Shock Trauma
The life you save may take your own
Shock Trauma Handshake
If you’re at death’s door, we’ll pull you through
If you have cirrhosis and take another hit, you are gonna die
Hook heliox into the air inlet of the vent, then set fio2 at 21% to get heliox mix. Always use left-selective tube when using double lumen Myoglobin>10,000 use cvvh Fendolopam for urine output Atropine is too drying to use for spinal bradycardia To perform bal Wedge in bronchus Infuse 40-60 initially, set suction to 80 or manually withdraw 20 cc, infuse 20 cc more Should see foam layer (surfactant) Lab can check for alveolar macrophages to make sure it is a good sample Spinal cord Alpha agents increase lung water Dopamine makes them pee which makes them negative, but vessels already wide, so they need to be positive They need volume and dobutamine b/c of spinal cord induced heart dysfunction (probably present in brain injury as well) The lungs of a copder are extremely compliant. This makes it very difficult to fix atelectasis as any increased pressure simply expands the compliant areas and does not go towards the atelectatic areas. COPDers lungs are incredibly compliant, so atelectasis is near impossible to resolve b/c all the pressure you add goes to the non-collapsed areas. Esophageal opening pressure is 15 so keep IPAP of NIV <15 How to wean 1. Bring to room air 2. Ventilations 3. Lower CPAP Should not see any expiratory work of breathing c ideal CPAP Should just see very slight insp zen belly breathing It may take 30-40 minutes for hypoventilation after hypocarbia to resolve even after CO2 normalizes Brain adjusts to low CO2s, so when you raise it, ICP rises. But a normal CO2 does not result in higher ICPs at baseline Should not actually be a gradient between ETCO2 and PaCO2, we create that gap
Servo I Open Lung Recruitment
Phase I-Baseline
Put PEEP 10 PC 20 to achieve 10 cc/kg Rate 20, 100%, I:E 1:1
Phase II-Open Lungs
Increase PEEP to 20
Increase PC by 5, then increase by another 5, then by 5, then last 5
to reach empiric opening pressure of 50; keep it for 2 minutes
Reduce PC until prerecruitment Vt is again reached
Phase III-Find Closing PEEP
Reduce PEEP by 2 every 30 seconds until a plateau and then a reduction in compliance is seen
Use cursor to find maximum
PEEP 2 above this level is optimal PEEP
Phase IV-Reopen lung
Increase PEEP to 15 then 20
Increase PC to get plat of 50
Hold two minutes
reduce PEEP to level in phase III
reduce PC until desired tidal volume
remember overdistension also ruins compliance
Scaleaisms
“bleeding with some personality”
Priority Trauma Activation
