric tube is often swallowed blood, but can be from gastroduodenal injury.
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In the patient with blunt injury who has persistent or recurrent hypotension, a search for occult hemorrhage will include
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a search for occult hemorrhage will include the Focused Assessment Sonography in Trauma (FAST),40,41 diagnostic peritoneal lavage (DPL),42,43 or abdominal CT, depending on the specific clinical circumstances.44 The unstable patient may be quickly identified to have intra-abdominal hemorrhage using the FAST or DPL and be rapidly transferred to the operating room. The FAST is an ultrasound exam that is done in the resuscitation room, usually by the trauma surgeon, which examines the recesses of the peritoneal cavity for fluid (presumed to be blood in the injured patient). FAST also allows an examination of the pericardial sac (see Chap. 17).45
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In the patient with blunt injury who has persistent or recurrent hypotension, a search for occult hemorrhage will include
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a search for occult hemorrhage will include the Focused Assessment Sonography in Trauma (FAST),40,41 diagnostic peritoneal lavage (DPL),42,43 or abdominal CT, depending on the specific clinical circumstances.44 The unstable patient may be quickly identified to have intra-abdominal hemorrhage using the FAST or DPL and be rapidly transferred to the operating room. The FAST is an ultrasound exam that is done in the resuscitation room, usually by the trauma surgeon, which examines the recesses of the peritoneal cavity for fluid (presumed to be blood in the injured patient). FAST also allows an examination of the pericardial sac (see Chap. 17).45
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