How many deaths per year are from unintentional injuries?

How many deaths per year are from intentional injuries?

92,000

MVC's, falls, poisionings, fires, drownings

*see unintentional more than intentional*

52,000

homicide, suicide

Approx 75% of hospital mortality r/t trauma occurs within __ hrs after admission; 1/3 of these die w/in __ hrs of arrival , so there is a high probability of death on OR table

What is the "Golden hour" of trauma?

within 48 hrs after admission; 1/3 of these die w/in 4 hrs of arrival

1st 60 min following an accident

pts have better chance of survival if we can treat them fast & they live past 60 min

Airway-admin O2, secure airway, ventilation, c-spine protection

Breathing-look, listen, feel; pneumo?

Circulation-1st STOP BLEEDING; 2nd vol replacement-not too little nor too much

Disability-fast neuro assessment: GCS, AVPU

Exposure-undress pt & do quick head to toe assessment of injuries/deformities

When does the primary survey begin?

What does it consist of?

Occurs simultaneously with 2 things?

begins in ER within 2-5 minutes

consists of ABCDE sequence in addition to basic monitoring (EKG, NIBP, SpO2)

occurs simultaneously with resuscitation and control of obvious hemorrhage

When does the secondary survey begin?

involves?

What finding here with a diagnostic peritoneal lavage will get the pt an immediate pass to the OR?

begins when ABCDE's are stabilized

involves more extensive head to toe exam including lab work & tests: 

 T&C, CXR, C-spine/pelvic/long bone films, CT scan, A-gram, DPT, FAST scan, placement of foley and NGT if not contraindicated

Blood in abdomin

When does the tertiary survery occur?

What is compiled?

may involve?

when are injuries most commonly missed?

occurs between 24 hours of injury and before discharge when pt is hopefully more awake and able to communicate

a comprehensive list of all injuries is compiled after initial resuscitation/surgery to identify those missed with 1 and 2 surveys

may involve dialogue with next of kin to determine health history

injuries are most commonly missed following blunt trauma

What are 5 red flags for potential cervical spine injuries?

 If you have any of these signs what is the incidence of C spine issues?

What about if you add a head injury?

Remember basic & advanced airway management

Severe distracting pain

Neck Pain

Any abnormal neuro s/s

Intoxication

Loss of consciousness at scene

SNAIL

2% with one above sign

10% with a sign plus a head injury

T/F c-spine injury is more likely in high-velocity blunt injuries/severe head injuries?

It is imperative to maintain immobilization of the neck in a ____ position.

Is c-spine alone reliable for stabilization?

What are the most reliable methods of stabilization?

Can you remove the anterior portion of the C collar to intubate your pt?

true

neutral

c-collar alone is not reliable for stabilization

most reliable methods: sandbags, bindings, backboard in addition to a properly fitted c-collar

Yes if pt is paralyzed and induced you can remove the anterior piece of C-collar, but have someone holding c-spine MILS!

remember to document how you protect C-spine

*What is the preferred method for opening the airway to ventilate in a trauma situation?

What is the means of preventing neck motion during laryngoscopy?

jaw-thrust maneuver

manual in-line stabalization=MILS=MOST EFFECTIVE ---do this as you jaw thrust

Nasal intubation is an option, but why might it not be ideal for a trauma? (2)

When should you avoid it?

Is it routinely recommended for trauma?

higher risk of aspiration

possible head fx etc with trauma

avoid in basilar skull fx (LeFort II, II)

*not routinely recommended in early trauma mgmt

What is the best intubation option for c-spine immobility? Will it work for laryngeal trauma?

Disadvantage.

When is it contraindicated?

Is this easy to use?

What should you always keep in reach?

What is another tool that can be used?

see last 2 airway slides for other techniques

Fiberoptic Bronchoscope

may work for laryngeal trauma

requires long patient prep time

(prolly more appropriate for controlled environment, not emergent situation)

contraindicated with presence of blood in airway d/t obstructed view

no, requires advanced skill level

*always keep a Bougie in reach*

Glidescope

Is the ASA algorithm for difficult airways applicable to trauma patients?

Give 100% O2 in a trauma case until get??

not entirely because awakening the patient for a failed intubation is SELDOM an option!

ABG back

What are the classic s/sx of a tension pneumo?

When is it difficult to diagnose?

What is definitive diagnosis?

tachypnea, hypotension, hypoxemia, JVD, ipsilateral loss of breath sounds, contralateral tracheal deviation

dx may be difficult in hypovolemic patient

definitive dx is CXR but unreasonable to wait for one in emergency

Treatment of tension pneumo?

Describe the technique

what are you going to need after?

What can worsen pneumo?

needle decompression

14g angiocath inserted into 2nd intercostal space at midclavicular line

be aware of need for a STAT chest tube

PPV/PEEP can worsen pneumo (d/t 1 way valve)

What are the cornerstones of hypovolemic shock resuscitation?

T/F no matter what fluids are used, they should be be given immediately even if not warm?

Should you use vasopressors?

review 1st 2 circulation slides & graphs

IV fluids and transfusion

FALSE

resort to vasopressors only when there's profound hypotension, coexisting cardiogenic shock, or cardiac arrest

Crystalloids (NS, LR, Plasmalyte)

inexpensive

readily available

non-allergenic

non-infectious

effectively restores total body fluid losses

mixes well with most infused meds

*What are 2 "better" crystalloid choices for resusc?

When do you need to prolly not use LR...?

What bad thing can a lot of NS cause?

P-lyte (isotonic, contains KCl, NaCl, Mg)

 LR (has K & Ca)

slightly hypotonic, careful in head injuries/incr ICP cause can get cerebral edema; 

NS more likely to cause hyperchloremic acidosis

*disadvantages for using crystalloids:

lack of ______ capacity & ______ capablility

limited ______ half-life

recent studies suggest ___ effects & promotion of cellular ___

__ in LR makes it incompatible w/ blood products

Why avoidavoid dextrose containing solutions with trauma?

lack of O2 carrying capacity

lack of coagulation capability

limited intravascular half-life

recent studies suggest immunosuppressant effects and promotion of cellular apoptosis

Ca in LR makes it incompatibile with blood products (although Wendy said studies have shown if blood is given over less than 2 hours, it's ok to use LR)

 can worsen ischemic brain injury (swelling)

*What is the half-life of crystalloids?

Only __ of infused vol remains intravascularly after ___ ?

20-30 min

1/4 of infused volume remains intravascularly after 1 hour

*What are the advantages of colloids? (2)

Is albumin as safe as saline/crystalloids?

more effective at rapidly restoring intravascular volume

more volume expansion in less amount of vol compared to crystalloid

controversy

Cochrane review-6% incr risk of death with albumin

meta analysis-no difference

SAFE trial: Saline vs Albumin, no difference in 28-day mortality

much more expensive than crystalloids

lack of O2 carrying capacity

lack of coagulation capability

What is the half-life of hetastarch?

How many days can it take for excretion?

about 3 hours

can take 8-28 days for excretion/elimination

What is the half life of Dextran?

In which pts is it prolonged?

about 12 hours

markedly prolonged in renal insufficiency

How long does type & cross matching take?

How long does it take for type-specific blood to be ready?

What kind of rxn can type-specific blood cause?

type & cross matching 45-60 min

type-specific blood is ready in 15 min

may cause minor Ab rxns

What is uncrossmatched blue card blood reserved for?

What type of blood is used?

life-threatening blood loss

usually O- but O+ is common and acceptable

What is the risk of major tsf rxn in cross matched blood?

uncrossmatched?

crossmatched = 1:100,000

uncrossmatched = 1:100-1:10,000

What type of blood product would ideally be used for trauma?

What is the standard norm for shock?

*What is the average HCT for whole blood?

*For PRBC's?

How can you decr viscosity of blood & increase the speed of admin?

ideall- cross-matched whole blood

shock-PRBCs

whole blood: avg HCT 40% per unit

PRBC's: avg HCT 70% per unit

mix w/ crystalloid

When is plasma indicated?

T/F It requires typing but not cross-matching?

Are tsf rxns a problem?

plasma indicated for coagulopathy associated with shock & massive volume replacement

TRUE

plasma carries similar risk of infectious disease and tsf rxns as PRBCs

When is plasma usually not needed?

When massive tsf protocols involving replacing one blood volume (~10U PRBCs) then the ratio is of PRBCs to plasma is ______?

plasma usually not needed for tsf of up to 4U of PRBCs (once have given 4-5 U then give a unit of plasma too per Wendy)

5:2

How can you gauge the necessity for plasma?

When will the surgeon ask for it?

check coags frequently

often ask for plasma based on amount of oozing in the field

Are trauma patients more likely to suffer from coagulopathy or platelet deficiency?

In MTP (massive transfusion protocol), when do pts receive PLTs?

coagulopathy

MTP - plts received after giving 10:4 PRBC:Plasma

(one blood vol given)

What is the half life of transfused plts?

When should the decision to administer them be made?

very short serum half-life

decision to administer them should be conservative

only when there's visible coagulopathy

Is it ok to give plts through warmers?

Why?

plts SHOULD NOT be given through warmers or rapid infusers

because they will bond to the inner surfaces of these devices and reduce the quantity that actually reaches the patient

What can rapid tsf of banked blood cause?

How?

What does this result in?

What are signs of this?

Tx?

look over last few cirulation slides

citrate toxicity

it binds free Ca which is essential to the clotting cascade

hypocalemia causes a neg. inotropic effect 

watch for hypotension & prolonged QT intervals

tx with IV Ca (CaCl)

How much Ca is in CaCl?

Ca gluconate?

CaCl - more potent 27mg/ml of Ca

Ca gluconate - 9mg/ml of Ca

end point of resuscitation

Clinical parameters like HR, BP, and UOP are ______ indicators

Lactate

Arterial pH

Arterial base deficit

Filling pressures/invasive DO2

SvO2

Gastric Tonometry

Tissue pO2

Near infrared spectroscopy

What are the best choices for IV induction in trauma?

MR?

How & when should you adjust doses?

What can happen regardless of drug choice?

What is nature's version of anesthesia?

What other drugs are used for RSI?

look at 1st mgmt in OR slide

Etomidate and Ketamine

Succs in NMB of choice for RSI

Can use Roc 1.2 mg/kg

dose of ANY induction agent must be decreased in presence of hemorrhage/hypovolemia

interruption of compensatory sympathetic outflow can lead to circulatory collapse no matter what drug you pick

Shock is nature's version of anesthesia

RSI may proceed with MR alone

Do trauma pts w/ blood loss & hypotn have a larger or smaller Vd? 

What do we have to keep in mind w/ these pts?

What drugs should be used to maintain mm relaxation?

Consider risk of _____ if using

MR with longer DOAs

What should we keep MAP?

smaller Vd

pts might not tolerate much of anesthetic

Roc, Vec, or Nimbex

consider risk of awareness if using MR with longer DOAs

MAP>50-60

What are some alternatives to gas? (3)

What gas should be avoided? Why?

What is key?

Ketamine IV 25mg q 15 min

Versed IV 1mg intermittently

Scopolamine IV 0.2-0.4mg

avoid N2O, esp if probability of pneumo

can make pneumo worse

limits inspired O2 concn

Key principle: small incremental doses... you can always give more

How can hypothermia affect the patient?

What does it do to the oxyhgb curve & metabolism?

worsens acid-base disorders, coagulopathy, and myocardial depression

shifts oxyhgb curve to the LEFT and slows metabolism

use warming measures/devices to keep temp >35 degrees C

Do we always hyperventilate TBI pt?

How can hyperventilation affect CBF in TBI?

What range should PaCO2 be?

Goal SBP for TBI?

read over last 2 slides

No

not necessarily appropriate unless s/s of herniation are present 

CBF in decr w/ TBI and the vasoconstriction w/ hyperventilation may further decr perfursion

PaCO2 30-35

SBP>110 for optimum CPP 

If a pt can talk can they also be obstructed?

Immediate intubation for the following 6 things with trauma?

NO

LOC

hypoventilation

absent gag

GCS<8

inhalation injury

thoracic trauma