Catecholamine response to injury:

  • Is maximal at 24-48 hours after injury
  • Increase ACTH (which increase cortisol and aldosterone)
  • ADH, Glucagon

Neck zones:

  • I: Below cricoid (greater potential for intrathoracic great vessel injury) (Angiography, bronchoscopy, rigid esophagoscopy, barium swallow, and pericardial window may be indicated) May need sternotomy to reach these lesions
  • II: Cricoid to angle of jaw (Most amenable to OR exploration)
  • III: Jaw to skull (Angiography, laryngoscopy)
  • May need jaw subluxation, digastric and sternocleidomastoid muscle release, mastoid sinus resection to reach vascular injuries in this location
  • Remember 1 to 3 = low to high (as with LeForte fx and embryology of PTH glands [inferior glands and thymus from 3rd pouch, superior from 4th pouch]) Lung zone opposite

#1 cause of preventable blunt trauma death is missed intra-abdominal injury

DPL: (Used in hypotensive patients w/blunt trauma)

Perform supra-umbilical if:

  • (+) Pelvic fx
  • Pregnant

Positive if:

  • 10cc frank blood
  • >100,000 RBC/ml
  • Food particles
  • Bile
  • Bacteria
  • >500 WBC/ml

Positive = explore

10cc/kg infusion for peds.

FAST: (Focused assessment with sonography for trauma)

  • Explores:
    • Perihepatic fossa
    • Perisplenic fossa
    • Pelvis
    • Pericardium
  • Misses:
    • Retroperitoneal Bleeding
    • Hollow viscus injury

Indications for thoracotomy for hemothorax after chest-tube insertion:

  • Hemodynamic instability
  • >1500 cc out initially
  • >250 cc/h. x 3 hours
  • 2500 cc/24h
  • Incompletely drained hemothorax despite 2 well placed tubes = thoracoscopic or open drainage

Cardiac tamponade:

  • Hypotension is due to decrease diastolic filling
  • US finding: impaired diastolic filling of the right atrium
  • Tapped blood does not clot
  • Beck’s triad:
    • Hypotension, jugular venous distention, muffed hearth sounds

Fat emboli:

  • Petechia, hypoxia, confusion/agitation
  • Sudan urine stain for fat

Diaphragm rupture from blunt trauma:

  • 8:1 on Left
  • Dx: by NGT in chest on CXR
  • Tx: laparotomy
  • Delayed presentation: consider approaching via chest since there will be adhesions


  • Lose tuftsin, properidin, fibronectin (non-specific opsonins)
  • Decrease IgM production
  • Splenectomy helps all patients with hereditary spherocytosis (anemia and jaundice remit)
  • Helps 80% of patients w/ITP
  • Do not do splenectomy for patients with TTP
  • (patients w TTP have: Low plts, hemolytic anemia, neuro changes)
  • Tx = plasmapheresis

Pulmonary compliance:

  • Change in Volume for a given change in Pressure
  • (Want high compliance)
  • Compliance decrease in ARDS, pulmonary edema (takes greater pressure to get same volume)

ARDS Criteria:

  • Acute onset
  • B/L pulmonary infiltrates
  • PaO2/FiO2 ratio: < 300 (alone)
  • PAOP < 18 mmHg
  • Acute respiratory distress syndrome
  • All the above with a PaO2/FiO2 ratio < 200

Aging: Reduces FEV1 and FVC

O2 delivery = C.O. x arterial O2 content =

  • C.O. x (Hgb x 1.34 x O2Sat + [pO2 x 0.003])

O2 use = C.O x (CaO2 - CvO2)

Pressure support ventilation: decreases the work of breathing

Normal Weaning parameters:

  • NIF (negative inspiratory force): > 20
  • FiO2: <35%
  • PEEP: 5
  • Pressure support: 5
  • RR: < 24/min
  • HR: < 120 beats/min
  • pO2: > 60 mmHg
  • pCO2: < 50 mmHg
  • Osat: >93%
  • pH: 7.35-7.45

Normal Hemodynamic Parameters

  • PCWP 6-12
  • CO (SV x HR) = 4-8 L/min
  • CI (CO/BSA) = 2.5-4L/min/m2
  • MAP = diastolic + 1/3 PP (assume diastole is 2/3 of cardiac cycle) = 75-100
  • SVR = (MAP-RAP)/CO x 80 = 800-1400 dynes/sec/cm5
  • O2 delivery: DO2 = (SaO2 x Hb x 1.38 x CO x 10) = 800-1600 ml/min

O2 consumption:

VO2 = (SaO2 - SVO2) x Hb x 1.38 x CO x 10 = 150-400 ml/min

Initial Tx for air embolus:

  • Place patient in Trendelenburg with L side down.
  • Then attempt air aspiration via central line in RA


  • Increase FRC
  • Increase compliance
  • Keeps alveoli open (recruitment)
  • Rare PTX unless very high PEEP

FRC: air in lungs after normal exhalation

Effect of pH on ionized Calcium:

  • Acidosis increases calcium (H displaces calcium from proteins)

  • Alkalosis decreases calcium

Inspiratory capacity: air breathed in from FRC

Vital capacity: Greatest vol. that can be exhaled= FEV

Hgb O2 dissociation:

  • With increase temp, CO2, H+, 2,3DPG (high altitude, babies) = "right shift" to provide O2

EDRF: Endothelium-derived relaxing factor = nitric oxide (NO).

  • Produced and released by the endothelium
  • Made from arginine
  • Promote smooth muscle relaxation
  • Vasodilatation via cGMP, increased in sepsis


Hydroflouric acid burns: Tx with topical Calcium

Carbon monoxide:

  • Falsely elevates the O2Sat reading

  • Reduces available Hgb.

  • Giving 100% O2 reduces T1/2 of CO from 5 hrs to 1 hr

Silvadene (silver sulfadiazine):

  • Poor eschar penetration
  • Not painful
  • Good activity against Candida
  • Do not use in G6PD deficiency
  • Do not use in sulfa allergy
  • Risk of neutropenia

Sulfamylon (Mafenide acetate):

  • Penetrates well: schar/cartilage
  • Painful
  • Safe in sulfa allergy
  • (Less H2CO3 -> H2O + CO2)
  • Metabolic acidosis due to carbonic anhydrase inhibition

Silver Nitrate:

  • Limited schar penetration
  • Electrolyte leeching èHyponatremia/hypochloremia
  • Methemoglobinemia

#1 infection in burn Patients is pneumonia

Burn patients: Have initial drop in cardiac output, and then are hyperdynamic

SCCA that develops in chronic wound = Marjolin’s ulcer

Treatment for hyperkalemia:

  • Antagonize membrane effects and stabilize membrane potential:
    • IV Calcium is cardio-protective and the most rapid way to treat hyperkalemia (even in normocalcemic patients).
    • Digitalis is a relative contraindication to calcium administration.

  • Accelerate Cellular Potassium Uptake:
    • Insulin (+ Glucose): rapidly stimulates hepatocytes and myocytes to take-up potassium.
    • Beta 2-agonists: administered in nebulizer form has an immediate onset of action albuterol = tachycardia.
    • Bicarbonate: in acidosis associated with hyperkalemia.
    • **It is associated with a large sodium load
    • **It should not be given after calcium is administered, as it binds calcium.
  • Enhance Potassium Removal:
    • Potassium-wasting diuretics include either loop or thiazide diuretics.
    • Sodium Polystyrene Resin (Kayexalate) exchanges Na for K in the GI tract. When given orally, coadministration of sorbitol can inhibit constipation; however, sorbitol should not be given in conjunction with the enema for èrectal perforation.
  • Dialysis is the most efficient way to reduce K+.

Indications for dialysis: (AEIOU)

  • Acidosis
  • Electrolytes
  • Ingestion
  • Overload of fluid
  • Uremia

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