Airway Management and Hemorrhagic Shock: Trauma Patient Care, Exams of Nursing

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Patients with a GSC of less than usually require intubation. 8 The "A" in ABCD stands for. Airway maintenance with CERVICAL SPINE PROTECTION You should assume that any patient in a multisystem trauma with an altered level of consciousness or blunt injury above the clavicle has what type of injury? Cervical spine injury Flail chest is invariably accompanied by which can interfere with blood oxygenation. pulmonary contusion - do NOT over fluid resuscitate these patients! Hypotension is caused by until proven otherwise. hypovolemia When you don't have/can't get a blood pressure, what are three things to look for when evaluating perfusion.

1. Level of consciousness (brain perfusion), 2. Skin color (ashen face/grey extremities) 3. Pulse (bilateral femoral - thready/tachy) Elderly patients have a limited ability to to compensate for blood loss. increase heart rate Resuscitation fluids should be warmed 39 degrees Celsius (102.2 F). Can you use a microwave to do this? YES - for CRYSTALLOID ONLY (but NOT for blood products).

Urinary catheters are good for assessing renal perfusion and volume status. List 5 signs of urethral injury that might prevent you from inserting one. Blood at urethral meatus, perineal ecchymosis, blood in scrotum, high-riding/non-palpable prostate, pelvic fracture Which arm should you NOT put a pulse-ox on? The arm with a blood pressure cuff on it Name two anatomical things that can interfere with doing a FAST scan. Obesity & intraluminal bowel gas When should radiographs be obtained? During the SECONDARY survey. How do you get an ample patient history? A=Allergies, M=Medications, P=PMH/Pregnancy, L=Last meal, E=Events/Environment of injury Why might you want a Bair Hugger for a patient who smells of alcohol? Vasodilation can lead to hypothermia What things are you looking for when you do a DRE in a trauma? Blood, high-riding prostate (in males), and sphincter tone What should you do for every female patient? Pregnancy test (females of childbearing age) Adult patients should maintain UOP of at least mL/kg/hr. Kids should have at least mL/kg/hr. Adults 0.5 mL/kg/hr, Kids 1.0 ml/kg/hr

Preventing hypercarbia is critical in patients who have sustained a injury. head What two places would you LOOK at a patient if you suspect hypoxemia? Lips and fingernail beds Patients may be abusive and belligerent because of , so don't just assume it's due to drugs, alcohol, or the fact that they are just inherently a jerk. hypoxia Can a patient breathe on their own after complete cervical cord transection? Yes, if the phrenic nerves (C3-C5) are spared. This will result in "abdominal" breathing. The intercostal muscles will be paralyzed though. Can you use an OPA (Guedel) in a conscious patient? No, it could make them vomit. An NPA (trumpet) would be okay. Bougies are typically inserted blindly, how do you know you are in the trachea and not the esophagus? You can feel the "clicks" as the distal tip rubs against the cartilaginous tracheal rings, or it will deviate right or left when entering either bronchus (usually at 50 cm). What do you NOT want to hear if you ascultate a patient after placement of an ET tube? Borborygmi - rumbling or gurgling noises suggesting esophageal insertion. What is the RSI dose for etomidate? 0.3 mg/kg (usually 20 mg) What is the RSI dose for sux? 1 - 2 mg/kg (usually 100 mg)

How does etomidate affect blood pressure? It doesn't - at least it SHOULDN'T have any significant effect on BP. Ketamine will increase BP, and propofol and thiopental will both drop BP. A RSI dose of sux usually lasts about minutes. 5 What hypnotic/sedative/induction agent do you NOT want to use for a severely burned patient? SUX - patients with severe burns, crush injuries, hyperkalemia, or chronic paralytic/neuromuscular diseases should NOT get sux because of hyperkalemia risk. We have an expert-written solution to this problem! Oxygen should flow at 15L for needle cricothyroidotomy, and have a Y-connector for insufflation if possible. What size needle do you use for adults? Kids? Adults 12 - 14 gauge, kids 16 - 18 gauge Cricoid cartilage is the only circumferential support for the upper trachea in kids, therefore surgical cricothyroidotomy is not recommended in kids under the age of. 12 In a "normal" patient without significant chest wall injury or lung disease, needle cricothyroidotomy can provide adequate oxygenation for approximately minutes. 30 - 45

For a patient with difficulty breathing, what things might you try before you provide a surgical airway? Chin-lift, jaw-thrust (NOT head-tilt while maintaining c-spine precautions), OPA (guedel), NPA (trumpet), LMA, Combitube, ET tube +/- bougie How do you know if an OPA/Guedel is the correct size for the patient? A correctly sized OPA will extend from the corner of the patient's mouth to the external auditory canal. What should do with the balloon on an ET tube/LMA/foley before you insert it? Inflate it to make sure it doesn't leak - then deflate and insert. What size LMA do you use for kid, woman/small man, large woman/man? Kid: 3, Woman/small man: 4, Large woman/man: 5 (C3,4,5 keep the diaphragm alive) The proper size ET tube for an infant is. The same size as the infant's nostril or little finger. (Usually size 3 for neonates, 3.5 for infants) What size cuffed endotracheal tube do you use for an emergency cricothyroidotomy? 5 or 6

Use size 3 ET tubes for neonates, 3.5 for infants 0 - 6 months, and size 4 for infants 6 - 12 months. How do you calculate what size ET tube to use for toddlers and kids? Age/4 + 4 mm = internal diameter Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. What are the 4 different types? Neurogenic, cardiogenic, hypovolemic, septic The most common cause of shock in the injured trauma patient is. hemorrhage Approximately % of the body's total blood volume is located in the venous circuit. 70 Why does shock actually reduce the total volume of circulating blood? Anaerobic metabolism --> can't make more ATP --> Endoplasmic then mitochondrial damage --> lysosomes rupture --> sodium and WATER enter the cell, which SWELLS and dies. Which vasopressors should you use to treat hemorrhagic shock? What are the drug doses? NEVER use pressors for hypovolemic shock - use VOLUME replacement. Pressors will worsen tissue perfusion in hemorrhagic shock. Compensatory mechanisms may preclude a measurable fall in systolic blood pressure until up to 30 % of the patient's blood volume is lost.

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Any patient who is cool and is tachycardic is considered to be until proven otherwise. in shock The definition of tachycardia depends on the patient's age. What heart rate is considered tachycardic for infants, toddlers/preschoolers, school age/prebuscent, and adults? Infants >160, toddlers/preschoolers >140, school age/prebuscent >120, adults > Elderly patients may not exhibit tachycardia in response to hypovolemia because of limited cardiac response to catecholamines. Why else might not they get tachy? They might be on a beta-blocker or have a pacemaker. A FAST scan is an excellent way to diagnose cardiac tamponade. What signs suggest tamponade? Becks's Triad: JVD, muffled heart sounds, and hypotension (will be resistant to fluid therapy). Will also likely be tachycardic. Patients with a tension pneumo and patients with cardiac tamponade may present with many of the same signs. What findings will you see with a tension pneumo that you will NOT see with tamponade? Absent breath sounds and hyperresonance to percussion over the affected hemithorax. Immediate thoracic decompression is warranted for anyone with absent breath sounds, hyperresonance to percussion, tracheal deviation, , and. Acute respiratory distress & subcutaneous emphysema

Can isolated intracranial injuries cause neurogenic shock? NO How do you calculate total blood volume in an adult? 70 mL per kg body weight. A 70 kg person has about 5 liters of circulating blood. (70*70=4900) How do you calculate total blood volume in an child? Body weight in kg x 80 - 90 mL The blood volume of an obese person is calculated based upon their weight. ideal Fluid replacement should be guided by , not simply by the initial classification (Class I-IV). The patient's response to initial replacment How much blood volume is lost with Class I Hemorrhage? Up to 15% Donating 1 pint, or ~500 mL of blood is about a 10% volume loss and would qualify as Class I Hemorrhage! How do you treat a Class I Hemorrhage?

You don't (usually). Transcapillary refill and other compensatory mechanisms usually restore blood volume within 24 hours. How much blood volume is lost with Class II Hemorrhage? 15 - 30% (750- 1500 mL in a 70 kg adult) How do you treat a Class II Hemorrhage? Usually just crystalloid resuscitation Subtle CNS changes such as anxiety, fright, and hostility would be expected in a patient with a Class II Hemorrhage. How much blood volume is lost with Class III Hemorrhage? 30 - 40% (2000 mL in a 70 kg adult) A patient with inadequate perfusion, marked tachycardia and tachypnea, significant mental status change, and a measurable fall in systolic blood pressure likely has a Class Hemorrhage. III or IV - These patients almost always require a blood transfusion, which depends on their response to initial fluid resuscitation. The first priority is stopping the hemorrhage. Loss of more than % of blood volume results in loss of consciousness. 50

How much blood volume is lost with Class IV Hemorrhage? More than 40%. Unless very aggressive measures are taken the patient will die within minutes. A Class Hemorrhage represents the smallest volume of blood loss that is consistently associated wiht a drop in systolic blood pressure. III Up to mL of blood loss is commonly associated with femur fractures. 1500 Unexplained hypotension or cardiac dysrhythmias (usually bradycardia from excessive vagal stimulation) are often caused by , especially in children. gastric distention How much crystalloid should you give an adult for an initial fluid resuscitation bolus? For kids? Adults: 2 liters, Kids: 20 mL/kg (may repeat and give as much as 60 mL/kg but with high reserve in kids, if they're in shock they should get blood sooner rather than later. We have an expert-written solution to this problem! Each mL of blood loss whould be replaced with mL of crystalloid, thus allowing for replacement of plasma volume lost into interstitial and intracellular spaces. 3

Blood on the floor x four more is a mnemonic for occult blood loss where? Chest, pelvis, retroperitoneum, and thigh For children UNDER 1 year of age, UOP should be mL/kg/hr. 2 Would patients in EARLY hypovolemic shock be acidodic or alkalotic? Alkalotic - respiratory alkalosis from tachypnea. .. followed later by mild metabolic acidosis in the early phase of shock. "Rapid responders" whose vital signs return to normal (and stay there) after fluid resuscitation likely have/had a Class Hemorrhage. I or II "Transient responders" are associated with Class Hemorrhage. II or III What differential diagnoses should you always consider for "non-responders" following fluid resuscitation? NON-HEMORRHAGIC causes, e.g. tension pneumothorax, tamponade, blunt cardiac injury, MI, acute gastric distention, neurogenic shock... Most patients receiving blood transfusions need calcium replacement. don't

How should you position the patient before placing a subclavian or IJ line? SUPINE, head down 15 degrees to distend neck veins and prevent embolism, only turn head away if C-SPINE HAS BEEN CLEARED FIRST. How long can you keep an IO line in? Intraosseous infusion should be limited to emergency resuscitation and shoudl be discontinued as soon as other venous access is obtained. Where do you want to make an incision for a saphenous vein cutdown and how long should your incision be? The saphenous vein can be accessed approximately 1 cm anterior and 1 cm superior to the medial malleolus. Make a 2.5 cm transverse incision through the skin and SQ tissue, careful not to injure the vessel. A patient arrives to the trauma bay intubated and there are absent breath sounds over the left hemithorax, where should you place your decompression needle? This may NOT be a pneumothorax, for intubated patients always suspect a right main-stem before attempting needle decompression. Where would you insert a large caliber needle to decompress a tension pnuemothorax? Into the 2nd intercostal space in the midclavicular line of the affected hemithorax. For an open pneumothorax, (sucking chest wound) air passes preferentially through the chest wall defect (least resistance) if the diameter of the defect is at least the diameter of the trachea.

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