Mod XII - M&M 39 - Miller 81: Trauma Management in Anesthesiology Flashcards Preview

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Flashcards in Mod XII - M&M 39 - Miller 81: Trauma Management in Anesthesiology Deck (105)
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1
Q

Trauma & Burn Management in Anesthesiology

Which aspect of the Nurse Anesthesiology Resident (NAR)’ background will play an important role for managing patients with trauma and burn injuries?

A

The critical-care background of the Nurse Anesthesiology Resident (NAR) will play an important role for managing patients with trauma and burn injuries

2
Q

Trauma & Burn Management in Anesthesiology

Trauma and burn patients require thorough assessment and immediate interventions due to

A

Pathophysiologic changes arising from traumatic injury

3
Q

Trauma & Burn Management in Anesthesiology

The bodies response to trauma and shock has been described as a

A

Complex series of neural and hormonal reflexes that are induced by injury

4
Q

Trauma & Burn Management in Anesthesiology​

Why shoould a great deal of effort be utilized to stabilize Trauma and burn patients in the operating room suite?

A

Trauma and burn patients are some of the most challenging patients to take care of in the operating room suite

5
Q

Trauma & Burn Management in Anesthesiology​

The Nurse Anesthesiology Resident (NAR) must be aware that cell injury can occur from

A

Alteration of normal homeostasis

6
Q

Trauma & Burn Management in Anesthesiology​

There needs to be emphasis on providing adequate ventilation, oxygenation, and perfusion to these patients. Why?

A

Trauma patients suffer from shock and hypoxic states.

7
Q

Trauma & Burn Management in Anesthesiology​

Proper fluid resuscitation and blood administration is vital for survival in these patients. Why?

A

Trauma results in hemorrhagic blood loss or sequestration of extracellular fluid in the injured tissues

Loss of circulating volume triggers a response by low-pressure baroreceptors in the carotid arteries and aorta

8
Q

Understanding the Trauma Patient

Trauma is classified at which type of medical situation?

A

Medical emergency

The trauma patient is considered a medical emergency and these patients may present totally obtunded. The NAR may not have any background information when caring for these patients

9
Q

Understanding the Trauma Patient

Rapid sequence induction should always be utilized in this population. Why?

A

Full-stomach

All trauma patients are treated as a full-stomach and are high risk for aspiration.

10
Q

Understanding the Trauma Patient

Compromised attempts to place an ETT - why?

A

Head injuries - cervical spine fractures - c-spine stabilization

These patients can also suffer from head injuries etc., which can compromise any attempts to place an ETT. Also, these patients may present with cervical spine fractures and require c-spine stabilization which could also impede ETT placement.

11
Q

Understanding the Trauma Patient

How would the NAR go about intubating a patient with multiple facial fractures or the patient that has a completely deviated anatomy structure from injury?

A

Establishing an airway is essential for these patients

The NAR should consider utilizing a GlideScope or fiberoptic measures (if needed) to establish an airway

12
Q

Understanding the Trauma Patient

Most patients come to the OR suite intubated. Whose responsibility is it to verify placement? How is this done?

A

Is the responsibility of the CRNA to verify placement by c_hecking breath sounds_ etc.

13
Q

Understanding the Trauma Patient

In the case that a patient cannot be intubated by the primary anesthesia team, the surgery team should be on standby for

A

Tracheostomy

Understanding the Trauma Patient

Are there certain drugs to avoid in the trauma patient?

14
Q

Understanding the Trauma Patient

Are there certain drugs to avoid in the trauma patient?

A

15
Q

Understanding the Trauma Patient

Due to the emergency nature of these patients, many things are often overlooked which leads to

A

Life-threatening outcomes

16
Q

Understanding the Trauma Patient

Due to the emergency nature of these patients, many things are often overlooked which leads to life-threatening outcomes. Some of the common overlooked diagnosis include

A

Pneumothorax

Cardiac tamponade

Cardiac contusion

Cervical spine injury

Open/closed head injury

Major blood vessel injury

17
Q

Understanding the Trauma Patient

Resuscitation efforts should be prompt! Which time frome after traumatic injury often determines if a patient will survive?

A

The first 60 minutes after traumatic injury

18
Q

Understanding the Trauma Patient

Resuscitation efforts should be prompt! The first 60 minutes after traumatic injury often determines if a patient will survive. This is known as:

A

The “golden hour

19
Q

Understanding the Trauma Patient

The chances of survival during the The “golden hour” are decreased in patients in

A

Hemorrhagic shock

20
Q

Understanding the Trauma Patient

To provide some genuine advice I would advise all NARs to do what prior to intubating these patients?

A

Stabilize the cervical spine

21
Q

Understanding the Trauma Patient

if no c-collar is in place

A

Stabilize and document

Have another provider to hold the neck

Have another provider to hold the neck if no c-collar is in place

Document this thoroughly in the chart to protect your license

Unfortunately, everything is blamed on “ANESTHESIA” in the OR suite and no NAR would like to be blamed from exacerbating a c-spine injury that was present in the first place

Please stabilize and document that intervention! ALWAYS!

22
Q

Understanding the Trauma Patient

T/F: Trauma patients require both invasive and non-invasive monitoring

A

True

23
Q

Understanding the Trauma Patient

Access required to assist with resuscitative efforts by the CRNA

A

Cordis (central venous sheath)

These patients usually require a cordis (central venous sheath) to assist with resuscitative efforts by the CRNA

Two large bore peripheral IVs

Although a cordis is frequently placed in these patients, a good rule of thumb is to place two large bore peripheral IVs

24
Q

Understanding the Trauma Patient

Trauma patients require frequent monitoring of:

A

Urinary output

Chest tube output (if applicable)

ETCO2 monitoring

Temperature

Blood pressure via arterial line and NIBP

SPO2

EKG

Many trauma centers monitor CVP, CO etc. during the trauma process

25
Q

Understanding the Trauma Patient

Advanced hemodynamic monitoring is used for:

A

To guide fluid/blood resuscitation

26
Q

Understanding the Trauma Patient

There also needs to be frequent lab work completed to

A

Guide blood administration and

Guide usage of electrolyte replacement such as calcium, etc

In the OR; we usually do serial I-STATs every 30 minutes until patient is stabilized

27
Q

Understanding the Trauma Patient

In the OR; we usually do serial I-STATs how frequently until patient is stabilized?

A

every 30 minutes

28
Q

Most Common Problems in Trauma

A
  1. Hypotension
  2. Desaturation
  3. Hypertension
  4. Tachyarrhythmias and Brady-arrhythmias
  5. Sudden Cardiac Arrest
29
Q

Most Common Problems in Trauma

Hypotension is u sually caused by

A

Hypovolemia

It is imperative that the CRNA or NAR initiate fluid resuscitation to combat hypotension

Vasoactive medications are usually utilized to help maintain adequate acceptable MAP goals

Be certain to rule out major vessel tears that can be the primary cause of hypotension

In rare situations, trauma patients are transported to the Interventional Radiology (IR) suite to both located and eliminate a major vessel tear

30
Q

Most Common Problems in Trauma

In rare situations, where are trauma patients transported to both located and eliminate a major vessel tear?

A

Interventional Radiology (IR) suite

31
Q

Most Common Problems in Trauma

Desaturation - When desaturation occurs check for

A

Adequate FIO2, ventilation, and perfusion

Look for signs of a pneumothorax (distended neck veins, tracheal deviation)

Rule out pulmonary contusions, mucous plugs etc.

Patient may require a STAT chest x-ray to rule out more pertinent issues

32
Q

Most Common Problems in Trauma

Hypertension - When do Trauma Patients frequently become hyperdynamic?

A

After resuscitation

33
Q

Most Common Problems in Trauma

How is Hypertension is mostly treated?

A

By deepening the anesthetic or offering opioid therapy

34
Q

Most Common Problems in Trauma​

What should be considered first when these issues Tachyarrhythmias and Brady-arrhythmias arise?

A

Hypoxemia and hypercarbia

Monitoring lab work for electrolyte imbalances should also be utilized for prompt correction

35
Q

Most Common Problems in Trauma​

Sudden cardiac arrest is often a strong indication for

A

Open thoracotomy

To inspect the heart for pericardial tamponade

Surgeons often have to open the chest and perform a cardiac massage

36
Q

Most Common Problems in Trauma​

In addition to monitoring lab work for trauma patients; the CRNA must pay close attention to blood glucose levels - why?

A

Trauma patients may need insulin to bring glucose levels to an acceptable level in the OR

On the other hand, trauma patients rapidly consume their gluconeogenic substrate which causes significant hypoglycemia to occur

However, these patients are more likely to experience hyperglycemia than hypoglycemia

Data has shown that preexisting hyperglycemia increases damage of ischemic/hypoxic events

37
Q

Most Common Problems in Trauma​

What are the most common causes of coagulopathy in the trauma patients?

A

Dilutional thrombocytopenia

Hypofibrinogenemia

38
Q

Most Common Problems in Trauma​

Dilutional thrombocytopenia is the most common cause of coagulopathy in the trauma patient, followed by hypofibrinogenemia. These conditions are treated with

A

Platelets, FFP, and cryo as indicated

In the OR we use the level one infuser via massive transfusion protocol (MTP) [1:1 PRBCs/FFP] until the patient is stabilized

39
Q

Most Common Problems in Trauma​

T/F: Remember when giving platelets to never run them through the warmer

A

True

Never run them through the warmer!!!

40
Q

Trauma management in Anesthesiology

For trauma patients its very important to know the pathophysiology behind the mechanism of injury - Trauma caused by high-velocity or low-velocity impact, generally from dull objects is known as:

A

Blunt trauma

41
Q

Trauma management in Anesthesiology

For trauma patients its very important to know the pathophysiology behind the mechanism of injury - Trauma that results from the piercing of tissues by sharp objects such as knives or bullets is known as:

A

Penetrating trauma

42
Q

Trauma management in Anesthesiology

In which type of injuries are Mixed blunt and penetrating trauma often seen?

A

Impalement injuries

43
Q

Trauma management in Anesthesiology

Falls from substantial heights can cause which types of injuries?

A

Vertical high-velocity injuries

44
Q

Burn Management in Anesthesiology

Burns are caused by which types of exposures?

A

Thermal, electrical, or chemical exposure

45
Q

Burn Management in Anesthesiology

Airway burns and smoke inhalation injuries are often associated by poisoning from which gas?

A

Carbon monoxide

46
Q

Burn Management in Anesthesiology​

T/F: Chemical, biological, and nuclear injuries are other forms of trauma

A

True

47
Q

Burn Management in Anesthesiology​

Environmental injuries can be caused by events such as

A

Poisonous insect bites

Animal bites

Venomous snake bites

48
Q

Common Mechanisms of Injury in the Trauma Patient

A
  1. Penetrating Injury/Blunt Trauma
  2. Motor Vehicle Accident Trauma
  3. Thoracic Trauma
  4. Abdominal Trauma
  5. Orthopedic Trauma
  6. Head Injury
  7. Spinal Cord Injury
49
Q

Penetrating Injury/Blunt Trauma

Unfortunately the CRNA may experience this type of trauma from:

A

Gun shots or stab wounds

These injuries are often fatal unless thorough assessment and interventions for stabilization are used

50
Q

Penetrating Injury/Blunt Trauma

These patients usually undergo an open-chest or open abdomen by the trauma surgeon to assess for

A

Major vessel tears

51
Q

Penetrating Injury/Blunt Trauma

These patients my have to have chest tubes - why?

A

often times the bullets penetrate the lungs which compromises oxygenation in these patients

The patient suffering from these type of injuries must have their organs assessed for damages that could lead to irreversible damage if missed

52
Q

Penetrating Injury/Blunt Trauma

Some patients experience this type trauma from head injuries and may require

A

an emergency craniotomy

53
Q

Penetrating Injury/Blunt Trauma

As a CRNA you have to be ready for anything that hits the door - Gun shots wounds to the chest and head are extremely stressful cases - When you are in these cases sometimes very little help is available to stabilize these patients - You have to be on your A-game and intervene quickly - Many times you will have to use your critical-care background to guide care - Answering which important questions could guide care delivery?

A

Does the patient needs a bi-carb drip?

Did I start TXA?

Did we give antibiotics?

Does the patient need to have a vasopressin gtt started?

Does the patient need to be transported to IR?

Is the patient bleeding somewhere else that the surgeon may have missed or overlooked?

Is the blood pooling in the peritoneum?

All of this falls on you as the CRNA

54
Q

Penetrating Injury/Blunt Trauma

As a CRNA you have to be ready for anything that hits the door - Gun shots wounds to the chest and head are extremely stressful cases - When you are in these cases sometimes very little help is available to stabilize these patients - You have to be on your A-game and intervene quickly - Many times you will have to use your critical-care background to guide care - You have to be very aggressive and firm in your decision-making - Why?

A

One near-miss can lead to a fatal outcome

55
Q

Motor Vehicle Accident Trauma

These are the patients who come in with multi-system deviations due to the impact associated with motor vehicle crashes (MVCs) - These deviations include:

A

Orthopedic injuries

These patients usually suffer from a variety orthopedic injuries

Cervical spine injury

The cervical spine absorbs a large energy impact and may be compromised

Severe head injuries & Laryngeal fractures

Patients hitting the dashboard can suffer from severe head injuries and could possible have laryngeal fractures direct impact on the trachea

Spinal cord injury

Further spinal cord injury occurs from hyperflexion, hyperextension, or direct compression

56
Q

Motor Vehicle Accident Trauma

Unfortunately, when the body moves forward during impact which part of the body suffers the first point of contact?

A

the Head

57
Q

Motor Vehicle Accident Trauma​

Chances of survival are decreased significantly in patients who do not wear

A

a seat belt

58
Q

Thoracic Trauma

Blunt thoracic trauma often results when drivers do not wear a […….] and collide with the [………] during the MVC

A

Blunt thoracic trauma often results when drivers do not wear a seatbelt and collide with the steering wheel during the MVC

59
Q

Thoracic Trauma

Injuries to thoracic structures compromise anesthesia care by affecting

A

Gas exchange &

Cardiac output

Chest injuries may be the result of continued hemodynamic and ventilatory compromise

60
Q

Thoracic Trauma

Which Life threatening conditions may develop when the pleural cavity is punctured, and presents as creation of a one-way valve that controls the flow of air into this cavity

A

Tension pneumothorax

Life threatening conditions such as tension pneumothorax may develop when the pleural cavity is punctured, creating a one-way valve that controls the flow of air into this cavity

61
Q

Thoracic Trauma

How does Tension pneumothorax manifest?

A

With each breath more air becomes trapped in this the pleural cavity, increasing intrapleural pressure to the point that it eventually exceeds all other intrathoracic pressures

This causes the ipsilateral lung to collapse and shift structures of the mediastinum (trachea, great vessels, heart) into the opposite hemothorax which compresses the contralateral lung

62
Q

Thoracic Trauma

Which ventilation technique increases the size of the pneumothorax?

A

Positive pressure ventilation

The size of the pneumothorax rapidly increases during positive pressure ventilation

63
Q

Thoracic Trauma

Why is the use of nitrous oxide contraindicated in these patients?

A

it helps to expand the already present pneumothorax

64
Q

Thoracic Trauma

Patients with a pneumothorax often present with which S/S?

A

Hypotension

Subcutaneous emphysema of the neck or chest

Unilateral decrease in breath sounds

Diminished chest-wall motion

Distended neck veins

Tracheal shift

65
Q

Thoracic Trauma

Which will provide a definite diagnosis for pneumothorax?

A

A chest x-ray

66
Q

Thoracic Trauma​

A chest x-ray will provide a definite diagnosis but in emergency situations, what can be done to relieve tension from the pneumothorax?

A

a large-bore intravenous catheter is inserted into the second superior portion of the intercostal space along the midclavicular line

67
Q

Thoracic Trauma​

Another life threatening emergency caused by bleeding from the heart and great vessels is known as

A

Massive Hemothorax

68
Q

Thoracic Trauma​

The life threatening emergency that restricts filling of the cardiac chambers during diastole and produces a fixed low cardiac output is known as

A

Pericardial tamponade

Immediate correction is needed which require a pericardiocentesis

69
Q

Abdominal Trauma

Extremely unstable patients with abdominal trauma usually come to the OR for which procedure?

A

Exploratory laparotomy

70
Q

Abdominal Trauma

Extremely unstable patients with abdominal trauma usually come to the OR for and Exploratory laparotomy. What’s an appropriate initial intervention for the CRNA?

A

Drop an NG/OG tube to decompress the stomach

71
Q

Abdominal Trauma

Retroperitoneal injuries can damage which structures?

A

Abdominal aorta

Inferior vena cava

Kidneys

Pancreas

Duodenum

72
Q

Abdominal Trauma

Intraperitoneal injuries can occur to which organs?

A

Spleen, liver, stomach, small bowel, colon, or rectum

73
Q

Abdominal Trauma

Anesthetic problems in patients with abdominal trauma include

A

hemorrhage,

hypothermia,

sepsis, and

interference with ventilation

74
Q

Abdominal Trauma

Hypothermia is a common complication of abdominal trauma surgery because of

A

increased heat loss through the open mesentery and

reduced heat production associated with shock

75
Q

Abdominal Trauma

For all trauma patients all fluids should be warmed -why?

A

Hypothermia is a common complication of abdominal trauma surgery

76
Q

Abdominal Trauma

Which drugs are used to prevent shivering?

A

Neuromuscular blocking agents

Do not be afraid to have the circulating RN to turn up the temperature in the room

77
Q

Abdominal Trauma

Why must shivering be prevented in trauma patients?

A

Shivering increases oxygen consumption by 200-400%

without improving oxygen delivery

Do not be afraid to have the circulating RN to turn up the temperature in the room

78
Q

Orthopedic Trauma

Ideal time to repair open fractures operatively is

A

within the first few hours after injury

79
Q

Orthopedic Trauma

Certain secondary vascular injuries commonly occur because

A

Sharp edges of fractured bones are forced into neighboring blood vessels and nerves

Assessment for nerve damage should be included in the plan of care for these patients

80
Q

Orthopedic Trauma

Massive hemorrhage can associated with pelvic fractures - why?

A

Pelvic fractures can cause major blood loss into the retroperitoneal space

Although blood loss from pelvic fractures involving the iliac artery is notorious, significant blood loss can also occur from fractures associated with disruption of axillary, brachial, femoral, and popliteal arteries

81
Q

Orthopedic Trauma

Which respiratory complication is common from long-bone factrures? what’s its cause?

A

Hypoxic respiratory failure

The hypoxia results from continuous seeding of marrow fat into the venous circulation

Long-bone fractures also carryout the risk the patient developing a FAT EMBOLISM

It is imperative to have serial blood gases/I-stat lab work to guide care to initiate therapy

82
Q

Orthopedic Trauma

What’s the Theory #1 (mechanical) Pathophysiology for Fat Embolism?

A

Large fat droplets are released into the venous system

These droplets are deposited in the pulmonary capillary beds and travel through arteriovenous shunts to the brain

Microvascular lodging of droplets produces local ischemia and inflammation, with concomitant release of inflammatory mediators, platelet aggregation, and vasoactive amines

83
Q

Orthopedic Trauma

What’s the Theory #2 (biochemical) Pathophysiology for Fat Embolism?

A

Hormonal changes caused by trauma and/or sepsis induce systemic release of free fatty acids as chylomicrons

Acute-phase reactants, such as C-reactive proteins, cause chylomicrons to coalesce and create the physiologic reactions described above

The biochemical theory helps explain nontraumatic forms of fat embolism syndrome

84
Q

Orthopedic Trauma

What are the Signs of Fat Embolism Under General Anesthesia?

A

Acute decrease in ETCO2

Hypoxia/increased A-a gradient

Tachycardia

Petechial rash on the upper portions of the body

(petechiae occur in only 20-50% of patients but are virtually diagnostic)

Pulmonary compliance will likely decrease

PA pressures will rise and cardiac output will fall

85
Q

Orthopedic Trauma

Although there is no literature that provides a treatment regimen for fat embolism, which Protocol can be utilized to treat fat embolism?

A

A-OK protocol (off-label protocol) may assist with stabilization

A = atropine 1mg IV

(blocks the vagal reflexes and prevents systemic hypotension)

O = ondansetron 8mg IV

(Impedes serotonin activity in the lungs and inflammatory system resulting from platelet activation)

K = Ketorolac 30mg IV

(Inhibits thromboxane and halts activation of the coagulation cascade)

Also use appropriate vasoactive drugs to help stabilize the patient

86
Q

Head Injury

Anesthesia management of the head-injured patient includes

A

Early control of the airway to maintain SPO2 greater than 90%

Establishing cardiovascular stability

Intracranial hypertension (> 20mmHg) and systolic hypotension (<90 mmHg) should be avoided

87
Q

Head Injury

Which Neuro assessment data should be carefully documented before therapeutic maneuvers are initiated

A

Baseline evaluation of Glasgow Coma Scale (GCS) score,

Pupillary reactivity and

Motor function

88
Q

Head Injury

What may Patients with head injury need to have placed to monitor and troubleshoot rising intracranial pressures (ICP)?

A

External Ventricular Drain (EVD)

89
Q

Head Injury

As an NAR you will have to know how to care for the patient that is undergoing a craniotomy - These are very critical operations and prompt interventions need to occur to get the patients safely through surgery and to the Neuro-ICU afterwards - Which drugs should be avoided during these procedures?

A

KETAMINE and Nitrous oxide

90
Q

Spinal Cord Injury (SCI)

The leading cause of death in patients with Spinal Cord Injury (SCI) is:

A

Aspiration pneumonia

91
Q

Spinal Cord Injury (SCI)

SCI have many devastating physical and psychological effects - Avoidance of hypoxia and systemic hypotension is crucial in these patients because

A

it can further compromise neural function

Hypoxia and hypercarbia can further accentuate the damage sustained with SCIs

92
Q

Spinal Cord Injury (SCI)

REMEMBER THAT INJURIES AT C1 AND C2 level result in

A

Complete Respiratory Paralysis

Death can happen quickly if an airway isn’t established

Tubing these patients are critical

93
Q

Spinal Cord Injury (SCI)

Why is Succinylcholine is not recommended for intubation of the patient with acute SCI?

A

Muscle fasciculation may exacerbate the SCI

94
Q

Spinal Cord Injury (SCI)

The CRNA/NAR should be aware of the six (6) conditions that are highly correlated with SCIs:

A
  1. Paralysis
  2. Pain
  3. Position
  4. Paresthesias
  5. Ptosis
  6. Priapism
95
Q

Spinal Cord Injury (SCI)

Why it is imperative to have someone hold in-line stabilization of the head to intubate these patients and to get a cervical collar ordered STAT for these patients?

A

Care should be used to avoid extension, flexion, or rotation of the neck

Consider using a GlideScope to minimize neck movement with someone holding c-spine

96
Q

Spinal Cord Injury (SCI)

What vertebral level is the most common site of injury for SCI patients?

A

C-7

97
Q

Spinal Cord Injury (SCI)​

Patient with SCIs at which level have severely impaired CNS function?

A

T6 level or higher

98
Q

Spinal Cord Injury (SCI)​

CV effects of Spinal Cord Injury (SCI)​ include:

A

Decreased cardiac output

Hypotension

The SCI also interrupts sympathetic pathways from the hypothalamus (temperature control center) to peripheral blood vessels

99
Q

Spinal Cord Injury (SCI)​

Respiratory effects of Spinal Cord Injury (SCI)​ include:

A

Rapid development of pulmonary edema if their fluids are vasoactive drug therapy is not guided

100
Q

Spinal Cord Injury (SCI)​

What makes neurologic recovery from SCI very difficult but possible?

A

Spinal cord flow is disrupted from injury

There may be decreased blood flow to needed vessels

This can lead to irreversible damage

101
Q

Spinal Cord Injury (SCI)​

Which complication from Spinal Cord Injury (SCI)​ manifest as a sudden massive sympathetic discharge resulting from stimulation below the level of spinal-cord transections

A

Autonomic Hyperreflexia

102
Q

Spinal Cord Injury (SCI)​​

Hyperreflexia is seen in 85% of SCI patients with lesions above

A

T5

103
Q

Spinal Cord Injury (SCI)​​

Signs and symptoms of Autonomic Hyperreflexia include:

A

Paroxysmal hypertension

Bradycardia

Cardiac dysrhythmias in response to stimuli below the level of the transection

104
Q

Spinal Cord Injury (SCI)​​

Signs and symptoms of Autonomic Hyperreflexia are not usually seen until after

A

The spine shock phase has passed

105
Q

Spinal Cord Injury (SCI)​​

The CRNA/NAR must control the massive hypertensive spikes of these patients by

A

Deepening anesthesia or

Giving a medication to treat hypertension