TCRN Review - Special Situations (Shock, Psychosocial Issues Related to Trauma, SIRS & MOD, Exams of Traumatology

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(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Describe the process of Obstructive Shock. - correct answer Myocardium contracts against high afterload -> Sympathetic over activity leads to vasoconstriction in order to maintain BP -> Despite normal BP, organs are poorly perfused due to a reduction in blood flow -

Back pressure leads to venous congestion List the 4 Classifications of Shock - correct answer Hypovolemic Distributive Cardiogenic Obstructive Describe hypovolemic shock - correct answer Lack of Volume Describe distributive shock - correct answer Mal-distribution of blood (vasodilation) Describe cardiogenic shock - correct answer Inadequate cardiac output Describe obstructive shock - correct answer Inability of blood to enter or exit the heart adequately

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is another name for early hypovolemic shock? - correct answer Compensatory Shock The adrenergic system is active during the _____ phase of shock. - correct answer Compensatory The _____ system is active after the phase of shock has passed to bring the body back to a state of homeostasis. - correct answer Cholinergic Another name for the sympathetic system is _____. - correct answer Adrenergic system Another name for the parasympathetic system is _____. - correct answer Cholinergic system What is the name of the process in which glycogen stores in the liver are broken down into glucose? - correct answer Glycogeonolysis What is the process in which glucose in the serum is converted to glycogen for storage in the liver? - correct answer Glyconeogenesis

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is the term for the speed at which electricity moves through the heart? - correct answer Automaticity What is the role of alpha receptors in the adrenergic (sympathetic) system? - correct answer Vasoconstriction, Glycogeonolysis, Diaphoresis What is the role of the alpha receptors in the cholinergic (parasympathetic) system? - correct answer Vasodilation, Glyconeogenesis, Dry Skin Sympathetic vs. Parasympathetic is also known as what? - correct answer Fight or Flight; respectively What is the role of Beta-One receptors in the adrenergic (sympathetic) system? - correct answer Increased: heart rate, contractility, automaticity What is the role of Beta-One receptors in the cholinergic (parasympathetic) system? - correct answer Decreased: heart rate, contractility, automaticity

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is the role of Beta-Two receptors in the adrenergic (sympathetic) system? - correct answer Increased respiratory rate Bronchodilation What is the role of Beta-Two receptors in the cholinergic (parasympathetic) system? - correct answer Decreased respiratory rate Bronchoconstriction What is another term for late shock? - correct answer Decompensated shock What occurs during late or decompensated shock? - correct answer Activation of the inflammatory system During late or decompensated shock and the activation of the inflammatory system, what do inflammatory mediators cause? ( things) - correct answer Vasodilation Increased capillary permeability Increased coagulation

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What are the signs of early or compensated hypovolemic shock? ( signs/symptoms) - correct answer Deceptively normal or slightly elevated blood pressure Narrowing Pulse Pressure Tachycardia (weak and thready) Tachypnea (deep and rapid) Normal serum lactate levels Cool and clammy skin CNS: anxious and restless Decreased urinary output What are the signs of late or decompensated hypovolemic shock? ( signs/symptoms) - correct answer Decreased blood pressure Tachycardia (may not be palpable peripherally) Tachypnea (shallow and rapid) Serum Lactate > 2-4 mmol/L Cool, clammy and mottled skin CNS: loss of consciousness Anuria

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is the average blood volume of an adult? - correct answer 4700- 5500 ml What is the average blood loss of a thoracic injury? - correct answer 2000 ml What is the average blood loss of an intra-abdominal injury? - correct answer 2000 ml What is the average blood loss of a tibial fracture? - correct answer 650 ml What is the average blood loss of a femur fracture? - correct answer 1000 ml What is the average blood loss of a pelvic fracture? - correct answer 3000 ml How many classes of hypovolemic shock are there? - correct answer 4

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Describe Class I hypovolemic shock: (8 answers) - correct answer < ml of blood loss <15% of blood loss Pulse < Normal Blood Pressure RR is 14- Urinary Output >30 ml/hr CNS: slightly anxious Fluid Replacement: Crystalloid Describe Class II hypovolemic shock: (8 answers) - correct answer 750- 1500 ml of blood loss 15-30% of blood loss Pulse 100- Normal Blood Pressure RR is 20- Urinary Output 20-30 ml/hr CNS: Mildly anxious Fluid Replacement: Crystalloid

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Describe Class III hypovolemic shock: (8 answers) - correct answer 1500-2000 ml of blood loss 30-40% of blood loss Pulse 120- Decreased Blood Pressure RR is 30- Urinary output 5-20 ml/hr CNS: Anxious and confused Fluid Replacement: Crystalloid and Blood Describe Class IV hypovolemic shock: (8 answers) - correct answer

2000 ml of blood loss 40% of blood loss HR > Decreased Blood Pressure RR > Urinary output: negligible CNS: confused and lethargic Fluid Replacement: Crystalloid and Blood

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

During which class of hypovolemic shock does blood pressure begin to decrease? - correct answer Class III Which class of hypovolemic shock should have consideration for blood replacement? - correct answer Class III When evaluating the HR in hypovolemic shock, what should be considered? - correct answer Patients taking beta-blockers will not present with an increase in heart rate Rather than Systolic or Diastolic BP, what are better indicators of shock?

• correct answer Pulse Pressure (PP) or Mean Arterial Pressure (MAP) How do you calculate the Mean Arterial Pressure (MAP)? - correct answer Diastolic Pressure x2 PLUS Systolic Pressure x Divide the total by 3 Ex: 120/ 70+70+120 = 260, then divide by 3 = 86. What is the treatment for hypovolemic shock? - correct answer Aggressive airway management

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Control Hemorrhage IV/IO Access Fluid Resuscitation Prevent Hypothermia Describe aggressive airway management in hypovolemic shock treatment: - correct answer 100% oxygen via non-rebreather with a goal of maintaining the SpO2 between 94% and 98% Consider intubation and mechanical ventilation (avoid excessive pressure to protect the blood pressure) Describe Hemorrhage control in hypovolemic shock. - correct answer Apply direct pressure Apply splints Timely OR (operative) intervention Describe the insertion point of an IO to the distal femur. - correct answer Anterior midline above external epicondoyles, 1-3 cm above femoral plateau.

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What are some positioning techniques for inserting an IO in the distal femur? - correct answer The knee should be slightly flexed, the hip externally rotated and flexed Where is the insertion point for an IO into the Distal Tibia? - correct answer Just proximal to the medial malleolus What are some positioning techniques for inserting an IO in the distal tibia? - correct answer Slightly abduct and externally rotate the hip, angle the needle 10-15% cephalad Where is the insertion point for an IO in the Humerus? - correct answer Directly above the greater tuberosity What are some positioning techniques for inserting an IO in the humerus? - correct answer Adduct the shoulder with the palm of hand over umbilicus, so the greater tuberosity is prominent. Insert the needle at a 90 degree angle directly into the greater tuberosity. Where is the insertion point for an IO in the proximal tibia? - correct answer 2 cm distal and slightly medial to the tibial tuberosity

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What are some positioning techniques for inserting an IO in the proximal tibia? - correct answer Support the flexed knee by placing a towel under the calf List 4 ways to ensure IO placement: - correct answer Needle should stand up on its own Aspirate bone marrow (note the presence of marrow confirms placement, but the lack of marrow does not rule out placement) Push a 5-10 ml bolus of crystalloids; resistance should be minimal, and extravasation should not be evident (watch the calf area) Fluid may run via gravity, but an IV pump or pressure bag is needed to flow fast enough for resuscitation What are some contraindications of IO placement? - correct answer Fractures of the bone Previous attempts in the same bone Can IO access be long term? - correct answer No

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Ideally, how soon should an IO be discontinued? - correct answer 3- hours In exceptional cases, how long can an IO be used? - correct answer 72- 96 hours What are some risks with long term IO usage? - correct answer Higher rate of infection Dislodgement Which fluids are Chrystalloid? - correct answer Normal Saline Lactated Ringers What is the replacement ratio for fluid loss in hypovolemic shock? - correct answer 3 ml of Crystalloid for each 1ml of blood loss 3: In hypovolemic shock, if blood loss is unknown, how much fluid bolus should an adult receive? - correct answer 1-2 L of fluid

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

In hypovolemic shock, if blood loss is unknown, how much fluid should a child receive? - correct answer 20 ml/kg List some colloid fluids: - correct answer Albumin, Hetastarch, Dextran What is a protein-based colloid? - correct answer Albumin What are some non-protein-based colloids? - correct answer Hetastarch Dextran In hypovolemic shock, what is the ratio of replacement for colloid fluids? - correct answer 1 ml of colloid fluid for each 1 ml of blood loss Compare intravascular persistence between crystalloid and colloid fluids. - correct answer Crystalloid - poor intravascular persistence Colloid - good intravascular persistence Compare crystalloid and colloid fluids regarding hemodynamic stabilization. - correct answer Colloid has prolonged hemodynamic stabilization, crystalloid has transient hemodynamic stabilization

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

In comparing crystalloid and colloid fluids, which requires a larger infusion volume? - correct answer Crystalloid requires a larger infusion volume Compare the risk of tissue edema between crystalloid and colloid fluids.

• correct answer Crystalloid has an obvious risk of tissue edema while Colloid has an insignificant risk of tissue edema. Compare crystalloid and colloid fluids regarding the enhancement of capillary integrity. - correct answer Crystalloid fluids have poor enhancement of capillary integrity. Colloid fluids have good enhancement of capillary integrity. Compare crystalloid and colloid fluids regarding the risk of anaphylaxis.
• correct answer Crystalloid fluids - No Risk of anaphylaxis Colloid fluids - Low to Moderate risk of anaphylaxis How do crystalloid fluids change colloid oncotic pressure? - correct answer Crystalloid fluids reduce colloid oncotic pressure

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Describe the cost of crystalloid and colloid fluids. - correct answer Crystalloid - Inexpensive Colloid - More expensive Describe whole blood transfusion. - correct answer Contains all components (PRBC, Platelet, FFP, Cryoprecipitate) but may be deficient in clotting factors. Which blood component does NOT require an ABO status prior to transfusing? - correct answer Platelets What is the typical volume of a unit of whole blood? - correct answer 500 ml per unit of whole blood What is the dosage for transfusing whole blood in pediatric patients? - correct answer 20 ml/kg in the pediatric patient How does one unit of PRBC's affect the hemoglobin/hematocrit? - correct answer 1 Unit of PRBC should raise the Hgb by 1 g/dL and teh hct by 3%

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is the typical volume of a unit of PRBC's? - correct answer 250 ml per unit of PRBC's What is the dosage for transfusing PRBC's in the pediatric patient? - correct answer 10 ml/kg in the pediatric patient How does transfusing 1 unit of platelets change the platelet coung? - correct answer Transfusing 1 unit of platelets elevates the platelet count 5,000 to 10,000 u/dL What is the dosage for transfusing Platelets in the pediatric patient? - correct answer 1 unit of platelets for each 7-10 kg in the pediatric patient How long does it take for Fresh Frozen Plasma to thaw? - correct answer 20 minutes are required to thaw FFP Once thawed, within how many hours must FFP be transfused? - correct answer 6 hours to transfuse FFP Describe cryoprecipitate. - correct answer Rich in factor VIII, Fibrinogen, von Willebrand's Factor and Factor XIII

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What blood type is the universal donor for PRBC's? - correct answer O Negative is the universal donor for PRBC's What is the universal donor type for FFP? - correct answer AB Negative is the universal donor for FFP If a patient's blood type is A, what type of PRBC's and what type of FFP can they receive? - correct answer Patient : Type A = PRBC - Type A and Type O FFP - Type A and Type AB If a patient's blood type is B, what type of PRBC's and what type of FFP can they receive? - correct answer Patient: Type B = PRBC - Type B and Type O FFP - Type B and Type AB If a patient's blood type is AB, what type of PRBC's and what type of FFP can they receive? - correct answer Patient: Type AB PRBC - Type A, Type B, Type AB, Type O

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

FFP - Type AB If a patient's blood type is O, what type of PRBC's and what type of FFP can they receive? - correct answer Patient: Type O PRBC - Type O FFP - Type A, Type B, Type AB, Type O What type of Rh transfusions must a person with RN Neg. blood receive? - correct answer A person with Rh NEG must receive Rh NEG blood if they may carry children in the future What type of transfusions can a person with Rh POS blood receive? - correct answer A person with Rh+ may receive Rh- and Rh+ blood List 5 complications associated with PRBC's. - correct answer Hypothermia Hyperkalemia Hypocalcemia Acidosis Coagulopathies

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Why is hypothermia a concern with PRBC transfusion? - correct answer Hypothermia is a concern with PRBC transfusion becasue it: Inhibits efforts to reverse metabolic acidosis and slows the clotting cascade. Why is Hyperkalemia a concern with PRBC transfusion? - correct answer Hyperkalemia is a concern with PRBC transfusion because: It may affect cardiac contractility and drive arrhythmias Why is Hypocalcemia a concern with PRBC transfusion? - correct answer Hypocalcemia is a concern with PRBC transfusion because: If more than 10 units of blood or blood products are given more than every 5 minutes, monitor calcium levels and be prepared to administer calcium chloride or calcium gluconate. Calcium is required for clotting. What electrolyte is required for clotting? - correct answer Calcium is required for clotting.

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What does extravasation of calcium chloride or calcium gluconate cause? - correct answer Extravasation of calcium chloride or calcium gluconate causes tissue necrosis. What is the pH of banked blood? - correct answer The pH of banked blood is 7.1 Why is acidosis a concern with PRBC transfusion? - correct answer The pH of banked blood is 7.1, acidotic. Acidosis can cause arrhythmias. Why are coagulopathies a concern with PRBC transfusion? - correct answer PRBC's contain few clotting factors. What 4 negative impacts do traditional fluid rescuscitation (2L of crystalloid fluids followed by PRBCs) have? - correct answer Hemodilation Coagulopathies Organ Dysfunction Compartment Syndrome

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Describe damage control resuscitation. - correct answer Attempts to reduce complications associated with traditional fluid restriction. Minimizes amount of crystalloid fluids used. Utilized PRBC's, Plasma and Platelets as opposed to PRBC's alone Compare Whole blood transfusion with Damage control resuscitation in regard to volume. - correct answer One unit of Whole Blood = 500 mL Damage Control Resuscitation = 660 mL How does one unit of whole blood affect hematocrit compared to how damage control resuscitation affects hematocrit - correct answer Hematocrit: Whole Blood = 38-50 % Damage Control = 29% Compare platelet count in whole blood vs. Damage control resuscitation

• correct answer Platelet Count: Whole Blood = 150,000-400,000 Damage Control = 87,000

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Compare coagulation activity in whole blood vs. damage control resuscitation. - correct answer Coagulation Activity: Whole Blood = 100% Damage Control = 65% Compare Fibrinogen content in whole blood vs. damage control resuscitation. - correct answer Fibrinogen: Whole Blood = 1500 mg Damage Control = 750 mg Compare the amounts of anticoagulants / additives between whole blood and damage control resuscitation. - correct answer Anticoagulants / Additives: Whole Blood = 63 mL Damage Control = 205 mL List 3 disadvantages to transfusing whole blood. - correct answer Must be used within 24-48 hours for maximal effectiveness. Increased risk of disease transmission. Lacks a universal donor

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

What is permissive hypotension? - correct answer Providing minimal fluid resuscitation allowing the blood pressure to remain low What are advantages of permissive hypotension? - correct answer Decreases liklihood of coagulopathy Less likely to cause hypothermia Decreases risk factors that cause acidosis Diminishes dislodgment of clots due to elevated pressure. What is the ideal pressure for survival? - correct answer Approximately 70/40 mmHg What are the risk factors of permissive hypotension? - correct answer Permissive hypotension can: Exacerbate head injuries Is not safe for pediatric or elderly patients What vital sign is non-predictive of the state of tissue perfusion in the acute traumatic setting? - correct answer Blood Pressure is non- predictive of the state of tissue perfusion in the acute traumatic setting.

(Shock, Psychosocial Issues Related to

Trauma, SIRS & MODS) (questions and

answers)

Urinary output of less than _____ is an early sign of inadequate perfusion. - correct answer 0.5 ml/kg/hr What 3 things must be considered when measuring urinary output in the trauma patient? - correct answer Diabetes Insipidus Renal Failure Diuretic Therapies When assessing mental status in the trauma patient, what must be considered? - correct answer Pre-Existing conditions Alcohol Drugs How often is invasive hemodynamic monitoring used in trauma? - correct answer Hemodynamic Monitoring - No often - not used in many patients because of complications What does Central Venous Pressure (CVP) meausre? - correct answer CVP measures Right Ventricular Preload