What are SIRS criteria? What is sepsis? What is severe sepsis? What is septic shock? What is MODS?
SIRS: Temp > 38 (100.4) or < 36 (96.8), HR > 90, RR > 20 or PaCO2 < 32, WBC > 12k, < 4k or > 10% bands. SEPSIS = SIRS + likely source of infection. SEVERE SEPSIS = SEPSIS + lactic acidosis, SBP < 90 or SBP drop > 40. SEPTIC SHOCK = SEVERE SEPSIS + hypotension despite fluid resuscitation. MODS = SEPTIC SHOCK + 2 organ failure
Indications for intubation
Signs of impending airway obstruction: Stridor, hoarseness, use of accessory muscles and respiratory retractions (soft tissues between ribs on inspiration), penetrating trauma to larynx or trachea. Inadequate respiratory effort, GCS < 9 and inability to protect airway
Once you clear the aiway, you find decreased breath sounds. How do you proceed?
CXR and pulse-ox
When can you remove a chest tube in a patient with hx of ptx?
When the lung is fully inflated and no further apparent air leak
Tx of sucking chest wound
Seal w/occlusive dressing and place chest tube elsewhere
When do you insert a second chest tube?
Wrong location (subcutaneous tissues) or not functioning properly (air leak or clotted off)
Pt continues to leak air after chest tube for 6 hours with normal functioning tube. What next?
Major airway rupture (can also cause pneumomediastinum). Next step is thoracotomy.
Indications for observation of ptx
Small, not enlarging, no free fluid in pleural space, asymptomatic and no other injuries (b/c if you need to operate anesthesia has PEEP of 20-40mmHg).
Why do patients with tension ptx present with hypotension?
The pleural pressure exceeds venous pressure and compresses venous return to the heart
Trauma patient presents with JVD, hypotension and pentrating chest trauma. Lungs are clear to ausculatation bilaterally. What's your next step?
Pericardiocentesis in the subxiphoid approach followed by emergent pericardial window in the OR to find the cause of bleeding.
Signs of myocardial contusion
Arrrhythmias on ECG and elevated cardiac enzymes
Most common cause of hypotension in trauma patients?
How is the degree of hemorrhage classified as it relates to shock?
Note that significant blood must be lost before compensatory physical exam symptoms begin to manifest (increased HR, RR and decreased urine output are the 1st signs, BP, decreased cap refill and mental status changes come later). Signs of adequate re-hydration include adequate urine output (>30cc/hr), improved HR (<100), improved mental status, improved BP, decreased lactic acidosis (base deficit) and normalization of SvO2 (venous O2 saturation)
Next step when a trauma patient in shock fails to respond to resuscitation?
Urgent lap or thoracotomy. If there is time to do a central line do it, if there is a ptx, do it on the same side of the ptx.
Pathophysiology of the Cushing reflex
Shock -> hypotension -> brain ischemia -> sympathetic outflow to vasoconstrict and increase cerebral perfusion pressure. Bradycardia happens because the vagus nerve is unaffected by the sympathetic outflow and responds to the increased BP by decreasing HR.
Evaluation of a pregnant woman in shock
On her right side to avoid IVC compression and hypotension
Reasons to suspect a urethral injury
Blood at the meatus, penile/scrotal hematoma and high riding prostate. Confirm w/retrograde cystourethrogram.
When can you clear a patient of a C-spine injury? What do you do if you can't clear it?
No c-spine tenderness or deformities, sensorimotor function intact, radiographs cleared by radiologist, neurologically intact with no distracting pain. If you can't clear...neuro consult, IV steroids to maximize recovery of damaged nerves and extreme caution if patient needs to be intubated.
A patient in a car accident has priapism, what are you worried about?
Fresh spinal cord injury
What merits emergent thoracotomy?
> 1500mL blood evacuated at initial tube thoracostomy, > 200mL over 3+ hours or failure of hypotension to resolve after placement of chest tube.
How does management of a gunshot wound to the abdomen differ from a stab wound?
Gunshot wounds always merit abdominal exploration for injury to surrounding structures due to the unpredictable path of bullets.
Pt presents with widened mediastinum on AP films after car accident, what is your next step?
If stable, PA film to assess widened mediastinum due to transection (no aortic knob etc). Aortic angiography follows as gold standard dx, then proceed to OR. If patient is unstable go straight to the OR.
Types of injuries that require further evaluation despite abscence of signs/symptoms of injury
Unprotected trauma (pedestrians, motorcycles, assaults w/objects), High-energy trauma (MVA w/death at scene, high speed, no seat belts) and Patients w/limited physiologic reserve (elderly, immunosuppressed)
Next step in a patient with fractured pelvis and hypotension
Check FAST, if negative go to pelvic angiogram and embolization if needed. Definitive surgery with pelvic reduction and external fixation is necessary.
Pt is stable and presents w/splenic laceration on CT. When do you do surgical exploration?
Grade IV and V lacerations. In unstable patients you try to balance preserving the spleen with blood transfused and assess need for splenectomy that way.
Dx of ruptured mesentery
Difficult to dx on CT, may see leaking bowel...need ex lap
Tx of liver lacerations
Ex lap if unstable. Observation is routinely practiced w/stable patients.
Most important step prior to operating on a renal laceration?
IV pyelogram to make sure there is another kidney there.
Management of pancreatic transection
Debridement and drainage if minor injury, resection of devitalized pancreas and repair of duodenum in complex injuries. Duodenal diversion for severe injuries
Tx for duodenal hematomas
NPO and TPN 5-7 days while duodenum recovers