17- Trouma & ER Explains Flashcards
1
Q
When should heparin be given in the management of pulmonary embolism?
A
Heparin should be given if there is an intermediate or high clinical probability before imaging.
2
Q
What are the considerations for using unfractionated heparin (UFH)?
A
Unfractionated heparin (UFH) should be considered as a first dose bolus, in cases of massive pulmonary embolism, or when rapid reversal of effect may be needed.
3
Q
What is the target INR range for anticoagulation?
A
The target INR (international normalized ratio) range for anticoagulation is 2.0-3.0. Once this range is achieved, heparin can be discontinued.
4
Q
When should oral anticoagulation be commenced?
A
Oral anticoagulation should only be commenced once venous thromboembolism (VTE) has been reliably confirmed.
4
Q
What is the preferred anticoagulant over UFH in most cases?
A
In most cases, low molecular weight heparin (LMWH) is considered preferable to UFH. It has equal efficacy and safety and is easier to use.
5
Q
What is the standard duration of oral anticoagulation for pulmonary embolism?
A
The standard duration of oral anticoagulation is 4 to 6 weeks for temporary risk factors, 3 months for the first idiopathic case, and at least 6 months for other cases. The risk of bleeding should be balanced with the risk of further VTE.
6
Q
How is clinically massive pulmonary embolism diagnosed?
A
Clinically massive pulmonary embolism can be reliably diagnosed using CTPA (computed tomography pulmonary angiography) or echocardiography.
7
Q
What is the first-line treatment for massive pulmonary embolism?
A
Thrombolysis is the first-line treatment for massive pulmonary embolism, especially in cases of circulatory failure. It may be instituted based on clinical grounds alone if cardiac arrest is imminent. A recommended dose is a 50 mg bolus of alteplase.
8
Q
When should invasive approaches like thrombus fragmentation and IVC filter insertion be considered?
A
Invasive approaches like thrombus fragmentation and IVC (inferior vena cava) filter insertion should be considered when facilities and expertise are readily available.
8
Q
What are some predisposing factors for aortic dissection in pregnancy?
A
Predisposing factors for aortic dissection in pregnancy include hypertension, congenital heart disease, and Marfan’s syndrome.
9
Q
What type of aortic dissections are mainly seen in pregnancy?
A
Mainly Stanford type A dissections are seen in pregnancy.
10
Q
What are some symptoms of aortic dissection in pregnancy?
A
Symptoms of aortic dissection in pregnancy include sudden tearing chest pain, transient syncope (fainting), feeling cold and clammy, hypertension, and an aortic regurgitation murmur.
11
Q
What may happen if the right coronary artery is involved in aortic dissection?
A
Involvement of the right coronary artery may cause an inferior myocardial infarction.
12
Q
What is the most common cause of mitral stenosis in pregnancy?
A
Most cases of mitral stenosis in pregnancy are associated with rheumatic heart disease.
13
Q
What is the surgical management for aortic dissection based on the gestational timeframe?
A
For aortic dissections before 28 weeks of pregnancy, aortic repair is performed with the fetus kept in utero. Between 28 and 32 weeks, it depends on the fetal condition. After 32 weeks, a primary cesarean section is followed by aortic repair during the same operation.
14
Q
Is mitral stenosis becoming more or less common in British women?
A
Mitral stenosis is becoming less common in British women.
15
Q
What is the most common cardiac condition seen in pregnancy?
A
The most common cardiac condition seen in pregnancy is mitral stenosis.
16
Q
What is the preferred treatment for mitral stenosis?
A
Valve surgery, specifically balloon valvuloplasty, is preferred for the treatment of mitral stenosis.
17
Q
What is the leading cause of mortality in pregnancy?
A
Pulmonary embolism is the leading cause of mortality in pregnancy.
18
Q
What is the recommended treatment for pulmonary embolism during pregnancy?
A
Treatment with low molecular weight heparin is recommended throughout pregnancy and 4-6 weeks after childbirth for pulmonary embolism.
19
Q
What imaging tests are used to aid in the diagnosis of pulmonary embolism?
A
Half dose scintigraphy is used initially, and a CT chest may be performed if there is underlying lung disease to aid in the diagnosis of pulmonary embolism.
20
Q
Is warfarin safe to use during pregnancy?
A
Warfarin is contraindicated in pregnancy, but it may be continued in women with mechanical heart valves due to the significant risk of thromboembolism.
21
Q
What percentage of blunt chest trauma requires operative intervention?
A
Less than 10% of blunt chest trauma requires operative intervention.
22
Q
What are the physiologic consequences of thoracic trauma?
A
The physiologic consequences of thoracic trauma are hypoxia, hypercarbia, and acidosis.
23
What can cause hypoxia in thoracic trauma?
Contusion, hematoma, alveolar collapse, or changes in intrathoracic pressure relationships (such as tension pneumothorax and open pneumothorax) can cause hypoxia in thoracic trauma.
24
What is a tension pneumothorax?
A tension pneumothorax is often a laceration to the lung parenchyma with a flap, causing pressure to develop in the thorax. The most common cause is mechanical ventilation in a patient with pleural injury.
24
What can cause respiratory acidosis in thoracic trauma?
Hypercarbia, which is caused by inadequate ventilation due to changes in intrathoracic pressure relationships and a depressed level of consciousness, can cause respiratory acidosis in thoracic trauma.
25
What are the symptoms of tension pneumothorax?
Symptoms of tension pneumothorax overlap with cardiac tamponade, but a hyper-resonant percussion note is more likely in tension pneumothorax.
26
What is flail chest?
Flail chest occurs when the chest wall disconnects from the thoracic cage. It is characterized by multiple rib fractures (at least two fractures per rib in at least two ribs) and is associated with pulmonary contusion.
27
What precautions should be taken with flail chest patients?
It is important to avoid overhydration and fluid overload in patients with flail chest.
28
What is the most common cause of pneumothorax in thoracic trauma?
The most common cause of pneumothorax in thoracic trauma is lung laceration with air leakage.
29
When should a chest drain be inserted in patients with traumatic pneumothorax?
Patients with traumatic pneumothorax should never be mechanically ventilated until a chest drain is inserted.
30
What is the most common cause of haemothorax in thoracic trauma?
Haemothorax in thoracic trauma is most commonly due to laceration of the lung, intercostal vessel, or internal mammary artery.
31
When is surgical exploration warranted in cases of haemothorax?
Surgical exploration is warranted if there is an immediate drainage of more than 1500ml of blood.
31
How should large haemothoraces be treated?
Large haemothoraces that are visible on a chest X-ray should be treated with a large bore chest drain.
32
What are the characteristics of cardiac tamponade?
Cardiac tamponade is characterized by Beck's triad (elevated venous pressure, reduced arterial pressure, reduced heart sounds) and pulsus paradoxus. It may occur with as little as 100ml of blood.
33
What is the most common potentially lethal chest injury?
Pulmonary contusion is the most common potentially lethal chest injury.
34
What are the important diagnostic tools for pulmonary contusion?
Arterial blood gases and pulse oximetry are important diagnostic tools for pulmonary contusion.
35
When should early intubation be considered in cases of pulmonary contusion?
Early intubation within an hour should be considered if there is significant hypoxia in cases of pulmonary contusion.
36
What usually causes blunt cardiac injury?
Blunt cardiac injury usually occurs as a secondary injury to chest wall injury.
37
What features may be seen on an ECG in blunt cardiac injury?
An ECG may show features of myocardial infarction in blunt cardiac injury.
38
What are some sequelae of blunt cardiac injury?
Sequelae of blunt cardiac injury include hypotension, arrhythmias, and cardiac wall motion abnormalities.
39
What are some common causes of diaphragm disruption?
Most cases of diaphragm disruption are due to motor vehicle accidents and blunt trauma, causing large radial tears.
40
What should be done in cases of diaphragm disruption?
In cases of diaphragm disruption, it is important to insert a gastric tube, as it may pass into the intrathoracic stomach.
41
Which side is diaphragm disruption more common on?
Diaphragm disruption is more commonly seen on the left side.
42
What suggests a great vessel injury in mediastinal traversing wounds?
The presence of a mediastinal hematoma or pleural cap suggests a great vessel injury
43
What does mediastinal traversing wounds refer to?
Mediastinal traversing wounds refer to cases where there is an entrance wound in one hemithorax and an exit wound or foreign body in the opposite hemithorax.
44
What is the sensitivity of FAST scanning in pregnancy?
The sensitivity of FAST scanning is reduced in pregnancy, especially with advanced gestational age. It ranges from 60-80% across all trimesters and is 90% in the first trimester.
44
What are the advantages of sonography and FAST scanning in pregnant trauma patients?
Sonography and FAST scanning in pregnant trauma patients have the advantage of avoiding ionising radiation.
45
What is the mortality rate of mediastinal traversing wounds?
The mortality rate of mediastinal traversing wounds is 20%.
46
What is the recommended first-line investigation in major trauma cases in pregnant patients?
CT scanning remains the first-line investigation in major trauma cases where significant visceral injury is suspected.
47
Does a pelvic CT scan fall below the maximum safe dose of radiation in pregnancy?
Yes, a pelvic CT scan would fall below the maximum safe dose of radiation in pregnancy.
48
What is the maximum safe dose of radiation in pregnancy?
The maximum permitted safe dose of radiation in pregnancy is 5mSv.
49
What are the risks of radiation exposure in pregnancy?
Early exposure to radiation increases the risk of developmental anomalies and fetal loss, while late exposure increases the risk of childhood cancer twofold.
50
What is the most sensitive test for identifying complications such as placental abruption in pregnant trauma patients?
CT scanning remains the most sensitive test for identifying complications such as placental abruption in pregnant trauma patients.
51
How should patients with head injuries be managed?
Patients with head injuries should be managed according to ATLS principles, and extra cranial injuries should be managed alongside cranial trauma.
52
What can compromise CNS perfusion regardless of the nature of the cranial injury?
Inadequate cardiac output can compromise CNS perfusion regardless of the nature of the cranial injury.
53
Where do the majority of extradural hematomas occur?
The majority of extradural hematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
53
What is an extradural hematoma?
An extradural hematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head.
54
What are the features of an extradural hematoma?
Features of an extradural hematoma include raised intracranial pressure and some patients may exhibit a lucid interval.
55
What is a subdural hematoma?
A subdural hematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes and may be either acute or chronic.
56
What are the risk factors for a subdural hematoma?
Risk factors for a subdural hematoma include old age and alcoholism.
57
What is the onset of symptoms like for a subdural hematoma compared to an extradural hematoma?
The onset of symptoms for a subdural hematoma is slower than that of an extradural hematoma.
58
What is a subarachnoid hemorrhage?
A subarachnoid hemorrhage usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may also be seen in association with other injuries in a traumatic brain injury.
59
What are the types of primary brain injury?
Primary brain injury can be focal (contusion/hematoma) or diffuse (diffuse axonal injury).
60
What can exacerbate the original injury and cause secondary brain injury?
Cerebral edema, ischemia, infection, tonsillar or tentorial herniation can exacerbate the original injury and cause secondary brain injury.
60
What is diffuse axonal injury?
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons.
61
What happens to the brain's auto regulatory processes following trauma?
Following trauma, the brain's normal cerebral auto regulatory processes are disrupted, rendering the brain more susceptible to blood flow changes and hypoxia.
62
What is the management for life-threatening rising intracranial pressure?
In cases of life-threatening rising intracranial pressure, such as extradural hematoma, the use of IV mannitol/frusemide may be required while theatre is prepared or transfer is arranged.
62
What is the Cushings reflex and when does it often occur?
The Cushings reflex, characterized by hypertension and bradycardia, often occurs late and is usually a pre-terminal event.
63
What may diffuse cerebral edema require?
Diffuse cerebral edema may require decompressive craniotomy.
64
What is the management for open depressed skull fractures?
Open depressed skull fractures require formal surgical reduction and debridement, while closed injuries may be managed non-operatively if there is minimal displacement.
65
When is ICP monitoring appropriate in head injuries?
ICP monitoring is appropriate in patients with a GCS score of 3-8 and a normal CT scan.
66
When is ICP monitoring mandatory in head injuries?
ICP monitoring is mandatory in patients with a GCS score of 3-8 and an abnormal CT scan.
67
What is the most likely cause of hyponatremia in head injuries?
Hyponatremia is most likely to be due to the syndrome of inappropriate ADH secretion.
68
What is the minimum cerebral perfusion pressure in adults?
The minimum cerebral perfusion pressure in adults is 70mmHg.
69
What is the minimum cerebral perfusion pressure in children?
The minimum cerebral perfusion pressure in children is between 40 and 70 mmHg.
70
How can pupillary findings be interpreted in head injuries?
Pupil size and light response can help interpret pupillary findings in head injuries.
71
What does unilaterally dilated pupil with sluggish or fixed light response indicate?
Unilaterally dilated pupil with sluggish or fixed light response indicates 3rd nerve compression secondary to tentorial herniation.
72
What does bilaterally dilated pupil with sluggish or fixed light response indicate?
Bilaterally dilated pupils with sluggish or fixed light response indicate poor CNS perfusion or bilateral 3rd nerve palsy.
73
What does unilaterally dilated pupilor equal pupil size with a cross reactive (Marcus-Gunn) light response indicate?
Unilaterally dilated pupil or equal pupil size with a cross-reactive (Marcus-Gunn) light response indicates optic nerve injury.
74
What does bilaterally constricted pupil indicate?
Bilaterally constricted pupil may be difficult to assess, but it can be associated with opiate use, pontine lesions, or metabolic encephalopathy.
75
What does unilaterally constricted pupil indicate?
Unilaterally constricted pupil with preserved light response indicates sympathetic pathway disruption.
76
What are the three types of burns?
Thermal, chemical, and electrical.
77
What is the immediate management for burns?
Remove the burning source and irrigate the burned area.
78
What needs to be assessed after a burn?
The extent of the burns, which can be recorded using various charts.
79
How does the degree of injury relate to burns?
The degree of injury relates to the temperature and duration of exposure.
80
What are most domestic burns in young children?
Most domestic burns in young children are scalds.
81
What is a common complication of large burns?
Immunosuppression and bacterial translocation from the gut lumen.
81
What are the local and systemic responses to burns?
Locally, there is progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects, fluid loss, sequestration of fluid, and a catabolic response.
82
What is a common cause of death following major burns?
Sepsis.
83
What is the management for each type of burn?
Epidermal/superficial burns normally heal with no intervention, superficial partial thickness burns may need surgical intervention, deep partial thickness burns require surgical intervention, and full thickness burns require transfer to a burns center.
83
What are the types of burns based on skin layers affected and appearance?
Epidermal/superficial, superficial partial thickness, deep partial thickness, and full thickness.
84
How can the depth of burns be assessed?
By checking for bleeding on needle prick, sensation, appearance, and blanching to pressure.
85
What are the methods for estimating percentage burn?
Lund Browder chart (most accurate), Wallace rule of nines, and palmar surface (0.8% burn for each palm).
86
When should a patient with burns be transferred to a burn center?
If they require burn shock resuscitation, have face/hand/genital burns, deep partial thickness or full thickness burns, or significant electrical/chemical burns.
87
What is the initial aim in managing burns?
To stop the burning process and resuscitate the patient.
88
What is the fluid resuscitation calculation for burns?
Volume of fluid = total body surface area of the burn % x weight (Kg) x 2-4 (preference for lower amount). Half of the fluid is administered in the first 8 hours.
89
What should be done for circumferential burns affecting a limb or severe torso burns?
Escharotomy may be required to divide the burnt tissue.
90
What is the management for superficial burns and mixed superficial burns that will heal in 2 weeks?
Conservative management.
91
What may be required for more complex burns?
Excision and skin grafting.
91
Is excision and primary closure generally practiced for burns?
No, as there is a high risk of infection.
91
Is antimicrobial prophylaxis or topical antibiotics recommended for burn patients?
No, there is no evidence to support their use.
92
When are escharotomies indicated?
Escharotomies are indicated in circumferential full thickness burns to the torso or limbs. They can improve ventilation or relieve compartment syndrome and edema.
93
When are intravenous fluids required for children and adults with burns?
Children with burns greater than 10% of total body surface area and adults with burns greater than 15% of total body surface area.
94
What should be done after fluid resuscitation for burns?
Insert a urinary catheter and provide analgesia.
95
What is the mechanism of injury for thoracic aorta rupture?
Decelerating force, such as a road traffic accident or fall from a great height.
96
What is the outcome for most people with thoracic aorta rupture?
Most people die at the scene.
97
What may survivors of thoracic aorta rupture have?
Survivors may have an incomplete laceration at the ligamentum arteriosum of the aorta.
98
What are the clinical features of thoracic aorta rupture?
Persistent hypotension caused by a contained hematoma.
99
How is thoracic aorta rupture detected?
It is mainly detected by history and changes seen on chest X-ray (CXR).
100
What changes can be seen on CXR for thoracic aorta rupture?
Widened mediastinum, trachea/esophagus shift to the right, depression of the left main stem bronchus, widened paratracheal stripe/paraspinal interfaces, obliteration of space between aorta and pulmonary artery, and rib fracture/left haemothorax.
101
What is the preferred diagnostic test for thoracic aorta rupture?
Angiography, usually CT aortogram.
102
What is the treatment for thoracic aorta rupture?
Repair or replacement. Ideally, the patient should undergo endovascular repair.
103
What are the clinical features of thoracic aorta dissection?
Tearing interscapular pain and a discrepancy in arterial blood pressures taken in both arms. It may also show mediastinal widening on chest X-ray.
104
What is diffuse esophageal spasm?
It is a spectrum of esophageal motility disorders characterized by uncoordinated contractions of the esophageal muscles.
105
What may be seen on a barium swallow for diffuse esophageal spasm?
It may show "nutcracker esophagus."
106
What is a common cause of retrosternal discomfort?
Gastro-esophageal reflux is a common cause of retrosternal discomfort.
106
What are the symptoms of diffuse esophageal spasm?
Symptoms include dysphagia, retrosternal discomfort, and dyspepsia.
107
What are the associated symptoms of gastro-esophageal reflux?
Associated symptoms include regurgitation, odynophagia, and dyspepsia.
108
How are the symptoms of gastro-esophageal reflux usually managed?
Symptoms are usually well controlled with proton pump inhibitor (PPI) therapy.
108
What is Boerhaave's syndrome?
It is the spontaneous rupture of the esophagus, often caused by episodes of repeated vomiting, usually associated with alcohol excess.
109
What are the typical symptoms of Boerhaave's syndrome?
There is usually an episode of repetitive vomiting followed by severe chest and epigastric pain.
109
How is Boerhaave's syndrome diagnosed?
It is diagnosed by CT and contrast studies.
110
What is the treatment for Boerhaave's syndrome?
Treatment is surgical, with primary repair during the first 12 hours. Beyond this, the usual approach is creation of a controlled fistula with a T Tube. Delay beyond 24 hours is associated with fulminant mediastinitis and is usually fatal.
111
What is achalasia?
Achalasia is a condition characterized by difficulty swallowing (dysphagia) to both liquids and solids, and sometimes chest pain.
112
What is the most common cause of achalasia?
It is usually caused by the failure of distal esophageal inhibitory neurons.
113
How is achalasia diagnosed?
Diagnosis is made through pH and manometry studies, as well as contrast swallow and endoscopy.
114
What are the treatment options for achalasia?
Treatment options include botulinum toxin injection, pneumatic dilatation, or cardiomyotomy.
115
What are the two main causes of local anesthetic toxicity?
Toxicity can result from accidental intravascular injection or excessive dosage.
116
What effects do local anesthetic agents have on the body?
Local anesthetic agents not only stabilize peripheral nerves but also act on excitable membranes within the central nervous system (CNS) and heart.
117
Which type of neurons in the CNS are suppressed first?
Sensory neurons in the CNS are suppressed before motor neurons.
118
What are the early symptoms of local anesthetic toxicity?
The early symptoms are typically circumoral paraesthesia (tingling around the mouth) and tinnitus (ringing in the ears), followed by a decrease in the Glasgow Coma Scale (GCS) and eventually coma.
119
What are the steps in managing local anesthetic toxicity?
Stop injecting the anesthetic agent, administer high-flow 100% oxygen via a face mask, monitor cardiovascular function, administer lipid emulsion (Intralipid 20%) as a bolus, consider lipid emulsion infusion, and if toxicity is due to prilocaine, administer methylene blue.
120
What is the safe dose of lignocaine (lidocaine) 1%?
A 10ml solution of lignocaine 1% contains 100mg of the drug. In a 50kg patient, 70% of the maximum safe dose would be constituted by this amount. Up to 7mg/kg can be administered if adrenaline is added to the solution.
121
What are the recommended doses of local anesthetics?
For lignocaine: 3mg/kg plain, 7mg/kg with adrenaline. For bupivacaine: 2mg/kg plain, 2mg/kg with adrenaline. For prilocaine: 6mg/kg plain, 9mg/kg with adrenaline. These doses are a guide and may vary depending on the site of administration, tissue vascularity, and co-morbidities.
122
What are the options for eye opening in the Glasgow Coma Scale?
Spontaneous, to speech, to pain, or none.
123
What are the options for verbal response in the Glasgow Coma Scale?
Orientated, confused, words, sounds, or none.
124
What are the options for motor response in the Glasgow Coma Scale?
Obeys commands, localizes to pain, withdraws from pain, abnormal flexion to pain (decorticate posture), extending to pain, or none.
125
What GCS score is generally associated with severe brain injuries?
Severe brain injuries are generally associated with a Glasgow Coma Scale score of less than 8.
126
breakdown of the GCS scoring:
Eye-Opening Response:
Spontaneous: 4
To speech: 3
To pain: 2
None: 1
Verbal Response:
Oriented: 5
Confused conversation: 4
Inappropriate words: 3
Incomprehensible sounds: 2
None: 1
Motor Response:
Obeys commands: 6
Localizes pain: 5
Withdraws from pain: 4
Abnormal flexion (decorticate posturing): 3
Extensor response (decerebrate posturing): 2
None: 1
127
What is sick euthyroid syndrome?
Sick euthyroid syndrome, now referred to as non-thyroidal illness, is a condition in which thyroid hormone levels are altered due to systemic illness.
128
What factors determine the management of splenic trauma?
The management of splenic trauma is dictated by associated injuries, hemodynamic status, and the extent of direct splenic injury.
128
What is the typical pattern of hormone levels in sick euthyroid syndrome?
While it is often said that TSH, thyroxine (T4), and triiodothyronine (T3) are low in sick euthyroid syndrome, in the majority of cases, the TSH level is within the normal range. This is considered inappropriately normal given the low levels of thyroxine and T3.
129
Are the changes in hormone levels reversible?
Yes, the changes in hormone levels seen in sick euthyroid syndrome are reversible upon recovery from the systemic illness.
130
What are the management options for splenic trauma?
The management options for splenic trauma include conservative management, laparotomy with conservation, resection, and splenectomy.
131
What are the indications for conservative management in splenic trauma?
Conservative management is indicated for small subcapsular hematoma, minimal intra-abdominal blood, and no hilar disruption.
132
When is laparotomy with conservation performed in splenic trauma?
Laparotomy with conservation is performed when there are increased amounts of intra-abdominal blood, moderate hemodynamic compromise, and tears or lacerations affecting less than 50% of the spleen.
133
When is resection performed in splenic trauma?
Resection is performed for hilar injuries, major hemorrhage, and major associated injuries.
134
What post-operative care is required after splenectomy?
Post-operatively, the patient will require prophylactic penicillin V and pneumococcal vaccine.
134
What is the technique for splenectomy in splenic trauma?
The technique for splenectomy involves making a long midline incision, inserting a self-retaining retractor if time permits, packing all four quadrants of the abdomen, assessing the viability of the spleen, dividing and ligating the short gastric vessels, clamping the splenic artery and vein, being careful not to damage the tail of the pancreas, washing out the abdomen, placing a tube drain to the splenic bed, and considering implanting a portion of the spleen into the omentum.
135
What are some complications of splenectomy in splenic trauma?
Complications of splenectomy in splenic trauma can include hemorrhage, pancreatic fistula, thrombocytosis, and encapsulated bacteria infection.
136
What is the difference between emergency and elective splenectomy?
Emergency splenectomy is performed in the setting of trauma, while elective splenectomy is a planned procedure. Elective splenectomy is often performed laparoscopically and may involve extracting the spleen inside a specimen bag.
137
What are the common complications of splenectomy?
Common complications of splenectomy include hemorrhage (from short gastrics or splenic hilar vessels), pancreatic fistula (from iatrogenic damage to the pancreatic tail), thrombocytosis (requiring prophylactic aspirin), and encapsulated bacteria infection such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.
138
What is primary intracerebral hemorrhage (PICH)?
Primary intracerebral hemorrhage (PICH) is a type of stroke that accounts for approximately 10% of cases. It is characterized by symptoms such as headache, vomiting, and loss of consciousness.
138
What are the characteristics of total anterior circulation infarcts (TACI)?
Total anterior circulation infarcts (TACI) involve the middle and anterior cerebral arteries. They are associated with symptoms such as hemiparesis/hemisensory loss, homonymous hemianopia, and higher cognitive dysfunction, such as dysphasia.
139
What are the characteristics of partial anterior circulation infarcts (PACI)?
Partial anterior circulation infarcts (PACI) involve the smaller arteries of the anterior circulation, such as the upper or lower division of the middle cerebral artery. They are associated with higher cognitive dysfunction or at least two of the three TACI features.
140
What are lacunar infarcts (LACI)?
Lacunar infarcts (LACI) involve the perforating arteries around the internal capsule, thalamus, and basal ganglia. They present with symptoms such as isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia.
141
What are posterior circulation infarcts (POCI)?
Posterior circulation infarcts (POCI) involve the vertebrobasilar arteries. They present with features of brainstem damage, including ataxia, disorders of gaze and vision, and cranial nerve lesions.
142
What is lateral medullary syndrome (posterior inferior cerebellar artery)?
Lateral medullary syndrome, also known as Wallenberg's syndrome, is caused by an infarct in the posterior inferior cerebellar artery. It is characterized by ipsilateral symptoms such as ataxia, nystagmus, dysphagia, facial numbness, and cranial nerve palsy. Additionally, it may cause contralateral limb sensory loss.
143
What is Weber's syndrome?
Weber's syndrome is characterized by ipsilateral third (III) cranial nerve palsy and contralateral weakness.
144
What are the characteristics of anterior cerebral artery infarcts?
Anterior cerebral artery infarcts result in contralateral hemiparesis and sensory loss, with the lower extremity being more affected than the upper extremity. They may also cause a disconnection syndrome, middle cerebral artery infarcts result in contralateral hemiparesis and sensory loss, with the upper extremity being more affected than the lower extremity. They may also cause contralateral hemianopia, aphasia (Wernicke's), and gaze abnormalities.
145
What are the characteristics of lacunar infarcts?
Lacunar infarcts present with symptoms such as isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia.
146
What are the characteristics of posterior cerebral artery infarcts?
Posterior cerebral artery infarcts result in contralateral hemianopia with macular sparing. They may also cause a disconnection syndrome.
147
What are the characteristics of lateral medulla infarcts (posterior inferior cerebellar artery)?
Lateral medulla infarcts, caused by the posterior inferior cerebellar artery, result in ipsilateral symptoms such as ataxia, nystagmus, dysphagia, facial numbness, and cranial nerve palsy. They may also cause contralateral limb sensory loss.
148
Which populations are commonly affected by sickle cell anemia?
Sickle cell anemia is more commonly found in individuals of African, Middle Eastern, and Indian descent.
148
What are the characteristics of infarcts involving the seventh (VII) cranial nerve?
Infarcts involving the seventh (VII) cranial nerve result in contralateral hemiparesis.
148
What is Horner's syndrome?
149
What are the characteristics of pontine infarcts?
Pontine infarcts result in horizontal gaze palsy of the sixth (VI) cranial nerve and contralateral hemiparesis.
150
What are the causes of sickle cell anemia?
Sickle cell anemia causes short red cell survival, obstruction of microvessels, and infarction. It can be precipitated by dehydration, infection, and hypoxia.
150
What is sickle cell anemia?
Sickle cell anemia is an autosomal recessive genetic disorder caused by a single base mutation. It results in the deformation of red blood cells into a sickle shape when they are deoxygenated.
151
At what age does sickle cell anemia manifest?
Sickle cell anemia typically manifests at around 6 months of age.
152
How is sickle cell anemia diagnosed?
Sickle cell anemia is diagnosed through Hb electrophoresis.
153
What are some symptoms of sickle cell crises?
Sickle cell crises can cause symptoms such as bone pain, pleuritic chest pain (acute sickle chest syndrome, the commonest cause of death), CVA (cerebrovascular accident), seizures, papillary necrosis, splenic infarcts, priapism, and hepatic pain.
154
What is the management approach for sickle cell anemia?
The management of sickle cell anemia involves supportive care, the use of hydroxyurea, repeated transfusions preoperatively, and exchange transfusion in emergencies.
155
What are the long-term complications of sickle cell anemia?
Long-term complications of sickle cell anemia include infections such as Streptococcus pneumoniae, chronic leg ulcers, gallstones (due to hemolysis), aseptic necrosis of bone, chronic renal disease, and retinal detachment/proliferative retinopathy.
156
What are some surgical complications associated with sickle cell anemia?
Surgical complications associated with sickle cell anemia include bowel ischemia, cholecystitis, and avascular necrosis.
157
What is sickle cell trait?
Sickle cell trait refers to the heterozygous state for sickle cell anemia. It is usually asymptomatic, but symptoms may arise in extreme situations such as complications during anesthesia. Additionally, sickle cell trait provides some protection against Plasmodium falciparum, the parasite that causes malaria.
158
What is the indication for fluid resuscitation in burns?
Fluid resuscitation is indicated for burns that involve more than 15% of the total body area in adults or more than 10% in children.
159
What is the main aim of fluid resuscitation in burns?
The main aim of fluid resuscitation in burns is to prevent the burn from deepening.
160
When is most fluid lost after a burn injury?
Most fluid is lost within the first 24 hours after a burn injury.
161
What type of fluid should be avoided in the first 8-24 hours of fluid resuscitation?
Colloid fluids, especially, should be avoided in the first 8-24 hours of fluid resuscitation.
161
What happens to fluid shifts in the first 8-12 hours after a burn injury?
In the first 8-12 hours after a burn injury, fluid shifts occur from the intravascular to the interstitial fluid compartments, which can compromise circulatory volume.
162
What is a concern regarding the traditional Parkland formula for fluid resuscitation in burns?
There are concerns that the traditional Parkland formula resulted in the administration of excessive quantities of intravenous fluids in patients with burns.
163
What is the current consensus guideline for fluid resuscitation in second- and third-degree burns?
According to the current consensus guidelines, fluid resuscitation should begin at 2 ml of lactated Ringers per kilogram of the patient's body weight, multiplied by the percentage of total body surface area (TBSA) affected by the burn.
164
How is the remaining one-half of the total fluid volume administered after the first 8 hours?
The remaining one-half of the total fluid volume is administered during the subsequent 16 hours.
165
How is the calculated fluid volume for resuscitation initiated in the first 8 hours after a burn injury?
One-half of the total fluid volume is provided in the first 8 hours after the burn injury.
166
How is the efficacy of fluid replacement determined in burn patients?
The efficacy of fluid replacement in burn patients is determined by monitoring urine output.
167
What is the recommended urine output for adults and children in fluid resuscitation for burns?
For adults, the recommended urine output is around 0.5 ml per kilogram of body weight per hour. For children weighing less than 30 kg, the recommended urine output is 1 ml per kilogram of body weight per hour.
168
What is the fluid resuscitation approach for different types of burns in adults and children?
The fluid resuscitation approach varies based on the type of burn and the age or weight of the patient. The fluid rates and urine output targets differ accordingly.
169
What is the fluid resuscitation approach for electrical injuries in all age groups?
For electrical injuries in all age groups, fluid resuscitation involves administering 4 ml of Hartmann's solution per kilogram of body weight, multiplied by the percentage of total body surface area (TBSA) affected by the burn, until urine clears. The urine output target is 1-1.5 ml per kilogram of body weight per hour until urine clears.
170
What is the fluid resuscitation approach after 24 hours in burns?
After 24 hours, maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml multiplied by the burn area and the patient's body weight. Colloids are rarely used. Other parameters such as packed cell volume, plasma sodium, base excess, and lactate should be monitored.
171
Do high tension electrical injuries and inhalation injuries require more fluid?
Yes, high tension electrical injuries and inhalation injuries may require more fluid due to the greater soft tissue involvement and associated muscle death.
172
What additional measure can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns?
Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns.
173
What are the main causes of craniomaxillofacial injuries in the UK?
The main causes of craniomaxillofacial injuries in the UK are interpersonal violence (52%), motor vehicle accidents (16%), sporting injuries (19%), and falls (11%).
174
What are the features of a Le Fort 1 fracture?
A Le Fort 1 fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and goes through the pterygomaxillary junction to interrupt the pterygoid plates.
175
What are the features of a Le Fort 2 fracture?
Le Fort 2 fractures have a pyramidal shape and extend from the nasal bridge at or below the nasofrontal suture through the frontal process of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
176
What are the features of a Le Fort 3 fracture?
Le Fort 3 fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid.
177
What is the most common ocular injury resulting from severe force to the lateral wall of the orbit?
Superior orbital fissure syndrome is the most common ocular injury resulting from severe force to the lateral wall of the orbit. It leads to complete ophthalmoplegia and ptosis, relative afferent pupillary defect, dilatation of the pupil and loss of accommodation and corneal reflexes, and altered sensation from the forehead to the vertex.
178
What is an orbital blow out fracture?
An orbital blow out fracture typically occurs when an object slightly larger than the orbital rim strikes the incompressible eyeball. The bone fragment is displaced downwards into the antral cavity, remaining attached to the orbital periosteum. This can interfere with the inferior rectus and inferior oblique muscles, causing diplopia on upward gaze.
179
What should be done in the case of nasal fractures?
In the case of nasal fractures, it is important to ensure that the deformity is new and not old. Epistaxis should be controlled, and the presence of CSF rhinorrhea indicates a breach of the cribriform plate, requiring antibiotics. It is usually best to allow bruising and swelling to settle before clinically reviewing the patient. Major persistent deformities may require fracture manipulation within 10 days of the injury.
180
What is a retrobulbar hemorrhage?
A retrobulbar hemorrhage is a rare but important ocular emergency. It presents with pain within the globe, proptosis, loss of pupil reactions, paralysis of eye movements, and loss of visual acuity (with color vision being lost first). It may be a result of Le Fort type facial fractures.
181
What is the management of a retrobulbar hemorrhage?
The management of a retrobulbar hemorrhage includes administering Mannitol 1g/kg as a 20% infusion (osmotic diuretic), Acetazolamide 500mg IV (reduces aqueous pressure), and Dexamethasone 8mg orally or intravenously. In some cases, an urgent cantholysis may be needed prior to definitive surgery.
182
How long should amnesia (antegrade or retrograde) last to require an immediate CT scan of the head in children?
More than 5 minutes
183
How long should loss of consciousness last (witnessed) to require an immediate CT scan of the head in children?
More than 5 minutes
184
What level of drowsiness is considered abnormal and requires an immediate CT scan of the head in children?
Abnormal drowsiness
185
How many discrete episodes of vomiting are required to warrant an immediate CT scan of the head in children?
Three or more
186
What clinical suspicion indicates a need for an immediate CT scan of the head in children?
Suspicion of non-accidental injury
187
In the case of a post-traumatic seizure but no history of epilepsy, should a CT scan of the head be performed?
Yes
188
What is the minimum GCS score that requires an immediate CT scan of the head in children?
Less than 14
189
For children under 1 year old, what GCS score requires an immediate CT scan of the head?
GCS (paediatric) less than 15
190
What signs indicate a need for an immediate CT scan of the head in children?
Suspicion of open or depressed skull injury, tense fontanelle, any sign of basal skull fracture (haemotympanum, panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign), or focal neurological deficit
191
What is considered a dangerous mechanism of injury that requires an immediate CT scan of the head in children?
High-speed road traffic accident (as pedestrian, cyclist, or vehicle occupant), fall from a height greater than 3 m, high-speed injury from a projectile or object
192
What head injuries in children under 1 year old require an immediate CT scan of the head?
Presence of bruise, swelling, or laceration of more than 5 cm on the head
193
What is tension pneumothorax?
Tension pneumothorax is a condition where positive pressure builds up within a pneumothorax throughout the respiratory cycle due to a one-way valve breach in the pleura, allowing air to enter the intra-pleural space.
194
What is the risk factor for developing tension pneumothorax?
The risk of developing tension pneumothorax is highest in ventilated trauma patients due to the use of positive pressure.
195
What are the classic clinical features of tension pneumothorax?
The classic clinical features of tension pneumothorax include chest pain, dyspnea, hypoxia, hypotension, tracheal deviation, ipsilateral hyperpercussion note, and decreased air entry. In ventilated patients, cardiovascular disturbance and subcutaneous emphysema are more common.
195
What are the chest x-ray features of tension pneumothorax?
Chest x-ray features of tension pneumothorax include lung collapse towards the hilum, diaphragmatic depression, increased rib separation, increased thoracic volume, ipsilateral flattening of the heart border, and contralateral mediastinal deviation.
196
What percentage of trauma deaths are attributed to undiagnosed tension pneumothorax?
Undiagnosed tension pneumothorax accounts for 3.8% of trauma deaths.
197
What is the recommended management for tension pneumothorax?
Immediate needle decompression followed by definitive wide bore chest drain insertion is the recommended management for tension pneumothorax.
198
What are the potential life-threatening complications of untreated hyperkalemia?
Untreated hyperkalemia may cause life-threatening arrhythmias.
199
What should be addressed in the management of hyperkalemia?
In the management of hyperkalemia, precipitating factors such as acute renal failure should be addressed, and aggravating drugs like ACE inhibitors should be stopped.
200
What is the goal of treatment in managing hyperkalemia?
The goal of treatment in managing hyperkalemia is twofold: stabilization of the cardiac membrane and removal of potassium from the body.
201
What is the recommended intravenous medication for stabilizing the cardiac membrane in hyperkalemia?
Intravenous calcium gluconate is recommended for stabilizing the cardiac membrane in hyperkalemia.
202
What is the purpose of a combined insulin/dextrose infusion in hyperkalemia management?
A combined insulin/dextrose infusion is used to achieve a short-term shift of potassium from the extracellular to intracellular fluid compartment.
203
What medication can be administered via nebulization in the management of hyperkalemia?
Nebulized salbutamol can be used in the management of hyperkalemia.
204
What medication can be used for the removal of potassium from the body in hyperkalemia management?
For the removal of potassium from the body, calcium resonium can be administered orally or via enema.
205
What type of diuretics can be used in hyperkalemia management?
Loop diuretics can be used to help remove potassium from the body in hyperkalemia management.
206
What is another treatment option for hyperkalemia if the above measures are not effective?
Dialysis is another treatment option for hyperkalemia if the above measures are not effective.
207
What is the recommended approach for managing ventricular tachycardia in a peri-arrest situation?
In a peri-arrest situation, if the patient has adverse signs such as systolic BP < 90 mmHg, chest pain, heart failure, or a heart rate > 150 beats/min, immediate cardioversion is indicated assuming the tachycardia is ventricular in origin.
208
What should be done in the absence of adverse signs in ventricular tachycardia?
In the absence of adverse signs, antiarrhythmics may be used to manage ventricular tachycardia.
209
Which drugs are commonly used for drug therapy in ventricular tachycardia?
Commonly used drugs for drug therapy in ventricular tachycardia include amiodarone (ideally administered through a central line), lidocaine (use with caution in severe left ventricular impairment), and procainamide.
209
What is the next step if antiarrhythmics fail to manage ventricular tachycardia?
If antiarrhythmics fail, electrical cardioversion with synchronised DC shocks may be needed.
210
Is verapamil recommended for ventricular tachycardia?
No, verapamil should NOT be used in ventricular tachycardia.
211
What are the options if drug therapy fails in managing ventricular tachycardia?
If drug therapy fails, an electrophysiological study (EPS) may be performed. Additionally, implantable cardioverter-defibrillator (ICD) placement is particularly indicated in patients with significantly impaired left ventricular function.
212
What is the trimodal death distribution following trauma?
Following trauma, there is a trimodal death distribution. The first peak occurs immediately after the injury and is typically due to brain or high spinal injuries, cardiac or great vessel damage, with a low salvage rate. The second peak occurs in the early hours after the injury and is often due to phenomena such as splenic rupture, subdural hematomas, and hemopneumothoraces. The third peak occurs in the days following the injury and is usually due to sepsis or multi-organ failure.
212
What is the ABCDE approach in trauma management?
The ABCDE approach is an important aspect of trauma management. It stands for Airway, Breathing, Circulation, Disability, and Exposure.
213
How should tension pneumothoraces be managed in trauma?
Tension pneumothoraces should not be managed with vigorous ventilation attempts as they can deteriorate.
214
What is the preferred method of hemorrhage control in trauma?
In trauma, the preferred method of hemorrhage control is packing, rather than blind application of clamps. Tourniquets should not be used as a rule.
214
What precautions should be taken when inserting urinary catheters and nasogastric tubes in trauma patients?
When inserting urinary catheters and nasogastric tubes in trauma patients, caution should be taken in cases of basal skull fractures and urethral injuries.
215
How should patients with head and neck trauma be managed?
Patients with head and neck trauma should be assumed to have a cervical spine injury until proven otherwise.
216
What is the management approach for a simple pneumothorax in trauma?
In trauma, a simple pneumothorax should be managed by inserting a chest drain. Aspiration is risky as the pneumothorax may be from lung laceration and convert to a tension pneumothorax.
217
What are some examples of thoracic injuries in trauma?
Some examples of thoracic injuries in trauma include simple pneumothorax, mediastinal traversing wounds, tracheobronchial tree injury, haemothorax, blunt cardiac injury, diaphragmatic injury, aortic disruption, and pulmonary contusion.
218
What is the recommended approach for mediastinal traversing wounds in trauma?
Mediastinal traversing wounds, which result from situations like stabbings, require further evaluation. Exit and entry wounds in separate hemithoraces, along with the presence of a mediastinal hematoma, indicate the likelihood of a great vessel injury. CT angiogram and esophageal contrast swallow should be performed for further assessment.
219
What is the usual cause of diaphragmatic injury in trauma?
Diaphragmatic injury in trauma is usually left-sided. Direct surgical repair is performed for this type of injury.
219
What is the commonest cause of death after road traffic accidents or falls in trauma?
Traumatic aortic disruption is the commonest cause of death after road traffic accidents or falls in trauma. It is usually an incomplete laceration near the ligamentum arteriosum.
220
What is the recommended approach for managing pulmonary contusion in trauma?
In trauma, pulmonary contusion is common and can be lethal. Early intubation and ventilation are recommended for managing this condition.
220
Which organs are commonly injured in blunt trauma requiring laparotomy?
In blunt trauma requiring laparotomy, the spleen is most commonly injured (40%).
221
What structures are most commonly traversed by stab wounds in trauma?
Stab wounds in trauma most commonly traverse the liver (40%).
222
What is the recommended investigation for suspected urethral injury in trauma?
In trauma, urethrography is the recommended investigation for suspected urethral injury.
223
What are some of the investigations used in abdominal trauma?
In abdominal trauma, diagnostic peritoneal lavage, abdominal CT scan, and ultrasound (USS) are commonly used investigations.
223
What are the advantages and disadvantages of diagnostic peritoneal lavage in abdominal trauma?
The advantages of diagnostic peritoneal lavage in abdominal trauma include early diagnosis and sensitivity (98% accurate). The most specific for localizing injury (92 to 98% accurate). Non-invasive and repeatable early diagnosis (86 to 95% accurate). The disadvantages include invasiveness, potential to miss retroperitoneal and diaphragmatic injuries, location of the scanner away from facilities, time taken for reporting, need for contrast, and operator dependence.
224
When is Abdominal CT scan used?
To document organ injury if the patient is normotensive
225
What should be considered if amylase levels are normal following pancreatic trauma?
If amylase levels are normal following pancreatic trauma, other factors should be considered to assess the extent of the injury.
225
When is Diagnostic Peritoneal Lavage used?
To document bleeding if the patient is hypotensive
226
When is USS (Ultrasound) used?
To document fluid if the patient is hypotensive
226
What are the advantages of Diagnostic Peritoneal Lavage?
Early diagnosis, high sensitivity (98% accuracy)
227
What are the advantages of Abdominal CT scan?
Most specific for localizing injury, high accuracy (92 to 98%)
228
What are the advantages of USS (Ultrasound)?
Early diagnosis, non-invasive, repeatable, relatively high accuracy (86 to 95%)
229
What are the disadvantages of Diagnostic Peritoneal Lavage?
Invasive, may miss retroperitoneal and diaphragmatic injury
230
What are the disadvantages of USS (Ultrasound)?
Operator dependent, may miss retroperitoneal injury
230
What are the disadvantages of Abdominal CT scan?
Location of scanner away from facilities, time taken for reporting, need for contrast
231
What is the recommended management for simple pneumothorax?
Insert a chest drain
231
What should be done for patients with exit and entry wounds in separate hemithoraces and the presence of a mediastinal hematoma?
Undergo CT angiogram and esophageal contrast swallow
232
What are the indications for thoracotomy in the case of thoracic trauma?
Largely related to blood loss
233
What are the features suggesting tracheobronchial tree injury in blunt trauma?
Haemoptysis and surgical emphysema
234
What is the usual cause of haemothorax in thoracic trauma?
Laceration of lung vessel or internal mammary artery by rib fracture
235
What are the indications for thoracotomy in the case of haemothorax?
Loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours
236
What is the recommended action for cardiac contusions in thoracic trauma?
Perform echocardiography to exclude pericardial effusions and tamponade
237
What is the usual treatment for diaphragmatic injury in thoracic trauma?
Direct surgical repair
238
Which structures are most commonly traversed by stab wounds in abdominal trauma?
Liver (40%)
238
What are the common injuries in abdominal trauma requiring laparotomy from blunt trauma?
Spleen (40%)
238
What is the recommended action for pulmonary contusion in thoracic trauma?
Early intubation and ventilation
239
Which structures are most commonly injured in abdominal trauma from gunshot wounds?
Small bowel (50%)
239
What does blood at the urethral meatus suggest in abdominal trauma?
Urethral tear
240
What does a high-riding prostate on rectal examination suggest in abdominal trauma?
Urethral disruption
241
When should mechanical testing for pelvic stability be performed in abdominal trauma?
Only once, it should be performed once
242
What are the three possible causes of bony injury resulting in a fracture?
Trauma, stress-related, pathological
243
What factors should be considered in the diagnosis of a fracture?
Site and type of injury, associated injuries, distal neurovascular deficits
244
What imaging is usually required for fracture diagnosis?
Radiographs of proximal and distal joints
245
What should be assessed when evaluating x-rays of a fracture?
Changes in bone length, angulation of the distal bone, rotational effects, presence of foreign material
246
What is an oblique fracture?
Fracture that lies obliquely to the long axis of the bone
247
What is a comminuted fracture?
Fracture with more than two fragments
248
What is a segmental fracture?
Presence of more than one fracture along a bone
249
What is a transverse fracture?
Fracture that is perpendicular to the long axis of the bone
250
What is a spiral fracture?
Severe oblique fracture with rotation along the long axis of the bone
251
What is the Gustilo and Anderson classification system used to classify in open fractures based on?
Size of the wound and extent of soft tissue damage
252
What are the key points in the management of fractures?
Immobilize the fracture, monitor and document neurovascular status, manage infection, consider tetanus prophylaxis, use IV antibiotics for open injuries, debride open fractures within 6 hours of injury
253
What is Grade 1 in the Gustilo and Anderson classification system?
A low energy wound that is less than 1cm in size
254
What is Grade 3 in the Gustilo and Anderson classification system?
A high energy wound that is greater than 10cm in size and has extensive soft tissue damage
254
What is Grade 2 in the Gustilo and Anderson classification system?
A wound that is greater than 1cm in size and has moderate soft tissue damage
255
What does Grade 3B indicate in the Gustilo and Anderson classification system?
A subgroup of Grade 3 with inadequate soft tissue coverage
256
What does Grade 3A indicate in the Gustilo and Anderson classification system?
A subgroup of Grade 3 with adequate soft tissue coverage
257
What does Grade 3C indicate in the Gustilo and Anderson classification system?
A subgroup of Grade 3 with associated arterial injury
258
What is the mechanism of action of thrombolytic drugs?
Thrombolytic drugs activate plasminogen to form plasmin, which degrades fibrin and helps break up thrombi.
259
In which patients are thrombolytic drugs primarily used?
Patients who present with ST elevation myocardial infarction (STEMI).
260
What are some other indications for thrombolytic therapy?
Acute ischemic stroke and pulmonary embolism, with strict inclusion criteria.
261
Name three examples of thrombolytic drugs.
Alteplase, tenecteplase, streptokinase.
262
What are the contraindications to thrombolysis?
Active internal bleeding, recent hemorrhage/trauma/surgery, coagulation and bleeding disorders, intracranial neoplasm, stroke within the past 3 months, aortic dissection, recent head injury, pregnancy, severe hypertension.
263
What are the potential side effects of thrombolytic therapy?
Hemorrhage, hypotension (more common with streptokinase), and allergic reactions (with streptokinase).
263
What are opioids?
Substances that bind to opioid receptors, including both naturally occurring opiates (such as morphine) and synthetic opioids (such as buprenorphine and methadone).
264
What are some features of opioid misuse?
Rhinorrhea, needle track marks, pinpoint pupils, drowsiness.
265
What are some complications of intravenous opioid misuse?
Viral infections (HIV, hepatitis B & C) due to needle sharing, bacterial infections (infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis, groin abscess), pseudoaneurysm, venous thromboembolism, osteomyelitis.
266
What can an opioid overdose lead to?
Respiratory depression and death.
267
What is the recommended emergency management for opioid overdose?
Intravenous (IV) or intramuscular (IM) naloxone, which has a rapid onset and relatively short duration of action.
268
What are the predisposing factors for aortic dissection in pregnancy?
Hypertension, congenital heart disease, and Marfan's syndrome
269
What is the main type of aortic dissection seen in pregnancy?
Stanford type A dissections
270
What are the symptoms of aortic dissection in pregnancy?
Sudden tearing chest pain, transient syncope
271
What are the clinical signs of aortic dissection in pregnancy?
Cold and clammy skin, hypertension, and an aortic regurgitation murmur
272
What is the surgical management for aortic dissection in pregnancy before 28 weeks?
Aortic repair with the fetus kept in utero
272
What can the involvement of the right coronary artery in aortic dissection cause?
Inferior myocardial infarction
273
What is the surgical management for aortic dissection in pregnancy between 28 and 32 weeks?
Dependent on fetal condition
274
What is the surgical management for aortic dissection in pregnancy after 32 weeks?
Primary Cesarean section followed by aortic repair at the same operation
275
What is the most common cause of mitral stenosis in pregnancy?
Rheumatic heart disease
276
Is mitral stenosis becoming more or less common in British women?
Less common
277
What is the most common cardiac condition in pregnancy?
Mitral stenosis
277
What should be suspected in immigrant women with cardiac symptoms in pregnancy?
Mitral stenosis
278
What is the preferred surgical treatment for mitral stenosis in pregnancy?
Balloon valvuloplasty
279
What is the leading cause of mortality in pregnancy?
Pulmonary embolism
279
What diagnostic tests can be used for pulmonary embolism in pregnancy?
Half dose scintigraphy and CT chest
280
What is the recommended treatment for pulmonary embolism in pregnancy?
Low molecular weight heparin throughout pregnancy and postpartum
281
Is warfarin safe to use in pregnancy?
No, it is contraindicated (except in women with mechanical heart valves)
282
Why is warfarin continued in women with mechanical heart valves during pregnancy?
Due to the significant risk of thromboembolism
282
What is compartment syndrome?
A complication characterized by raised pressure within a closed anatomical space
283
What can cause compartment syndrome?
Fractures or ischaemia re-perfusion injury in vascular patients
284
What are the symptoms and signs of compartment syndrome?
Pain (especially on movement), parasthesiae, pallor, preserved arterial pulsation (initially), and possible muscle paralysis
285
Which fractures are commonly associated with compartment syndrome?
Supracondylar fractures and tibial shaft injuries
286
How is compartment syndrome diagnosed?
By measuring intracompartmental pressure; pressures >20mmHg are abnormal and >40mmHg is diagnostic
287
What is the treatment for compartment syndrome?
Prompt and extensive fasciotomies
288
What should be considered when performing fasciotomies in the lower limb?
Ensuring deep muscles are adequately decompressed with appropriate incisions
289
What is a potential complication following fasciotomy for compartment syndrome?
Myoglobinuria, which can lead to renal failure; aggressive IV fluids are necessary
290
What should be done if muscle groups are necrotic at fasciotomy?
Debridement and amputation may be necessary
291
How quickly can muscle groups die in compartment syndrome?
Within 4-6 hours
292
What is the recommended timeframe for assessing patients with head injuries in the emergency department?
Within 15 minutes of arrival
293
When should the airway be stabilized for head injury patients?
If the GCS is less than or equal to 8
294
When should full spine immobilization be considered for head injury patients?
If GCS is less than 15, there is neck pain/tenderness, paraesthesia in extremities, focal neurological deficit, or suspected c-spine injury
294
When is a CT c-spine preferred over x-ray for suspected c-spine injury?
If the patient is intubated, GCS is less than 13, there are normal x-ray findings but continued concerns, presence of any focal neurology, a CT head scan is being performed, or initial plain films are abnormal
295
When is a 3 view c-spine x-ray indicated for suspected c-spine injury?
When there are symptoms or signs of c-spine injury
296
When should an immediate CT head scan be performed for head injury patients?
If GCS is less than 13 on admission, GCS is less than 15 two hours after admission, there is suspected open or depressed skull fracture, suspected skull base fracture, focal neurology, vomiting more than one episode, post-traumatic seizure, coagulopathy, or receiving anticoagulant
296
When should a neurosurgeon be contacted for head injury patients?
If there is persistent GCS less than or equal to 8, unexplained confusion lasting more than 4 hours, reduced GCS after admission, progressive neurological signs, incomplete recovery post-seizure, penetrating injury, or cerebrospinal fluid leak
297
How frequently should GCS be observed for head injury patients?
Every 30 minutes until GCS reaches 15
298
What is the first step in the management of anaphylactic shock?
Remove the allergen
298
What is the initial drug of choice for anaphylactic shock?
Adrenaline 1:1000, administered intramuscularly (not intravenous)
299
How much adrenaline should be administered for anaphylactic shock?
0.5ml
300
What should be done if there is no response to the initial adrenaline dose in anaphylactic shock?
Repeat the adrenaline dose after 5 minutes
301
What is the second drug administered in the management of anaphylactic shock?
Chlorpheniramine, given intravenously
302
What is the third drug administered in the management of anaphylactic shock?
Hydrocortisone, given intravenously at a dose of 100-200mg
303
What is the recommended initial treatment for Addisonian crisis?
Hydrocortisone, administered intramuscularly or intravenously at a dose of 100mg
303
What are some causes of Addisonian crisis?
Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism), adrenal hemorrhage (e.g., Waterhouse-Friderichsen syndrome), and steroid withdrawal
304
What should be done to address hypovolemia in Addisonian crisis?
Infuse 1 liter of normal saline over 30-60 minutes, or with dextrose if the patient is hypoglycemic
305
How often should hydrocortisone be continued until the patient is stable in Addisonian crisis?
Every 6 hours
306
Is fludrocortisone required for the management of Addisonian crisis?
No, it is not required as high cortisol exerts weak mineralocorticoid action
307
When can oral replacement therapy begin in Addisonian crisis?
After 24 hours
308
How should the oral replacement therapy be tapered in Addisonian crisis?
It should be reduced to maintenance over 3-4 days
309
What should be considered when analyzing the ECG of a hypothermic patient?
An organized cardiac rhythm may be converted to fibrillation if CPR is attempted inappropriately
309
What is considered as hypothermia?
Core body temperature below 35°C
309
What are the stages of hypothermia based on features and core temperature?
Stage 1: Awake and shivering (Mild, 32-35°C)
Stage 2: Drowsy and not shivering (Moderate, 28-32°C)
Stage 3: Unconscious and not shivering (Severe, 20-28°C)
Stage 4: No vital signs (Profound, Less than 20°C)
Stage 2: Drowsy and not shivering (Moderate, 28-32°C)
Stage 3: Unconscious and not shivering (Severe, 20-28°C)
Stage 4: No vital signs (Profound, Less than 20°C)
310
At what core temperature is severe hypothermia present?
Below 28°C
310
What rewarming technique is appropriate for mild hypothermia?
External rewarming devices
311
What rewarming techniques may be required for severe hypothermia?
Active core rewarming techniques such as peritoneal lavage, hemodialysis, or cardiac bypass
312
Do severely hypothermic patients generally respond to standard therapies or DC cardioversion for cardiac arrhythmias?
No, they do not generally respond to those treatments
313
What medication may be considered for severely hypothermic patients with cardiac arrhythmias?
Bretylium toslyte (sadly no longer available in most centers)
314
What are the ECG changes typically seen in pulmonary embolism?
No changes, S1, Q3, T3, tall R waves in V1, P pulmonale in inferior leads, right axis deviation, right bundle branch block, atrial arrhythmias, T-wave inversion in V1, V2, V3, and right ventricular strain
315
What does S1, Q3, T3 indicate in the ECG of a patient with pulmonary embolism?
It is a characteristic pattern seen in pulmonary embolism and refers to a deep S wave in lead I, a Q wave and inverted T wave in lead III
316
Where are tall R waves typically seen in the ECG of a patient with pulmonary embolism?
In lead V1
317
What does P pulmonale indicate in the ECG of a patient with pulmonary embolism?
Peaked P waves in the inferior leads (II, III, aVF)
317
What does right axis deviation and right bundle branch block indicate in the ECG of a patient with pulmonary embolism?
They are signs of right ventricular strain
317
What medication should all patients with acute coronary syndrome receive?
Aspirin 300mg
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What type of arrhythmias may be seen in the ECG of a patient with pulmonary embolism?
Atrial arrhythmias
318
Where are T-wave inversions typically seen in the ECG of a patient with pulmonary embolism?
In leads V1, V2, and V3
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What does right ventricular strain indicate in the ECG of a patient with pulmonary embolism?
It is associated with adverse short-term outcomes and adds prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure
320
What is the recommended approach for managing patients with unstable angina and non-ST elevation myocardial infarction (NSTEMI)?
Manage patients based on early risk assessment using a scoring system like GRACE to calculate predicted 6-month mortality
321
What medications can be used to relieve chest pain in patients with acute coronary syndrome?
Nitrates or morphine, if required
321
What antithrombin treatment should be offered to patients with acute coronary syndrome?
Low molecular weight heparin, unless there is a high risk of bleeding or angiography is planned within 24 hours. Unfractionated heparin should be given if angiography is likely within 24 hours or if the patient's creatinine is > 265 umol/l
321
Is oxygen therapy recommended for all patients with acute coronary syndrome?
No, oxygen therapy should only be given to patients who are hypoxic
322
When should intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) be given to patients with acute coronary syndrome?
They should be given to patients with an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) who are scheduled to undergo angiography within 96 hours of hospital admission
323
When should clopidogrel 300mg be given to patients with acute coronary syndrome?
It should be given to patients with a predicted 6-month mortality of more than 1.5% or patients who may undergo percutaneous coronary intervention within 24 hours of admission. Clopidogrel should be continued for 12 months
324
When should coronary angiography be considered in patients with acute coronary syndrome?
It should be considered within 96 hours of first admission to hospital for patients with a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in clinically unstable patients
325
What are the causes of shoulder fractures in the elderly and young males?
Low-energy falls in elderly females and high-energy trauma in young males
325
What is the third most common fragility fracture in the elderly?
Fractures of the proximal humerus
325
What complications can be associated with shoulder fractures?
Nerve injury, commonly axillary nerve injury, and fracture-dislocation of the humeral head
325
Which muscles attach to the greater tuberosity of the proximal humerus?
Supraspinatus, infraspinatus, and teres minor muscles
326
What are the different parts of the proximal humerus?
Articular head, greater tuberosity, lesser tuberosity, metaphysis, and diaphysis
327
Which muscle attaches to the lesser tuberosity of the proximal humerus?
Subscapularis muscle
328
What is the vascular supply of the humeral head?
Anterior and posterior humeral circumflex arteries
329
What imaging modalities are used for shoulder fractures and dislocations?
Radiographs (AP, axillary lateral, and scapula Y view) and CT for better delineation of the fracture pattern and intra-articular involvement
330
What is the Neer Classification used for in shoulder fractures?
To describe the fracture pattern, number of fragments, and degree of displacement
330
What is the recommended treatment for minimally displaced proximal humeral fractures?
Conservative management with immobilization in a polysling and progressive mobilization
331
When is operative management indicated for proximal humeral fractures?
In cases of irreducible fracture dislocation, large displacement, younger patients, and intra-articular fractures (head splitting). However, recent studies have suggested no benefit to operative intervention in certain cases
332
When is intramedullary nail used for surgical management of shoulder fractures?
It is suitable for extra-articular configuration, particularly surgical neck fractures with or without greater tuberosity fractures.
332
What is hemiarthroplasty used for in shoulder fractures?
It is used for un-reconstructable fractures in older patients who have good glenoid quality.
332
What does ORIF stand for and what does it involve?
ORIF stands for Open Reduction Internal Fixation. It involves plate and screw fixation to reconstruct complex fractures.
333
When is total shoulder arthroplasty performed in shoulder fractures?
It is performed for un-reconstructable fractures where a high functioning shoulder is required, as hemiarthroplasty may cause glenoid erosion.
334
What is reverse shoulder arthroplasty?
It is a type of total shoulder arthroplasty that provides better functional outcomes compared to conventional total shoulder replacement.
334
What are scapula fractures usually associated with?
High-energy trauma
335
Which parts of the scapula are most commonly involved in fractures?
Scapula body or spine (50%), glenoid fossa, and glenoid neck
336
Why is it important to exclude associated life-threatening injury in scapula fractures?
Because scapula fractures are often associated with high-energy trauma
337
What imaging modalities are used for scapula fractures?
Plain radiographs (AP, axillary lateral, and/or scapula Y view) and CT scanning for better visualization of intra-articular involvement, displacement, and three-dimensional reconstruction
338
How are scapula fractures classified?
Based on the location of the fracture, such as coracoid, acromion, glenoid neck, glenoid fossa, and scapula body
339
What is a "floating shoulder" in the context of scapula fractures?
It refers to the combination of an ipsilateral glenoid neck fracture and clavicle fracture, where the limb is effectively dissociated from the axial skeleton
340
When is fixation required for scapula fractures?
In cases of a floating shoulder or intra-articular and displaced/angulated glenoid fractures
340
What is the recommended treatment for the majority of scapula fractures?
Conservative management, which involves sling immobilization for two weeks followed by early rehabilitation
341
What should be considered for scapula fractures requiring surgery?
Intra-articular involvement and displaced/angulated glenoid fractures
