Chapter 39 Trauma, Bioterrorism, and Natural Disasters
Acute management of trauma patients
1. Trauma is the most common cause of death in what age group?
2. What resources are available at hospitals specializing in trauma (e.g., “level 1” trauma centers)?
3. In reference to traumatic injuries, what is “The Golden Hour”?
4. What are the management priorities when caring for a trauma patient?
5. What is ATLS? What is its relevance to all trauma providers?
6. What are the “ABCDEs” of trauma?
7. A motor vehicle accident victim arrives with an endotracheal tube in situ, a blood pressure of 80/60, heart rate 120, and an obvious right ankle deformity with exposed bone. What is the first step in management of this patient?
8. List the indications for endotracheal intubation after life-threatening trauma.
9. Prior to the arrival of a trauma patient, what should providers do to prepare for possible endotracheal intubation?
10. What intravenous medications are most commonly used to intubate the trachea in severely injured patients?
11. In the context of traumatic brain injury, what is a plateau wave?
12. How should a trauma patient’s head be positioned for asleep endotracheal intubation if the stability of the cervical spine is unknown?
13. In the event of airway obstruction and an inability to perform endotracheal intubation, how should the airway be secured?
14. How is shock defined in trauma care? What blood pressure and heart rate values are consistent with shock?
15. What are the most sensitive and specific markers of shock in trauma patients?
16. Into what three anatomic spaces can a trauma patient massively hemorrhage? How would identification of orthopedic injuries limit internal bleeding?
17. What degree of chest tube output requires operative intervention?
18. What does persistent hematuria in a trauma patient indicate?
19. What is the treatment for hypovolemic shock following injury?
20. What is the definition of massive transfusion? What is the significance of blood product ratios in massive transfusion?
21. What is the Glasgow Coma Scale (GCS) and how is it used to evaluate a trauma patient? What GCS score is considered “severe”? Why do patients with severe traumatic brain injury (TBI) require endotracheal intubation, even if protecting their airway?
22. What secondary insults should be avoided in patients with traumatic brain injury?
23. At what intracranial pressure (ICP) is treatment frequently recommended? Name some methods used to treat an increased ICP.
24. What osmotic diuretic is commonly used to decrease an elevated ICP?
25. Why should glucose-containing intravenous solutions be avoided in patients with traumatic brain injury?
26. Should corticosteroids be administered to a patient with traumatic brain injury and signs of an elevated ICP?
27. When should hyperventilation be performed to decrease ICP? What is the danger of excessive hyperventilation?
28. When does a trauma patient require cervical spine stabilization at the time of initial assessment? How do trauma providers “clear” a patient’s cervical spine?
29. How is the “E” of the “ABCDEs” addressed in the initial evaluation of a trauma patient?
30. How does the initial evaluation of a burn injury patient differ from other trauma patients?
31. What are some indications for endotracheal intubation in the trauma patient with a burn injury? What is the danger of delaying endotracheal intubation in a patient with suspected inhalational injury?
32. How is the percentage of body surface area burned estimated in an adult?
33. Why should burn patients be initially placed on 100% oxygen, regardless of pulse oximetry reading?
34. Why do burn patients require larger than typical amounts of fluid resuscitation? What volume of intravenous fluid should be initially ordered?
35. What type of fluid should be used to resuscitate burn patients? Why do burn patients often receive a different volume over the first 24 hours than that initially calculated?
36. How should providers evaluate a patient with a suspected closed-head injury?
Emergency surgery for trauma
38. How does the time since a patient’s last meal affect the initial airway management of a trauma patient?
39. How does the maintenance of general anesthesia differ in emergency trauma surgery compared to elective outpatient surgery?
40. How can movement during surgery be prevented if a trauma patient is too unstable to tolerate high levels of general anesthetic agents?
41. What are the basic principles of intraoperative fluid management for trauma patients needing emergency surgery?
42. What diagnostic tests are used to guide intraoperative fluid therapy?
43. What preparations are needed prior to surgical opening of the peritoneum in an exploratory laparotomy for abdominal injuries?
44. What injuries might result from trauma to the abdomen? How is the diagnosis of intraabdominal hemorrhage made in a trauma patient?
45. What is “damage control” surgery and how does it benefit trauma patients?
46. What is the treatment for a hypotensive motorcycle accident victim with pelvic instability on examination and presumed pelvic bleeding?
47. What is the definition of abdominal compartment syndrome?
Mass casualty disasters
48. What types of mass casualty disasters are possible? What are intentional disasters?
49. How long should hospitals be prepared to manage mass casualty disasters before state and national resources arrive?
50. What roles do anesthesia providers play during mass casualty events?
51. What are the goals of mass casualty triage? How are patients classified? What is an “expectant” mass casualty patient?
52. Where does decontamination of mass casualty patients occur?
53. What are the advantages of ketamine, when compared to other anesthetic agents, in facilitating surgical procedures during mass casualty scenarios?
54. What are the risks of neuraxial blockade in mass casualty patients?
Chemical and biologic terrorism
58. What are “category A” agents, with respect to bioterrorism?
59. The appearance of five young patients in the emergency department with low-grade fever and myalgias for several days, who all now present with severe substernal chest pain and severe hypoxemia, should raise suspicions of exposure to what bioterrorism agent? What finding on chest radiograph would support this diagnosis? What else should be done for these patients and exposed individuals?
60. How do the cutaneous manifestations of smallpox and varicella zoster differ?
61. How long is aerosolized plague viable if released in weaponized form? How is a patient with pneumonic plague managed?
62. A group of travelers were exposed to an unknown vapor during a terrorist attack. Twelve hours later, several of those exposed experience difficulty breathing and progressive weakness, with decreased salivation and urinary retention. What category A bioterrorism agent is the most likely cause of these symptoms? What treatment is available, and what precautions should a care provider take? How would the presumed agent differ if those exposed had increased salivation and urinary incontinence?
64. What is the treatment for Sarin-exposed individuals? How does pretreatment with pyridostigmine provide protection from nerve gas exposure?
Answers*
Acute management of trauma patients
1. Trauma is the leading cause of death among those younger than 45 years old. An estimated 5 million people worldwide die each year from injuries. (681)
2. Specialized trauma centers maintain the staff, space, and supplies required to provide immediate trauma care. This includes a number of different physician specialties (emergency medicine, trauma surgery, anesthesiology, neurosurgery, diagnostic and interventional radiology, orthopedic surgery), nursing staff, dedicated patient care areas in the emergency department, operating rooms, intensive care unit (ICU), immediate diagnostic resources, and a blood bank. In the United States, a hospital designated as a level 1 trauma center must be able to provide such services on an immediate basis 24 hours a day. (681)
3. “The Golden Hour” refers to the first hour after a patient sustains major injuries. Most trauma-related deaths occur during this first hour, usually as a result of uncontrolled hemorrhage. Early recognition and treatment of shock is therefore a major priority in acute trauma care. (681)
4. The immediate priorities in acute management of trauma patients are to keep the patient alive, identify life-threatening injuries, stop any ongoing bleeding, and provide definitive treatment as early as possible. (681)
5. ATLS is the acronym for the Advanced Trauma Life Support course that is administered worldwide through the American College of Surgery’s Committee on Trauma. ATLS is important to trauma providers because it provides a standardized algorithm that can be universally applied to all trauma patients, regardless of a provider’s background or available resources. While trauma providers may vary from the basic ATLS algorithm based on availability of certain resources, knowledge of ATLS is useful to all trauma providers because it establishes a baseline for trauma management and a universal language (e.g., primary survey, secondary survey, ABCDEs) that providers all share. (682)
6. The “ABCDEs” of trauma refers to the appropriate sequence of priorities in trauma management: Airway, Breathing, Circulation, Disability (neurologic status), Exposure/Environment. Providers must immediately assess the ABCDEs, in sequence, when initially evaluating a trauma patient. Compromise at any step should be corrected before moving on to the next. (681-685, Table 42-1)
7. Acute management of any trauma patient must begin with confirmation of a patent airway, therefore the first step in managing this patient is to confirm proper position of the endotracheal tube (ETT). Capnography, auscultation of bilateral breath sounds, pulse oximetry, direct laryngoscopy, arterial blood gases, and fiber-optic bronchoscopy are all commonly used to confirm that an “in situ” ETT is, in fact, in the trachea. (682)
8. Indications for endotracheal intubation after life-threatening trauma include inadequate airway protection, impending loss of airway (e.g., inhalational injury, expanding neck hematoma), laryngeal or tracheal injury, inadequate ventilation or oxygenation, severe head injury, and need for surgery under general anesthesia. (682, Table 42-2)
9. Management of a trauma patient should include prior preparation of functioning suction, oxygen delivery devices (oxygen source, breathing circuit, ventilator), airway equipment (face mask, oral/nasal airways, intubation equipment), pharmaceuticals (for intubation of the trachea and management of hemodynamics), intravenous access with fluids and tubing, monitors, and personal protective equipment. Assistants to help with cervical spine and aspiration precautions should be designated, as well as equipment and personnel needed for a surgical airway if endotracheal intubation cannot be performed. (682-683, Table 42-3)
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