TCAR
MAP (mean arterial pressure) equation
(MAP): Organ and tissue perfusion pressure; the pressure the organs actually receive. MAP=SBP=(DPBx2)/3 Normal is >65mm Hg
What is the oxygen consumption VO2 formula? Normal Value
(SpO2-SvO2) x Hgb x 1.36 x CO x10 180-280 ml/min
Auto Vs. Pedestrian Injuries variables include: (x5)
1)Height of the hood. 2)Height of the bumper. 3)Size and weight of the particular vehicle. 4)Height of the pedestrian. 5)Direction the pedestrian was facing when struck.
The Hemorrhaging patient. There are only two ways to drop h/h levels.
1)dilute the blood with IV fluids 2)shift fluid from other body compartments into the vascular space.
What's considered too much output form a chest tube?
1000-1500 initially 150-200 ml per hour x2-4 hours The amount of bleeding increases The patient remains hemodynamically unstable and requires ongoing transfusion
How many red cell units short is this patient?
15 g/dL (normal)-6 gdl (current)=9
How fast does an airbag inflate?
170-200 mph.
FIO2 x 5 = expected PaO2 21% x5=105 mm HG 40% x 5 = 60% x 5 = 100% x5 =
200 300 500
Minimum acceptable PP? (pulse pressure)
30-40 mmhg, or 25 % of SBP mean arterial pressure (MAP): Organ and tissue perfusion pressure; the pressure the organs actually receive. A dropping mean pressure threatens organ perfusion
When fully saturated, each HGB molecule can carry ______oxygen molecules.
4
How much blood can be contained within one adult hemithorax?
500-3000ml (10-60% of total blood volume)
Frontal collisions
65% of all crashes, most vehicle safety devices are engineered primarily for frontal impacts.
What is a normal LAB PH level?
7.35-7.45
Normal Lactate Level Normal PH Level Normal Base Level
<1 mmol/L Shock is >4 7.35-7.45 Shock is <7.3 +2 to -2 mEq/L Shock is > -6mEq/L
What is a normal P:F ratio? What is less than normal? What is Mild ARDS? What is Moderate ARDS? What is Severe ARDS?
> or equil 450 is normal 450-300 Less than normal 300-200 Mild ARDS 200-100 Moderate ARDS <100 Severe ARDS
What is a pulmonary contusion?
A big boggy bruise on the lung When the lung parenchyma is contused and edematous it becomes difficult for oxygen to move from the alveoli to the capillaries.
Impalement injury facts
A penetrating wound that doesn't involve an instrument designed to cut. Especially if the wound wasn't deliberately inflicted. A relatively low velocity of impalement injuries often pushes vital structures aside as the object enters the tissues.
What's a pulmonary laceration? What's the chief implication for care?
A tear in the lung parenchyma Associated with significant hemorrhage/Hemothorax May require emergent surgical intervention.
What classic chest radiograph finding suggests a thoracic artic injury?
A widened Mediastinum Chest CT with contrast provide DEFINITIVE diagnosis of traumatic aortic disruption.
What are some acute problems and chronic problems with alveoli?
Acute- Pulmonary Edema, Inhalation injuries Pneumonia, ARDS Chronic - COPD & Fibrosis
What is permissive hypotension premise?
Aggressive fluid resuscitation pops" the newly formed clots, dilutes the blood, promotes coagulopathy, and aggravates endothelial leakage. Keeps SBP 80-90 mm HG Plug the holes; then replace volume, preferably with same stuff the patient is losing. Considered most beneficial for penetrating trauma patients; INAPPROPRIATE for patients with traumatic brain injuries.
The Do not PEE hormone
Antidiuretic hormone (ADH) from the pituitary gland
What hormone promotes body water retention?
Antidiuretic hormone (ADH) release The renin-angiotensin-aldosterone system (RAAS)
What's a simple Pneumothorax?
Any air that enters the pleural cavity also leaves at the same rate; there is no accumulation under pressure Most patients can tolerate a simple pneumothorax for some period of time depending on it's sixe, the extent of other injuries, and the patient's underlying health status.
What is Trousseau's sign?
BP cuff inflated and causes a carpal spasm. (Low calcium)
Three reasons demand is too high with Hyper-metabolic sates.
Basal body demands (fever &growth) Injury/illness demands (healing wounds, Burns, or fractures) Patient activity demands (agitation, seizures, shivering)
Biomechanics of being struck by or against?
Blows of any kind, often multiple to various body sites. The force of a blow is equal to the bass of the object times its velocity squared. Even small objects can exert significant force.
What imaging studies are used to detect hepatic injury?
CT and FAST US
Our patient's HGB level is 6g/dl and his Sp)2 is 100%. What is his oxygen content (CaO2) ?
CaO2 = SpO2 x Hgb x 1.36 (100%x 6.0x 1.36=8.16/100 ml Blood) Normal CaO2 is 20ml O2/100 blood Patients oxygen carrying capacity is very low
The Peritoneal cavity
Can expand massively due to tumors ascites, pregnancy. Trauma patients can dump large volumes of blood into their bellies.
Order of death under oxygen restoration?
Cell Death Tissue Death Organ Death Organ System Death Patient death
What is the treatment for a simple pneumothorax?
Chest tube (AkA Tube thoracostomy)
What's the initial hemothorax intervention?
Chest tube insertion The patient with retained hemothorax may require video assisted thoracoscopic surgery (VATS) or interpleural tPA infusion a few days after injury to prevent infection (empyema) or scar tissue formation (fibrothorax)
Which patients are at particular risk for airbag injuries?
Children in rear-facing car seats in the front seat, any young child, anyone sitting close to the bag, short drivers.
How are bowel injuries assessed?
Clinical signs of infection: fever, leukocytosis Peritoneal signs: rebound tenderness Radiographic studies: free air in the belly Direct inspection during open or lap surgery (run the bowel)
Severe hypothermia causes _________ _______________ Failure
Clotting activation failure.
In a patient with chest trauma, what simple bedside test performed with a standard bp cuff that can be used to screen for Thoracic Aortic Injury?
Compare bilateral upper extremity SBP measurements. Retrograde (backward dissection, from the side of the disruption, occludes flow to the left subclavican artery, SBP drops. Normally, there should be less than 12mm Hg difference in SBP between the arms.
Which abdominal structures are retroperitoneal?
Completely - Kidneys, vena cava, aorta, spine Partially - Colon, Duodenum, Ureters, Pancreas
What injuries occur when lung tissue is exposed to force?
Contusions: bruise Lacerations: Tear Punctures (Pneumothorax): Pop
What are hypotonic crystalloids? What kind of patients?
D5W D5 half D5 .2 hypovolemic patients who are dehydrated. Give the cells a drink! INTRAVASCULAR volume increases
Oxygen delivery formula? DO2: Amount of Oxygen delivered to the tissues
DO2=SpO2 x Hgb X 1.36 x CO x 10 Saturation x Hgb x Cardiac output
Do spleens ever bleed after hospital discharge?
Delayed splenic bleeding is an unusual event, but can occur days or weeks after initial injury. (usually within 7 days). This means careful discharge teaching. Contact sports precautions for up to 8 weeks(depending on patient characteristics and splenic injury grade.)
Bariatric patients are at significant risk for ______,_______,_______ in patient care.
Delays to care, diagnosis and discharge
What common preinjury health issues do a bariatric patient have?
Diabetes, HTN, Weakness, Decreased respiratory reserves
Pulmonary contusions cause a problem at what point on the tissue oxygenation cascade?
Diffusion-Bruising (torn capillaries) and alveolar edema impair gas exchange
What are direct cardiac injuries, secondary causes, and medical causes of Cardiogenic Shock?
Direct-Penetrating or blunt trauma Secondary - Cardiac Temponade & tension Pneumo Medical- PE, Severe Dysrhythmias, Cardiomyopathies, Myocardial infarction.
If a trauma patient survives the first 48 hours and then dies, cause of death is usually .......
Distributive shock rather than hypovolemic shock.
What's the crucial intervention of the abdominal trauma patient in Hemorrhagic shock?
Emergent surgical intervention.
In fluid resuscitation, IV crystalloid administration contributes to _________damage and__________leakage
Endothelial Damage and capillary leakage. 3/4 of the fluid infused into the vascular space moves quickly into the interstitial space. This explains why pts who receive large amounts of isotonic crystalloids quickly "PUFF UP."
What is the Causative Agent in Trauma?
Energy
Rollover Collisions
Energy transmission depends primarily on deceleration distance because energy is dissipated over the distance of the roll (vs driving in a wall). Depends on whether or not the occupants were restrained.
Military -grade weapons achieve _______velocities
Even higher Velocities
What age trauma patient has the worse outcomes?
Extremes of age.
What are typical airbag injuries?
Facial abrasions/burns, Ocular injuries, hand and forearm injuries (drivers)
What are parasympathetic system compensatory mechanisms to resist shock?
Feed & breed or rest & digest. Constricts pupils, stimulates flow of saliva, constricts bronchi, slows heart, stimulates peristalsis and secretion, stimulates bile release, contracts bladder.
What are sympathetic system compensatory mechanisms to resist shock?
Fight for flight with tachycardia, increased cardiac contractility, tachypnea, pupillary dilation, hyperglycemia, vasoconstriction=blood redistribution.
What are the types of penetrating injury mechanisms?
Firearm injuries Stab injuries Impalement injuries
What is the acceleration of a fall?
For every second of fall time, seed increases by about 20mph (until terminal velocity is achieved)
What is the treatment for cardiac temonade?
Get the patient to definitive surgical care as quickly as possible Pericardiocentesis is recommended only if surgery will be delayed (buys time)
What does the liver do?
Glucose production and storage Clotting factor production Protein synthesis toxin Metabolism Bile production digestion immune funciton
Traumatic organ injuries are scored according to severity.
Grade 1 are the less severe, Grade 5 are the most severe that can be survived. Grade 6 are unsurvivable (Injuries to the heart, lungs, and major thoracic vessels.)
What is the significance of posterior rib fractures?
Great force was usually involved; typically a direct blow Look for associated T-Spine, cervical, aortic, and pulmonary injuries.
What are the risks of wearing only a lap belt?
Head and chest injuries (unrestrained upper torso). Abdominal organ injuries, Lumbar spine injuries (Hyperflexion fractures)
What is the site of defect with the pump for shock?
Heart. Cardiogenic Shock
Traumatic aortic Disruption causes......
Immediate death in 80% of patients. Patients who survive to surgical care have small or incomplete tears in which the outer vascular layer remains intact.
What are the most common post op problems associated with a bowel injury?
Infection:peritonitis, abscess formation, sepsis bowel edema fluid shifts Edema comes from the INTRAVASCULAR space. Acute edema predisposes patients to intravascular hypovolemia.
Restraint malposition contributes to ___________.
Injury
What's the primary problem with fresh frozen plasma?
It's Frozen! It takes 15-30 minutes to thaw a unit
Look for massive unilateral patient injury.
Lateral impact collisions (AKA broadside or T-bone)
What clinical finding suggest a splenic injury?
Left flank bruising LUQ pain/tenderness Abdominal distension/rigidity Tachycardia, hypotension falling H/H Kehr's Sign
Nearly 75% of passengers totally ejected from a moving vehicle sustain fatal injuries. Why?
Less energy is absorbed by the vehicle. Instead, more force is transmitted to the body surface and organs.
What are the effects to tissue oxygenation when a patient has hypothermia and alkalosis?
Less oxygen available to tissues.
Three reasons too little oxygen delivered to cells.
Low oxygen sats Low HGB level Low Cardiac Output (HR or SV)
A RH neg patient receives RH positive blood
May develop antibodies to the Rh antigen
What are the two types of bleeding?
Mechanical (anatomic)- hemorrhage from a hole Coagulopathic - harder to control (ICU)
What is the two most popular forces associated with injury?
Mechanical or gravitational forces.
What are the 6 types of injuring energy forces?
Mechanical, Gravitational, Thermal, Chemical, Electrical, Radiant
What are the effects to tissue oxygenation when a patient has fever and acidosis?
More oxygen available to the tissues
What is the gender risk of trauma?
More than 2/3 major trauma patients are MALE.
Falls
Most common mechanism of injury in all age groups.
What are 4 blunt trauma classifications?
Motor Vehicle Collisions, Auto-Pedestrian Incidences, Falls, Struck by or against an object.
What clinical findings suggest cardiac tamponade?
Muffled heart sounds Tachycardia Hypotension Narrowed pulse pressure Dyspnea and tachypnea 'Jugular vein distention Low voltage EKG waveform
In the patient with cardiac temponade, where is the blood usually coming form?
Myocardial penetration Superficial vessel laceration
A simple Rib fracture, does that mean it's not important?
No Do NOT underestimate the potential severity of rib fractures, particularly in older adults.
What are the pathological effects of a tension pneumothorax?
No lung function on the injured side Reduced function on the uninjured side Cardiac and great vessel compression (thoracic pressure exceeds vena caval pressure) REDUCED PRELOAD (compromised cardiac filling) REDUCED CARDIAC OUTPUT ( compromised cardiac empting INCREASED AFTERLOAD ( resistance to cardiac emptying)
How are hepatic injuries managed?
Non-invasively if they are small or subcapsular Invasively-emergent packing, suturing, and angioembolization. Injuries to specific hepatic structures (large vessels, bile duct) require surgical repair Devitalized tissue is resected.
Cryoprecipitate (CRYO)
Obtained from plasma, cooled until the desired blood components precipitate out. Requires time to thaw, if frozen Contains concentrated amounts of factors VIII, XIII, von willebrand factor, fibronectin , and fibrinogen In the trauma patient, cryoprecipitate is primary given to treat low fibrinogen levels
Thoracic Gun shot - Do retained projectiles ever move around?
Occasionally; bullet embolism may be an indication for surgical removal. Acute changes in the patient with a retained projectile may indicate migration.
What's the difference between an open and a closed pneumothorax?
Open Means the pleural cavity is open to the outside of the chest (to atmospheric pressure); The pleural space has lost negative pressure.
If PaO2 is less than expected for a given FiO2??
Oxygen diffusion is impaired.
How do I know if my patient's ventilation status is adequate?
PaCo2= 35-45 mm HG ETCO2 (end tidal) is always slightly lower than PaCO2 Clinical respiratory assessment of Rate, Depth, Work, Lung sounds, Etc.
What are signs of vasoconstriction?
Pale, cool, clammy skin. Delayed cap refill, absent bowel sounds, Oliguria, AMS
Which of the thoracic great vessels is most commonly injured in the trauma patient?
Penetrating trauma: any vessel in the path of the missile Blunt trauma: the descending aorta t the site of the ligamentum arteriosum (90% of the time).
Mild hypothermia and acidosis causes_______________ _____________________.
Platelet dysfunciton
Energy is transmitted to the Pedestrian at the _________________ __ ___________ with the vehicle.
Points of contact.
Two reasons for capillary occlusions or shunting.
Poor perfusion related hypovolemia or pump failure. vasoconstriction, microvascular clotting, inflammation, edema, vascular compression
What are some Pulmonary Hygiene techniques?
Positioning, suctioning, IS, Pep/Flutter valves, Coughing, Dangling, Ambulation
What is the inflammatory responses for shock?
Proinflammatory mediator production Cytokines Histamine Release Complement System activation Capillary leakage Reactive oxygen species formation
How does TXA work?
Prolongs body clotting factors. Inhibits the body's natural fibrin breakdown process, reserving clots by preventing lysis Must be administered within three hours of injury, but preferably within one hour. Some trauma units will follow with an eight hour infusion.
What are 4 possible problems with pulmonary circulation?
Pulmonary Emboli, Fat Emboli, Hypoperfusion, Pulmonary contusion
Neck Hyperextension followed by hyperflexion (Cervical Strain or whiplash)
Rear impact collisions
What procedure can be quickly performed to reestablish circulation in the penetrating thoracic trauma patient who just lost vital signs?
Resuscitative thoracotomy (aka emergent thoracotomy, ED thoracotomy (EDT), ER thoracotomy (ERT), and crack the chest." Most successful for the patient with PENETRATING (Vs. blunt) Thoracic trauma (not head or abdomen) who has just lost pulses (10 minutes or less), but still has signs of life (PEA, Agonal respirations, reactive pupils, spontaneous movement)
How do I know if my patients Diffusion status is adequate?
Saturation (SaO2 or SpO2) - how much oxygen is getting through the lungs. Patients who are very sensitive to sup oxygen are telling us they have a diffusion problem.
What are three mechanisms of injury for tissues?
Solid structures = Crack Hollow Structures = PoP Fixed points = Tear
Oxygen Content (CaO2)=
SpO2 x HGB x 1.36
How are most rib fractures managed?
Supportive care: analgesia and pulmonary hygiene Surgical rib fixation is reserved for multiple or displaced fractures, Flail chest, or flail sternum.
Trauma incidence peaks at what age?
Teen and young adult years.
What influences the size of the temporary cavity of a wound ballistic?
The Characteristics of the tissues involved.
Blood products come in bags of all sizes, so whats a "unit"?
The amount of a particular blood product derived from a single donor unit of whole blood.
How do rib fractures cause organ injuries?
The bones of the ribs can penetrate the lungs (mid-upper ribs) and great vessels, as well as the liver and spleen (lower ribs)
What is the second most commonly injured abdominal organ in the adult with blunt abdominal trauma?
The liver because its the largest solid organ, highly vascular, non-elastic.
Why are pancreatic injuries often difficult to detect with CT or FAST scan?
The pancreas is largely a retroperitoneal organ. Unlike the spleen or liver, the pancreas is not highly vascular. An injured pancreas leaks tiny drops of digestive enzymes rather than blood.
The shock index (SI)
The relationship between cardiac output (SBP) and the heart rate required to maintain it (Tachycardic Compensation) SI=HR/SBP Normal SI=0.5-0.7 Whenever HR exceeds SBP the patient is demonstrating cardiac compensation
Pulse Pressure (PP)
The relationship between cardiac output and the body's compensatory vasoconstrictive response. PP=SBP-DBP Output minus resistance
The body water conservation hormone
The renin-angiotensin-aldosterone system (RAAS) from the Kidneys
Thoracic Gun shot - What if there's only one hole?
There's a retained bullet
What are 4 types of burn injuries?
Thermal, Chemical, Electrical, Radiant
What are fixed points in the body? How do they respond in an injury?
They Tear Vessels Placenta tubes Ligaments and tendons Nerves Skin
Why do Airbags work?
They add deceleration distance.
What is the benefit of safety devices in vehicles?
They add deceleration distance. Airbags give occupants 12+ inches to dissipate energy. Seatbelts are designed to have stretch, allowing to "ride down" the energy. Flexible crash barriers (helmets, knee pads) add decel distance.
Thoracic Gun shot -When a patient is shot, where does it all go? Clothing, skin/hair, bone fragments.
This may require surgical debridement
Aortic injury- patient arrived with a bp of 92/66 and HR 137. Why was he not given a fluid bolus, prehospital or in the ER department?
This practice is known as "permissive hypotension" or "deliberate hypotensive resuscitation"
How do I perform a physical assessment of the injured patient?
Trauma care is not internal medicine; patients can not be adequately evaluated by simply asking question, looking at lab tests, and reviewing med lists. Appropriate trauma care involves serial physical exams to watch for evolving injuries and identify trends. Eyes and hands on every surface, top to bottom, front and back, everytime.
What red cell type can be safely given to any hemorrhaging patient?
Type O RH neg
Energy is generally applied in characteristic patterns. By analyzing _________ ,_________, _______,_________, and __________ it is possible to predict fairly accurately the injuries a patient will sustain.
Type, amount, location, direction, and duration.
What image study is used to detect cardiac tamponade?
Ultrasound:echo or FAST scan
Type AB blood people
Universal plasma donor. But type A is frequently substituted to to AB plasma shortages.
Simple pneumothorax is a problem at what point on the tissue oxygenation cascade?
Ventilation - The deflated portion of the lung is not participating in gas exchange
Tension pneumothorax causes problems where on the tissue oxygenation cascade?
Ventilation AND Cardiac Output
Thoracic gun shot wound - Is there likely to be a temporary cavity effect?
Yes and no, it depends! A gunshot wound (high velocity), and the chest is filled with soft tissue structures (subject to stretching), but eh caliber is small (.22 inches in diameter), and there wasn't enough energy for the bullet to get out the other side (no Exit Wound)
Is hand on abdominal assessment more challenging in the obese patient?
Yes it is more difficult to identify abnormalities such distention or rigidity, thus increasing the odds of missing significant findings.
Oxygen Debt =
actual O2 consumed (VO2) minus the body's O2 needs
What is qualitative data to measure cardiac output?
assessing HR, SBP,. and perfusion status: skin temp, cap refill, mottling, pulse quality, urine output, AMS
How far should you be from where the air bags deploy?
at least 12 inches
What's a hemothorax?
blood in the pleural space
Fluid shifts compensate for ongoing intravascular losses
body water redistribution. H/H measures of hemodilution rather than blood loss.
Systolic Blood Pressure (SBP)
correlates with CARDIAC OUTPUT- Volume PRELOAD and Contractility
For maximum protection, Vehicle occupants should contact the airbag when it's
fully inflated and not while it's still exploding outward
Wound ballistics - The size of the permanent cavity is?
is a function of the size, shape, and characteristics of the the missile (Mass).
Volume resuscitation with Normal saline?
is associated with hyperchloremic acidosis. The sodium content in normal saline is 10% higher than the normal serum level but the chloride content is 50% higher than the serum.
PaO2/Fio2 ratio (P/F) Quantifies the relationship between what goes into the
lungs and what gets through the blood.
What are some ventilation interventions?
positioning, pulmonary hygiene, assisted ventilation, drug therapy (bronchodilators) A patient can be well oxygenated without being adequately ventilated and vice versa.
TIC Treatment
with directed therapy is more effective than non-specific blood product replacement. Measure the coagulation process from start to finish. Thromboelastography (TEG) Rational Thromboelastometry (ROTEM) Both viscoelastography tests provide a visual representation of clot formation and lysis, identifying the specific site of the coagulation deficit Platelet mapping detects platelet inhibition.
What makes blast injuries complex?
MULITIPLE TRAUMA including delayed and subtle findings. It can consist of several potential mechanism types including Blast wave (shock wave, over pressurization wave), Fragment penetration (small flying objects), Blunt trauma (fall, thrown, hit), Crush injury (structure collapse, falling objects), Burns (thermal, chemical), Contamination (bilogical material, chemicals, or radiation).
We have evolved efficient responses to ____________ shock, but the body is poorly equipped to deal with _____________shock or ___________shock.
We respond to hypovolemic shock but poorly equipped to respond to cardiogenic or distributive shock.
A gunshot to the chest-What was the dose of energy involved.
High energy or low Energy? There is not always a simple, clear cut answer, but start by considering variables involved.
What are some environmental risks for trauma?
High risk jobs, associate with dangerous people, engage in extreme sport, abuse alcohol and other drugs, use weapons
How is the bowel injured in blunt abdominal trauma?
Hollow structures can POP due to direct abdominal blow or hyperflexion over a fixed object (belt lap) causing a massive and sudden increase in intra abdominal pressure
During surgery the patient received 33 units of blood products. Does that mean 33 units of packed cells?
Hopefully not!! The number should include plasma, platelets, and cryoprecipitate aiming for a 1:1:1 ratio
Our patients vitals in ICU HR 114, BP 96/66 Map= PP= SI= and what does this tell us? What kind of labs does this patient need?
MAP 76- Still maintaining organ perfusion PP 30 - but cardiac output is down and he is compensating by vasoconstricting SI=HR is>SBP - He's also compensating for low cardiac output by increasing HR. Markers of tissue ischemia/Anaerobic metabolism (lactate, pH, or base deficit) Markers of Hemostasis (H/H and clotting studies) Basic Serum Chemistries
What impact does obesity have on routine trauma care practices? And how can we accommodate the bariatric patient needs?
Patient transport may be difficult or delayed prehospital, interfacility, and within the hospital. Vascular access can be difficult Imaging studies are limited by patient size. Assistive devices may be required for routine care activities. Mobility is a challenge in the hospital and at home. Discharge planning options may be limited.
Can you live without a liver? How much liver do you need?
Patients don't need much functioning liver but hepatectomy is NOT an option. The liver must be preserved. Therefore, hepatic injuries are managed more aggressively than the splenic ones.
You dont really need a spleet? Why bother saving one? What does a spleen do?
Splenectomized patients have a increased lifetime risk overwhelming post-spleenectomy sepsis (OPPSS)
Intra-abdominal hemorrhage causes problems at what points on the tissue oxygenation cascade?
Starts with Hgb availability. Then cardiac output is the problem. Ventilation will be affected as well, as blood fills the abdomen and limits diaphragmatic excursion.
In car accidents....going fast isn't really the problem. It's not the speed but the ____ that kills.
Stop. Stop is when energy gets applied to the tissues. Both a patients SPEED and Deceleration distance predict potential injuries.
What impact does obesity have on patients' ability to recover from an injury event? Post ope increased incidence of:
Surgical site infections wound dehiscence renal failure rhabdo thromboembolic disorders complications of immobility Prolonged rehab
What is injury Mechanism?
The Means by which energy is transferred to the tissues.
Which of the four heart chambers is most frequently affected by Cardiac Trauma?
The RIGHT VENTRICLE, its the most anterior (front and center).
In patients who are shocky, septic, or otherwise compromised, even more fluid is required to replace blood loss because??
The body's inflammatory response makes the capillaries leaky.
Platelets Shelf life? Criteria for transfusion?
Thrombocytes Random pooled donors or single donor Shelf life is 5 days max Traditionally transfused only to trauma patients with a plt count <50,000. However a trauma pt's plts may be dysfunctional., despite an adequate number.
What is VO2? What is the normal level?
Tissue oxygen consumption (a.k.a. Extraction or utilization)=Difference between the oxygen sent to the cells and the amount that returns to the heart. Normal 20-30%
How is the pancrase injured in blunt trauma?
To crack a solid abdominal organ, the patine just needs to be bounced around; a direct blow is not mandatory. Injuries to the semi-soft pancreas are usually called by compression. A direct blow to the epigastrium compresses the pancreas between the rigid spine and a rigid object. (fist, steering wheel, bike handlebars)
Stab injures facts
Low velocity= no significant temporary cavity. The permanent cavity is the size and shape of the stabbing instrument. Damage is limited to structures directly in the objects path.
What are soft tissue structures of the thorax?
Lungs Trachea/Bronchi Heart Great vessels Esophagus Thoracic Duct Diaphragm
How can we indirectly detect hypoperfusion?
By monitoring markers of tissue ischemia/anaerobic metabolism Lactic Acid production PH levels Base
Interventions with Diffusion problem 1)Pulmonary Edema 2)Pneumonia 3)Atelectasis 4)ARDS 5)Chronic Lung Disease
1)Diuresis, Dialysis 2)Antibiotics, Careful fluid mgmt 3)Pulmonary Hygiene 4)Mech ventilation, PEEP 5)Sup Oxygen
What are the three factors predicting fall injuries?
1)Drop Height(velocity)? 2)Landing surface (deceleration distance)? 3)Point of impact on the body (Where the energy was initially applied; follow the force.)
What's a simple rib fracture?
A cracked rib, A non-displaced fracture, Often difficult to visualize on radiographs until healing occurs, A commonly missed injury With healing, fractures become visible as bony callus is formed.
What is Cardiac Tamponade (aka pericardial tamponade or hemopericardium)?
*Blood or other fluid in the pericardial sac compresses the cardiac chambers. *Usually associated with penetrating injury, less common following a blunt trauma. *The pericardium is non-elastic and normally contains only a small amount of serous fluid. *When volume in the sac increases, volume in the chambers decreases. *Pericardial blood can accumulate quickly.
Most trauma to the hear is the result of.........
Blunt cardiac injury AKA BCI
What are 5 injury mechanisms?
Blunt, penetrating, Crush, Burn, Blast
What are solid structures in the body? How does it respond in blunt force?
Bone is the most solid structure, cracks with blunt force. Spleen Liver Kidneys
In the post-resuscitation phase of a bowel injury, what does nausea and vomiting indicate?
Bowel contusion blossoming, edema, or ileus
What are semi-solid organs that will crack or even shatter in response to blunt injury?
Brain & Pancreas
Why is flail chest a problem?
Breathing is a very mechanical process. A flail segment makes breathing very inefficient.
What invasive study is commonly used to identify the location of tracheal or bronchial tears?
Bronchoscopy; radiographs show presence of subq air but they don't identify where the leak is. Small tears may be managed non-operatively or larger tears require urgent surgical repair.
What are some kinds of bowel injuries?
Bruise it -- Contusion or edema Tear it--Mesenteric injury POP it--Acute rupture or delayed rupture
Thoracic gun shot wound-What questions do we need answered to predict the injury?
Bullet caliber, gun type and velocity
What is the only mechanism of injury that does not involve mechanical or gravitational force?
Burn injuries
What clinical findings suggest hepatic injury?
Right flank bruising RUQ pain/Tenderness Abdominal distention/rigidity hypotension Tachycardia Dropping H/H (Same findings but opposite side)
Unrestrained occupants become free-floating objects, subject to the centrifugal forces. Can be spun out of the vehicle.
Rollover collision
In adults, Stoke volume and cardiac output both roughly correlate with
SBP, the numbers go up and down together
The priority intervention in the hemorrhaging patient is to....
STOP THE BLEEDING. Establish hemostatsis External hemorrhage control Normothermia Coagulopathy management Surgical intervention. REPLACE the LOST VOLUME
What emergent intervention is indicated for an open pneumothorax, but not for a closed pneumothorax?
Seal the hole!! cover the wound site completely with an occlusive dressing The lung can not re-expand until negative pressure is re-established.
When the Aorta is stretched, the weakest layers tear first.
If there is just enough force to tear through the intima and media, but not the tougher adventitia, blood will accumulate between the vessel layers, creating a false lumen that enlarges over time.
What is a "Damage Control" Laparotomy-DCL?
In the early phase of care, abdominal trauma patients die from triad of coagulopathy, hypothermia, and metabolic acidosis. Only life saving surgical interventions should be performed on cold, acidotic, hypovolemic patients. GET IN< STOP THE BLEED>GET OUT The abdomen is packed and left open, transferred to ICU to continue resuscitation. Definitive care is postponed until the patient is hemodynamically stable, warm, and out of metabolic acidosis. The focus of damage control surgery is to resor normal physiology, rather than normal anatomy.
How are pancreatic injuries identified?
Injuries are evident on CT if they ar large. Serial Amylase or Lipase level elevation identifies more subtle trauma, but may still fail to detect some injuries. Epigastric pain is often a DELAYED finding
What's the source of hemothorax blood?
Intercostal vessels=most common lung parenchyma mammary arteries great vessels heart (unusual)
What is the site of defect with the fluid for shock?
Intravascular, interstitial, and intracellular fluid. Hypovolemic shock (hemorrhagic and non-hemorrhagic)
Bleeding from Intercostal vessels
Should not be extensive and should taper off fairly quickly. If blood loss is large or ongoing, the source is likely to be a site other than the intercostal vessels.
Lateral impact collisions (AKA broadside or T-bone)
Side blow. There are only 6-8 inches between the occupant of one vehicle and the bumper of the other. Steel side beams and lateral airbags reduce force transmission.
Indicators of force. The force went somewhere...so where did it go?
Some indicators of force are readily notated on physical exam but others may not be evident for hours or days. Obvious, delayed and subtle.
Facts about Shotguns
Spherical pellets in shells rather than bullets. Shot comes in various sizes. Pellets disperse with distance. The combination of the pellet size and distance from the muzzle influence the effects of the shotgun blast.
What are the solid and encapsulated organs?
Spleen, Liver and Kidneys
What's the intervention of a thoracic aortic tear?
1) Aortic graft placement (traditional approach). 2)Thoracic endovascular aortic repair (TEVAR) (now preferred) 3) Repair may require transfer to a facility where TVAR is available 4)Prior to repair, control bp with antihypertensive agents.
What is the classic pattern of patient deterioration related to pulmonary ventilation?
1) Patient hyperventilate 2)blow off CO2 3) to create respiratory alkalosis 4) to compensate for metabolic acidosis 5)caused by lactic acid production 6) due to poor tissue oxygenation.
Understanding injury potential in a trauma patient involves analyzing WHAT 4 FACTORS?
1) The Nature and amt of force. 2)Various patient characteristics. 3)Characteristics of the wounding agent. 4)Tissue characteristics.
How do I know if my patients tissue oxygenation is adequate? There are four reasons for a tissue oxygen consumption imbalance.
1) To little O2 is delivered to the cells 2) Oxygen demand is too high (Hyper-metabolic states) 3)Capillary occlusion/shunting ( the cells aren't getting an adequate amt of oxygen delivered) 4)The cells can't use delivered oxygen and it simply recirculates.
What's a pneumothorax?
Air in the chest (where it doesn't belong, in the interpleural cavity.) A partially or completely deflated lung There are no ligaments attaching the lung to the chest wall; the normal lung stays inflated due to the presence of negative pressure and a thin layer of pleural fluid. Surface tension "sticks" the lung tissue (visceral Pleura) to the inner chest wall (parietal pleura)
How much blood can be put in a belly?
All off it!! 500-6000ml (total blood volume 4-5L). Bleeding is more difficult to see in an obese patient.
What imaging studies are indicated to assess the patient with overt signs of tension pneumothorax>
Although dramatic findings are evident on a CT, the diagnosis of tension pneumo should ALWAYS be based on clinical findings; delays for imaging could prove fatal
What's a Tension Pneumothorax?
An emergency which displaces the trachea and mediastinum away from the affected side, compressing them. Can affect venous return etc, treatment needed immediately!!! Air enters the pleural cavity but doesn't leave at the same rate, causing accumulation of air under pressure. The large volume of trapped air compresses all surrounding structures.
What is the site of defect with the pipes for shock?
Arteries, veins, capillaries. Septic shock, anaphylatic shock, Neurogenic shock. The vessels not only dilate, they become leaky as well.
Crush injury facts
Associated with massive tissue destruction. Machinery, pin-in road traffic collisions, animal bites, structure collapse, pedestrians who are run over
Shock is a ____________phenomenon; all derangements occur at the _______level. Clinical S/S are secondary and are usually________findings
CELLULAR. CELLULAR. LATE FINDINGS
What imaging studies are used to detect splenic injury?
CT FAST US (focused assessment with sonography for trauma) - is a way to quickly check for free fluid in the abdomen or thorax
Tissue Oxygenation cascade - Hemoglobin availability problem. What parameter are we looking at? What is our clinical assessment? What are potential etiologies? Potential interventions?
CaO2 (oxygen content) Assessment - Hemoglobin level Etiologies - Hemorrhage: external/Internal Hemodilution Interventions - Hemostasis, normothermia, transfusion, pro-clot agents
Encapsulated organs
Capsule acts like a stretchable skin around parenchymal tissues, which are prone to cracking. As long as the capsule remains intact, bleeding is contained. Once the capsule is torn, blood leaks into the peritoneal or retroperitoneal space. The presence of an intact capsule makes non-operative mgmt a feasible option for most splenic, hepatic, and renal injuries.
Cardiac Tamponade causes a problem at what point on the tissue oxygenation cascade?
Cardiac output: Limited ventricular filling (decreased preload) and poor ventricular ejection (decreased stroke volume
Two reasons the cells cant use delivered oxygen and it simply recirculates.
Cellular metabolic dysfunction (toxins, sepsis) Cell death
Rear Impact Collisions
Commonly low velocity (backing up or both moving forward). Rear seat occupants are greater risk. The body if first thrown forward while head lags behind.
Plasma Shelf life? How much of blood volume is plasma? How much per unit?
Contains albumin, fibrogen, globulins, and clotting factors (proteins), but no cells Can be transfused for almost any coagulation deficiency and for volume resuscitation. up to 7 years frozen shelf life. 1-5 days when thawed. Never frozen plasma has a shelf life of 26 days. 55-65% of blood volume 200-250 per unit
Progressive occlusion of the Aortic Lumen impairs what organ perfusion?
Coronary, renal, mesenteric, spinal, and femoral artery perfusion my be compromised.
Solid structures=____________injury Hollow Structures =______________ Fixed pints=_______________
Crack Pop Tear
Tissue Oxygenation cascade - Cardiac output problem. What parameter are we looking at? What is our clinical assessment? What are potential etiologies? Potential interventions?
DO2 (oxygen delivery) Assessment - Co or CI (HR x SV) Systolic pressure, pulse quality, distal perfusion Etiologies - Tachycardia/Bradycardia, volume loss/overload, Cardiac Tamponade/Tension PTX, Cardiac dysfunction, Vasodilation/constriction Interventions - Rate control, hemostasis/fluids/diuresis, obstruction removal, contractile support, vasopressor/dilator
Crystalloids - composed of small molecules that are readily capable of passing through capillary endothelium
Dextrose or Sodium chloride based solutions with our without other electrolytes. Hypotonic Isotonic Hypertonic Originally developed to treat dehydration, not hemorrhage. -Initial replacement of lost blood volume -Dehydration tmt -Maintenance fluids
How do we diagnose and manage BCI (blunt cardiac Injury)?
EKG, Cardiac monitoring, rest, antidysrhythmic or inotropic agents. Troponin levels. Penetrating wounds are much less common but are more devastating.
What does the Nature and amount of force mean?
Force is the dose of kinetic energy involved. Force=weight x speed *2 What was the dose of energy? A small increase in speed produces a significant increase in force.
With an open abdominal wound after a laparotomy, how are we going to warm a hypothermic patient?
Forced air warmers. Nother that will put pressure on the open abdomen. Warm IV fluids Keep pts room warm Acidosis and coagulopathy will not correct until we reverse hypothermia.
Look for indicators of force on anterior body surfaces.
Frontal Collisions.
How do I know if a Patient's Hemoglobin level is sufficient?
HCT is roughly equal to HGBx3 Calculating hemoglobin deficits (1g/dl of Hgb represents 1 unit of PRBCs.)
Two measures that can determine Cardiac Output
HR x SV SV=the amount of blood ejected from the heart with contraction.
Guns - Which ones have low velocities and which ones have high velocities?
Handguns = low Rifles/long guns = High
Initial shock after injury is most likely______________shock. In the post-resuscitation phase, other shock types become increasingly more likely.
Hemorrhagic Shock.
What are interventions for a low CaO2?
Hemostasis-Hemorrhage control, normothermia, coagulopathy mgmt Volume Replacement -PRBCs
What's the ongoing mgmt of the hepatic injury patient?
Serial Abdominal exams, H/H, CT scans for deteriation, Coag studies and liver enzymes Lab abnormalities are DELAYED findings
What do "Short and Obese"Have To do with seatbelt use?
Short people often put the shoulder strap behind the back or under the arm, because it sits too high on the neck or face. Obese people may have difficulty fitting into a seatbelt system and are less likely to be restrained. Obesity increases driver mortality by 20-80%.
Auto Vs. Pedestrian Injuries laws of physics
Mass of the vehicle times its velocity ^2, Majority of this force is transmitted to the pedestrian.
What assessment findings that suggest great vessel rupture?
Massive Hemothorax, shock, inability to resuscitate the patient.
What are the top three "dead -a-the-scene" injuries?
Massive head trauma High spinal cord injury Aortic rupture.
What are types of isotonic crystalloids? What kind of patients?
NS LR Plasma-Lyte A Stay in the EXTRACELLULAR space. Intravascular volume increases. Hypovolemic patients who are in need of circulating volume replacement. 3-4ml replacement/1ml loss
Thoracic Gun shot - Do retained bullets or fragments have to be removed?
No necessarily; the primary goal of surgery is damage repair, not bullet removal. However there are potential long term complications from lead toxicity.
Hypothermia reversal is a ________________responsibility.
Nursing
What makes FAST Ultrasounds and abdominal exams less reliable?
Obesity
What's the best parameter for for serially monitoring a patient's diffusion status?
P.F. Ratio shows CURRENT diffusion status. Its not acceptable to monitor SpO2 and SaO2 because they can look normal with poor diffusion. Changes in CT will lag hours behind a patient's clinical status.
What's the initial intervention for Tension Pneumothorax?
POP the BUBBLE! Needle of finger decompression (aka needle or finger thoracostomy) Followed by CT insertion
SV is three functions
PReload (volume into heart) Contractility (eject from heart) Afterload (resistance the heart must pump against)
Tissue Oxygenation cascade - Pulmonary ventilation problem. What parameter are we looking at? What is our clinical assessment? What are potential etiologies? Potential interventions?
PaCO2 &ETCO2 Assessment - Respiratory status with rate, depth, work, BS, CXR Etiologies - Hypoventilation with meds, PTX,HTX, rib fx, AMS, Airway occlusion, SCI Interventions - positioning, pulm hygiene, CT, Rib fixation, Assisted ventilation, drug therapy.
Tissue Oxygenation cascade - Diffusion problem. What parameter are we looking at? What is our clinical assessment? What are potential etiologies? Potential interventions?
PaO2:FiO2 (P:F)Ratio Assessment-PaO2 SpO2 or SaO2 Etiologies - Pulmonary Edema, atelectasis/contusion, pneumonia/ARDS, Pulmonary/Fat emboli Interventions - Sup O2, Mechanical Ventilation, PEEP/CPAP, Drug therapy
What are the assessment findings suggest tension Pneumothorax?
Pleuritic Chest Pain Respiratory Distress Tachycardia Hypoxemia, Agitation Diminished Breath Sounds Chest Dissymmetry Hyperresonance Hypotension Jugular Vein Distension Tracheal Deviation.
With cardiac Output (HR x SV)- what interventions can we do to manipulate the Stroke Volume? Preload Contractility Afterload
Preload - (The Fluid) with crystalloids, colloids, blood products, diuretics, dialysis Contractility- (The Pump) Reverse myocardial hypoxia, dobutamine, ventricular assistance. Afterload - (The Pipes) Relieve obstructions (cardiac temponade, tension Pneumo, PE), Vasoconstrict, or vasodilate
What is the primary benefit of wearing a lap seat belt?
Prevents ejection & Keeps occupants in the seat and in the vehicle
What medications can be used to control bleeding in the hemorrhaging patient?
Pro Clot Agents Factor rVlla (NovoSeven) Tranexamic acid (TXA) Fibrinogen concentrate (RiaSTAP)
If a patient was shot, beside their health what other issues are important in our care?
Pt may be a crime victim, search for and secure weapons, collect and preserve evidence. Clothing - store in paper bags-not plastic Bullets or anything else removed from body Maintain the legal chain of custody for evidence. Protect yourself and others
Which ribs are most frequently broken? And Why?
Ribs 4-9 because they're long, thin, and not well protected
Packed red blood cells? lifespan? shelf life?
The only oxygen-carrying blood component Hematocrit 55-70% Lifespan 100-120days Shelf life - 42 days
What are the three primary sites of the defect with shock?
The pump, the pipes, and the fluid. Trauma patients are at risk for all three shock types, particularly in the post -resuscitation phase of care.
Which organ is most commonly injured in the patient with penetrating abdominal trauma?
The small bowel There is small bowel in all four quads-6-7meters (20-23 feet long) Usually require surgical exploration
The velocity of a fall is....
The speed of gravity=32ft/sec/sec
Which abdominal organ is most commonly injured in blunt trauma?
The spleen are most common. Liver is second. Both organs are minimal elasticity and highly vascular. Tissue characteristics predict organ injuries.
What are hollow structures in the body? How do they respond in an injury?
They POP Air filled hollow structures = lungs & middle ear Fluid filled hollow structures = bladder, globe of eye, heart, pregnant uterus and sac Air and fluid filled hollow structures=stomach, esophagus, intestines, abdominal cavity, diaphragm
Why are retroperitoneal injuries missed?
They may be missed initially because they are located deep within the abdominal compartment and dont present weight classic abdominal signs.
Whats the acceleration speed for the listed Drop Height 3'4'' ? 13'4"? 30' 1"? 53'6"? 83'6"?
Whats the Drop Height? 10MPH 20MPH 30MPH 40MPH 50MPH
When is the hospitalized chest trauma patient most likely to develop a tension pneumothorax?
When POSITIVE pressure ventilation is initiated with a bag-mask device or mechanical ventilator. When a chest tube becomes kinked, clamped, or occluded in the patient with a significant air leak.
What is shock?
When the body's responses fail, the end result. A state in which cellular metabolic oxygen demand exceeds supply.
In the hospitalized patient, when is an open pneumothorax routinely and intentionally created?
Whenever a chest tube is inserted, disconnected from the water seal without clamping, or prematurely removed.
Cellular oxygenation can be interrupted at any number of pints along the tissue oxygenation cascade. Correctly identifying the origin of the problem is crucial to appropriate intervention. What are 4 questions to ask to identify the problem?
Where is it? How bad is it? What's causing it? What can we do about it?
What is component therapy?
Worldwide whole blood is rarely transfused . Component therapy conserves precious blood supplies, Maximizes product lifespan, treats specific blood disorders
The Retroperitoneum
is different from the peritoneal cavity. Is a pretty tight fit, with limited room to expand. Retroperitoneal bleeding will often tamponade itself, making on-operative mgmt a common option. Look for evolving bruising along the patient's flanks (Grey Turner's Sign), suggesting the presence of a retroperitoneal hematoma
How long will the "Spleen Watch" patient be hospitalized?
guidelines for the patient with an isolated splenic injury suggests Injury grade +1 day, although there is variability around this practice.
Aggressive fluid resuscitation
is no longer considered beneficial
Wound Ballistics - The size of the Temporary cavity is?
is the result of the bullet blast wave; a function of the bullet's speed (velocity).
What are three types of blunt cardiac injuries?
1)Bruise it: Myocardial contusions 2)Tear it: coronary artery dissection or thrombosis; valvular disruption 3)Pop it: Cardiac chamber rupture.
What pain control measures might improve patient's respiratory status?
Epidural, nerve blocks, local anesthesia, Acetaminophen, Lidocaine patches, rib splinting
How do I know my patients Cardiac output is adequate?
Direct measurement of cardiac output or cardiac index can be performed using sophisticated invasive, minimally invasive or noninvasive techniques. Clinical evaluation of cardiac output (qualitative vs. quantitative measurements)can be done by assessing HR SBP,. and perfusion status: skin temp, cap refill, mottling, pulse quality, urine output, AMS
What IV analgesic agents would be less likely than morphine to cause hypotension?
Fentanyl or Ketamine
What are the benefits with ambulating a pt with a Chest tube in place?
Fewer ventilator days, lower rates of hospital acquired infection, sorter ICU and hospital stays
What's 1:1:1 transfusion? Aka Close ratio resuscitation.
For every unit of red cells, one unit of plasma is immediately and automatically transfused. Plts are also administered to maintain a normal ratio. BEST PRACTICE
What two electrolyte abnormalities are associated with banked blood transfusion?
Hyperkalemia: Potassium is released from old or damaged blood cells Hypocalcemia: The administration of large volumes of citrated blood is associated with serum hypocalcemia Calcium replacement is almost always indicated in the massively transfused patient.
Tension Pneumothorax radiographic findings you never want to see??
Hyperlucency (too much black!) Long Hemithorax Flattened or inverted diaphragm Compressed heart Deviated trachea and mediastinal structures
What is the treatment for Damage control Resuscitation for a severely injured patient?
Hypotensive resuscitation PLUS Early blood product use PLUS Damage control surgery
What does a pulmonary contusion do over time?
IT "blossoms", Pulmonary status deteriorates for 24-72 hours after injury. In the post-resuscitation phase, watch patients carefully for progressive deterioration.
How are splenic injuries managed?
Invasively- Splenectomy (removal) Splenorrhaphy (repair), Angioembolization (IR) Non-Invasively-(aka conservative or on -operative mgmt, "Spleen Watch" Serial abdominal exams (eyes and hand on the belly Serial H/H Repeat CT scan Most can be managed NON-INVASIVELY -Nurses need to closely monitor
What blood test will best assess the calcium status of a patient who received a large volume of blood?
Ionized (aka corrected, unbound, or albumin-adjusted) calcium level. A TOTAL calcium level would aso measure the calcium bound to citrate and albumin (not just the the physiologically active calcium)
Trauma-Induced Coagulopathy (TIC)
Is a function of tissue injury, independent of other hemostatic factors, that differs from disseminated intravascular coagulopathy (DIC) Mulifactorial Rapid onset Significant patient variability Complex
diastolic blood pressure
Is a measure of Vascular Resistance (AFTERLOAD) the heart has to pump against. In pts with chronic diastolic HTN, resistance goes up due to vascular disease. Atherosclerosis & Diabetes In a hypovolemic patients Diastolic pressure reflects vasoconstriction - due to sympathetic compensation.
With cardiac Output (HR x SV)- what interventions can we do to manipulate the HR?
It can increase or decrease with drugs, cardioversion, and pacing.
What's the treatment for subcutaneous emphysema?
It reabsorbs over time. Chest tube is often indicated to drain pleural air and prevent tension pneumo but does not drain the air. Presence of subq air strongly suggests a patient may also have a pneumo and needs to be evaluated.
What are three ways to look at blood pressure that are more helpful than traditional than systolic and diastolic measurements?
Pulse pressure Mean Arterial pressure Shock Index
What parameters are used to assess ventilation?
Quantitative Measures - PCO2, ETCO2 Qualitative Measures - Clinical respiratory assessment Rate, depth, work of breathing, accessory muscle use, breath sounds, chest radiographs, skin color and perfusion.
O RH neg blood is usually reserved for which patient group?
RH neg moms -Hemolytic reaction to fetus RH neg Boys <18 years because they may need blood in the future. All others routinely receive O RH pos because negative supply is limited.
What can we do if an RH negative female receives RH positive RBCs?
RhoGAM (Rh (D) immune globulin), administered within 72 hours of transfusion, prevents antibody formation in Rh Neg patients after RH pos blood exposure.
Fractures of which thoracic bones are associated with significant force?>
Ribs: 1st 2nd, posterior Sternum Scapulae T2-10 vertebral bodies.
What causes Subcutaneous Emphysema?
Rice Krispies Subcutaneous air indicates a tracheal or brachial tear. Air travels along the fascial planes, between the muscles.
What's a flail chest?
Unstable chest wall Two or more adjacent ribs, fractured in tow or more places. If it weren't for the skin, fat, and muscles, the bone fragments would fall out.
What can be done wit minimize splenectomized patients risk for serious infections?
Vaccination and prophylactic antibiotic administration. Pneumococcal vaccine, Haemophilus influenza type B, Meningococcal vaccine, and annual flue shots. Infection prevention measures.
Hemothorax is a problem where on the tissue oxygenation cascade?
Ventilation and Hemoglobin availability. If sufficient blood is lost, cardiac output will be affected as well.
Thoracic cage fractures cause a problem at what point on the tissue oxygenation cascade?
Ventilation-they interfere with the mechanical process of breathing, chest expansion.
Tissue Oxygenation cascade - Tissue O2 problem. What parameter are we looking at? What is our clinical assessment? What are potential etiologies? Potential interventions?
VO2 (oxygen Consumption) Assessment - SvO2/ScvO2/MVO2, Serum lactate, Arterial PH, Base Deficit Etiologies - Low O2 delivery, high metabolic demands, capillary occlusion, cellular dysfunction Interventions - Increase O2 delivery, reduce O2 Demands, Vasoactive Medications, sepsis interventions.
What are two reasons for poor oxygen diffusion?
1)A problem with Alveoli. 2)A problem with the pulmonary circulation.
What could some specific etiologies of pulmonary ventilation problems?
Thoracic Fractures Spinal Cord injury Airway occlusion AMS Respiratory depressant drugs
