SSM TCAR review

What is the ratio for crystalloid replacement to blood loss?

3 or 4 : 1

What is the hallmark of an epidural hematoma?

A lucid interval after the injury, the as the bleeding puts more pressure on the brain-fixed & dilated pupils on the injured side, motor and sensory changes on the CONTRALATERAL side

Define Shock?

A state in which cellular oxygen demand exceeds supply When the cost of tissue oxygen is higher than the body can pay, an oxygen debt develops.

What are markers of tissue ischemia?

Lactate, pH, base deficit

What is the footprint of shock?

Lactic Acidosis

VS in shock?

Narrow pulse pressure Tachycardia Low CO

What is the chief nursing concern with a cerebral contusion?

Neurological deterioration, reassess frequently Early findings include confusion, drowsiness, irritability, Disorientation, H/A, N&V

H & H is a measure of ?

It is a measure of hemodilution rather than blood loss.

What is a intraparenchymal hemorrhage?

It is bleeding within the brain tissue, cerebrum, cerebellum or brainstem. They are NOT routinely or easily evacuated.

What is a cerebral contusion?

It is bruising of gray or white matter, that "blossom" over time

Why is autotransfused blood better than banked blood?

It is fresher, warmer, releases O2 better, and costs less

What is DO2?

It is oxygen delivery. It is impacted by manipulating: SpO2, Hgb, and CO

What is MAP, and how is it calculated?

It is the organ & tissue perfusion pressure, the pressure the organs actually receive. Normal is >65. SBP+DBPx2/3

Sub Q air is usually from?

It is usually from a tracheal or broncheal tear Fiberoptic bronchscopy best facilitates visualization below the cords MOST BLUNT TEARS OCCUR WITH IN 1" OF CARINA

What does of P:F ratio measure and how is it calculated?

It measures the extent of pulmonary shunting. It quantifies the relationship between what goes into the lungs and what gets into the blood. PaO2/FiO2

What is permissive hypotension?

Keeping SBP 80-90 Aggressvie fluid resuscitation disrupts new clots, dilutes blood, promotes coagulopathies, and aggravates endothelial leakage NOT APPRORIATE FOR TBI

What is a focal brain injury?

Local, indirectly affects consciousness. Focal injuries are something you could point to like a skull fracture or bleed

Blunt trauma Classifications include?

MVA Auto vs. pedestrian Falls Struck by or against an object

What are the 2 types of bleeding in a trauma patient?

Mechanical & Coagulopathic Mechanical requires surgery to fix hole Coagulopathic- later in ICU, TIC-trauma induced coagulopathy

Post-aricular hematoma or "Battle sign" is a result of?

Middle fossa fracture. If patient has a tympanic tear, CSF leaks -otorrhea

What is the normal PaCO2 and what does it measure?

Normal is 35-45 mmHg It is the measurement of ventilation Clinical assessment- rate, depth, and work of breathing

What is the normal PaO2 and what does it measure?

Normal is 80-100 mmHG It is a measurement of diffusion It reflects a problems with alveoli or pulmonary circulation

What is a normal P:F ratio?

Normal is >450, lower numbers are worse

What is TBI and second impact syndrome?

Occurs when an injured brain receives a SECOND blow in anywhere from minutes to weeks after the initial impact. This condition is often fatal

What is pericardial tamponade?

Occurs when fluid accumulates in the pericardial sac, as volume in the sac increases, volume in the chambers decreases. Temporarily overcome this by aggressive preload. Emergent surgical repair is the preferred treatment. Will see a narrow pulse pressure

What is Vo2?

Oxygen consumption or use. (It is the difference between the oxygen sent (SaO2) to the cells and the amount that returns to the heart (SvO2) ) Normal VO2 is 180-280

Car vs pedestrian injuries depend on?

Point of contact with the care Height of hood & bumper Size & weight of vehicle Height of patient Direction patient was facing when struck

What are the hormonal responses to shock?

Promote body water retentions by secretion of ADH & activation of RAAS

Types of shock per TCAR?

Pumps-Site of defect heart Pipes- site of defect is artery, veins or capillaries Fluid-intravascular, interstitial or intracellular

What is the treatment for TBI?

REST

What chamber of the heart is most commoly injured in blunt trauma?

RV because the heart is rotated to the left Majority of injuires are myocardial contusions

Normal pH?

Refernce range is 7.35-7.45, but actual normal range is 7.38-7.42

Physiologic criteria for trauma center care?

SBP<90 Resp rate <10 or >29 GCS <14

What does SBP estimate for you?

SBP= CO--they go up & down together It is an indication of volume (preload) and contractility

What are the inflammatory responses to shock?

SIRS Which is a production of pro-inflammatory mediators, histamine release, and capillary leakage

Needle thoracostomy is only appropriate for?

Tension PTX

What makes a fracture comminuted?

The bone is in multiple pieces

Force

The dose of energy involved

Dose of energy is?

The nature and amount of force

What is Kinematics?

The process of predicting potential injuries based on analysis of the forces involved

What is pulse pressure?

The relationship between CO & the body's compensatory vasoconstrictive response Pulse Pressure= SBP-DBP Minimal acceptable number is 30-40 or 25% of SBP

What is shock index?

The relationship between SBP & heart rate required to maintain it (tachycardic compensation). HR divided by SBP, normal is 0.5-0.7

What are symptoms of fat embolism syndrome and when do they occur?

Respiratory (tachypnea), neuro (agitation, anxiety) and dermal (petechial rash on chest), occur 12-72 hours after pelvic or long bone fractures

What are cervial spine patients at greatest risk for?

Risk of respiratory comprimise C3, 4, 5- Keep diaphragm alive C3 function is not adequate to support ventilaton C4-can move diaphragm, minimally adequate C5-have diaphragm, lack intercostals

What is the ankle-brachial pressure index?

SBP of ankle (lower leg) divided by SBP of brachial (upper arm), normal is 1, <0.8 means decreased flow

What are clinical findings suggestive of TBI?

Somatic-H/A, N&V, blurred vision, fatigue Cognitive-confusion, impaired judgement Emotional-depression, irritability, sleep disturbances

For every second of fall time, speed increases by?

Speed increases by approximately 20 MPH

A massive PE symptoms?

Sudden change in mental status Neck vein distention Hemodynamic instability Low O2 sat

How many ATP molecules are produced without oxygen?

2 ATP molecules

How many ATP molecules are produced with oxygen & glucose?

32 ATP molecules

Oxyhemoglobin dissociation shift to the right?

Acidosis, elevated temp More oxygen available to the cells

What are the earliest signs of neurological deterioration?

Altered LOC, drowsiness, confusion, disorientation, H/A, agitation, N&V

Peri-orbital ecchymosis or 'raccoon eyes" are result of?

Anterior fossa fracture

What is the magic pressure numbers? (ICP, ACS)

Approximately 20mm Hg is the pressure required to squeeze a capillary closed, regardless of where it is located, as soon as it closes, flow is impeded.

What is the cause of a Subdural hematoma?

Bleeding bridging vein is cause More common than epidural Blood on brain causes mechanical & chemical damage Will have same sided (ipsilateral) pupil dilation, contralateral weakness and sensory dysfunction

What diagnostic study best identifies intracranial bleeds?

CT, fractures and bleeds are readily apparent on CT, concussions and diffuse injuries are not

What are SIRS criteria?

When 2 or more are met: Temp >38.3 or <36 RR >20, HR>90, PaCO2< 32

What nursing assessment would make you suspet low calcium?

Carpal spasm (Trousseau Sign) while checking BP

Wound ballistics- permanent cavity

Cavity is the a function of the size, shape, and characteristic of the missile (mass)

What are the classic symptoms of brain herniation?

Cushing's Triad-irregular respirations, bradycardia, systolic hypertension (widened pulse pressure)

What does DBP estimate for you?

DBP is a measure of vascular resistance-afterload DBP reflects vasoconstriction due to sympathetic compensation

Energy transmission in a rollover depends on?

Deceleration distance Energy is dissipated over the distance of the roll and whether or not the occupants are restrained

What test can be used to screen for thoracic aortic disruption?

Checking the BP in both arms, normally there should be less than 12 mHg difference in SBP between the arms. Avoid HTN to limit further dissection & avoid rupture

What are markers of hemostasis?

Clotting factors and H&H

Pressure on which cranial nerve results in pupillary dilation and loss of reactivity?

Cranial nerve III

Banked blood causes what electrolyte abnormalities?

Elevated K-released from old or damaged blood cells Decreased Ca-citrate in blood binds with calcium so the ionized Ca level is low

What is muscle compartment syndrome?

Elevated fascial compartment pressure, higher than arterial pressure. MOST prominent symptom is unrelieved pain

What are the definitive options for pelvic fracture stabilization and hemorrhage control?

External Fixation Interventional Radiology Open reduction & Internal fixation

How do you calculate expected PaO2?

FIO2 x 5 If it's less than expected for a given FIO2, it is a diffusion problem

Factors predicting fall injuries are?

Fall height (velocity) Landing surface (deceleration distance) Point of impact on the body

What is the most common mechanism of injury in all age groups?

Falls

Oxyhemoglobin dissociation curve shift to the left?

Hypothermia, alkalosis Less oxygen available to the cells

What is Secondary Brain injury?

Hypoxemia -SpO2 <90% Hypotension-SBP<90

How are closed mid-shaft femur fractures managed?

Intramedullary nail fixation

Patients who are very sensitive to supplemental oxygen are telling us they have what type of problems?

It is a diffusion problem

Which gender is the majority of trauma?

Male

What is the best parameter to measure diffusion?

P:F ratio

What system is at greatest risk following initial stabilization?

Pulmonary

Incidence of trauma peaks at what age?

Teens and young adult

What 2 things affect the amount of oxygen availalbe to the cells?

Temperature & pH, which is the oxyhemoglobin dissociation curve

What are early findings of end organ hypoperfusion?

Widenend pulse pressure (dropping diastolic pressure) Decrease U/O, decreased pulse ox, increase resp rate, restlessness

Trauma mortality based on organ system failure?

1 organ system failure=4% 2 organ system failures=32% 3 organ system failures=67% 4 organ system failures=90%

What are the four collisions?

1. The vehicle 2. The occupants 3. The internal organs 4. The secondary impacts

Pulmonary contusion causes a problem where in the cascade?

Diffusion Bruising and edema impair gas exchange Best parameter to measure is P:F ration

What are hypotonic fluids?

Fluids that distribute throughout the body. Beneficial for dehydrated patients who need maintenance fluids.

What are isotonic fluids?

Fluids that fill the vascular space, for those that need circulating volume replacement. 3/4 of this fluid quickly moves to interstitial spaces

What are hypertonic fluids?

Fluids that helps pull fluid into the vascular space. Not good for patients at risk for fluid overload. 3% Saline

What events are typical of diffuse brain injuries?

Following the injury, there is a transient loss of consciousness, then the brain re-boots

Inadvertent esophageal intubation assessment findings include?

Gastric distention, absent breath sounds, minimal chest wall movement and rapid deterioration

What is a diffuse brain injury?

Global, generalized. Directly affects consciousness, such as diffuse axonal injury or concussion

What do patients need who drop their BP after opiod administration?

They need volume

What are the suggested lab studies for someone in Trauma induced cogulaopthy?

Thromboelastography (TEG) Rotational Thromobelastometry (ROTEM) both testes provide real-time visual representation of clot formation and clot lysis

Lactic acid is the marker of what?

Tissue ischemia -anaerobic metabolism Normal serum lactate is <2

Characteristic of wounding agent?

Type of energy and how it was applied

What is the most common site of an epidural hematoma?

Under the temporal bone, at site of the middle meningeal artery. Blood accumulates under the dura. On CT the hematoma appears convex

What is a subarachnoid hemorrhage?

Usually a medical problem, not traumatic. Commonly caused by aneurysm rupture of AVM, often at circle of Willis

A simple pneumothorax presents a problems where in the cascade?

Ventilation Deflated section of the lung is not participating in gas exchange An isolated PTX can be treated with a CT in the 2nd ICS

A tension pneuomothorax presents a problem where in the cascade?

Ventilation & CO Pulsus paradoxus and unilateral breath sounds

A hemothorax presents a problem where in the cascade?

Ventilation and Hgb availability CT insertion at 4-5th ICS Blood loss is commonly the intercostal vessels

Rib fractures cause a problem where is the cascade?

Ventilation- because it interferes with the mechanical process of breathing