NCLEX Prep

Trauma Triad Of Death

๐Ÿ’‰๐Ÿš‘๐Ÿš‘๐Ÿ’‰๐Ÿ’‰๐Ÿš‘๐Ÿš‘๐Ÿ’‰๐Ÿ’‰๐Ÿš‘๐Ÿš‘๐Ÿš‘๐Ÿš‘ The lethal trauma triad of death is one of the things that increases trauma patients morbidity & mortality. By majority, the answer would be hypovolemic shock. Hypovolemia is defined as a state in which there is a decrease in plasma volume within the body. Hypovolemia, if severe enough, produces shock. Shock is defined as inadequate tissue perfusion combined with the inadequate removal of cellular wastes, ultimately producing a defect in oxidative metabolism and therefore a subsequent dysfunction in the way that the body transports, delivers, and utilized oxygen. Hypovolemic shock in trauma patients often stems from acute hemorrhage. โ€ข

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Hypovolemic shock secondary to hemorrhage produces a lethal triad

of:

1.) acidosis

2.) hypothermia

3.) coagulopathy

Hypovolemic shock produces several defects in physiology. The decreased intravascular fluid volume decreases venous return to the heart, which ultimately reduces preload and stroke volume (SV). The body initially compensates for the decreased SV by increasing the heart rate in order to maintain cardiac output (CO). Eventually CO decreases and subsequently results in decreased end-organ perfusion.

As the body becomes deprived of oxygen, aerobic metabolism shifts to anaerobic metabolism. This shift causes the build up of lactic acid, which ultimately produces metabolic acidosis. The hemorrhage in hypovolemic shock results in extreme activation of prothrombin, which causes an excess of thrombin formation. The excess thrombin causes the conversion of fibrinogen to fibrin. Fibrin activation produces wide-spread clot formation. This process depletes coagulation factors. Overtime, secondary fibrinolysis and coagulopathy results in further bleeding. As the hemorrhage progresses, hypothermia results from excess shunting of blood away from extremities producing a โ€œshockyโ€ looking patient who is clamped down.

The patient usually has delayed cap refill and w/kids an early sign is a gap between central and peripheral pulses. Giving volume such as whole blood or 1:1:1 of PRBCโ€™s/platelets/FFP is what the patient needs in order to achieve homeostasis, maintain normal perfusion and to hopefully achieve a MAP of 65.

Stop The Bleed Instructor Course

Being a trauma nurse means studying on your days off. It means reading EBP articles because you want to know what is “cutting edge”. It means going to a class on a Sunday morning because you want to do more, teach more, and above all save more lives. Stay thirsty for knowledge my friends ๐Ÿ’‰๐Ÿ’ฏ๐Ÿ’ช๐Ÿป

~The Verkinator โœŒ๐Ÿผ

Sepsis Alert๐Ÿ’‰๐Ÿฆ Vanco

โ€ข @theedtraumacist Vancomycin is a tricyclic glycopeptide antibiotic used to cover gramโž•bacteria such as methicillin resistant Staphylococcus aureus. ๐Ÿ’‰

Vancomycin works by inhibiting bacterial cell wall synthesis by binding to D-alanyl-D-alanine cell wall precursors, inhibiting polymerization and preventing linkage to the glycopeptide polymer located within the bacteriaโ€™s cell wall.

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When dosing vancomycin a couple of factors should be considered including the patientโ€™s weight, renal function, and presenting disease state. It is normally

dosed at 15-20 mg/kg, and even higher for more severe infections (25-30 mg/kg in patients with sepsis, infective endocarditis, meningitis, etc. with a max dose depending on your hospital protocol).

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In a study by Fuller and colleagues that reviewed vancomycin management in the ED, they reviewed 4441 doses of vancomycin given to patients with a weight measurement available. Vancomycin was dosed correctly in only 22.1% of patients ๐Ÿ˜ง with 71 % of patients being dosed below the recommended dose of 15-20 mg/kg ๐Ÿ˜ฑ. Vancomycin dosing is not one size fits all and patient specific characteristics should be considered when dosing this medication. ๐Ÿ’‰

#theedtraumacist #trauma #traumaninjas #miamitrauma #traumiami #emergencymedicine #emergencydepartment #pharmacy #pharmacylife #pharmlife #pharmvida #pharmsohard #pharmacystudent #pharmacyresident #pharmer

AEIOUTIPS Mnemonic DDx for Altered Mental Status

Have you ever taken care of a pt who had an altered mental status (AMS)? Patients with an altered mental status (or ALOC)are among the toughest to assess since there is no classic, “one size fits all” presentation.

The clinical presentation is often obscure, which makes recognizing changes in mental status a challenging endeavor. There are certain underlying pathophysiological conditions that can cause AMS. This is one of the largest differential diagnoses you may encounter in the ED, EMS or hospital setting. 

1-START WITH THE ABCS, IV, O2, โœ”๏ธskins & 12 lead ๐Ÿ–ค๐Ÿ’™๐Ÿ–ค

2-ASSESS the pt & extrapolate info from the family (i.e. med list) ๐Ÿ’Š

3-GET labs: ISTATs, & venous blood gas (VBG) ๐Ÿ’‰

4-Use AEIOUTIPS mnemonic to help w/DDx

5-Listen to emergency trauma mamaโ€™s new podcast to review a super interesting case study ๐Ÿ˜ฒ๐Ÿ’ช๐Ÿป๐Ÿ’ฏ๐Ÿค—

Phenylephrine

@rishimd Phenylephrine is a selective alpha-1 receptor agonist used in various settings for its vasoconstrictive properties. Whether this is as a decongestant (constricting vessels in the nasal/sinus mucosa) or a mydriatic to perform a fundoscopic exam, this medicationโ€™s selectivity gives me an idea of the expected response as well as potential side effects. โ˜บ๏ธ
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I most commonly use phenylephrine in the ICU and OR to treat acute hypotension caused by vasodilation from hypnotics, halogenated volatile anesthetics, or acute blood loss in tandem with ongoing resuscitation. Iโ€™m comfortable using a peripheral IV to bolus 40-120 mcg over a short period of time, but in the rare event of tissue infiltration, phenylephrineโ€™s alpha agonist effects can be antagonized with medications like phentolamine administered subcutaneously. If the need for long term afterload enhancement arises, I almost always switch to a norepinephrine or vasopressin drip. ๐Ÿ’Š
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Acute increases in systemic vascular resistance (SVR) will activate baroreceptors (ie, the carotid sinuses) which, in turn, increase vagal tone to the heart. Since phenylephrine does not have any beta-agonist properties, the unopposed increase in vagal tone is the mechanism by which the patientโ€™s heart rate decreases in response to an acutely elevated SVR. ๐Ÿ’‰๐Ÿ‘จ๐Ÿฝโ€โš•๏ธ
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Tag a friend who uses phenylephrine, let me know if/when youโ€™ve used it, and drop me a comment with questions! ๐Ÿ‘‡
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CEN Review Question

answer: C. Remember the epidural bleeds are a tear of the middle meningeal artery, which is located in temporal lobe. The biggest clue is location AND pt presentation. The pt has a period of lucidity, and then falls into a decreased LOC after “they appear fine” right after the incident. Case in point, Natasha Richardson’s skiing accident proved fatal after she fell, struck her head (no helmet) and did not go to the ED to get a scan. Sadly, she died from her epidural bleed.