Acute/Critical Care Surgery Flashcards
What do you see with cardiac tamponade?
Presents with Beck’s triad: JVD, muffled heart sounds, hypotension; tx subxiphoid paricardiocentesis and go to OR
What do you consider when you see blunt trauma to the neck?
Consider possibility of laryngeal edema developing into airway obstruction
What do you see with hypovolemic shock?
Class I 40% with lethargy and anuria
How do you measure resuscitation for hypovolemic shock?
2 large-bore IV lines and 2 L crystalloid infusion is the standard therapy
resuscitation measured by urine output, HR, BP, and mental status
What do you do if hypovolemic shock treatment is unresponsive?
Search for the underlying cause, ex lap or thoracotomy may be indicated for continuous internal bleeding
What do you see in a closed head injury?
Brain edema and ischemia causing Cushing reflex– peripheral vasoconstriction (increasing BP), bradycardia (decrease in HR), and respiratory depression
What does priapism indicate?
Indicates fresh spinal cord injury; check for anal sphincter tone, bradycardia, and possibly neurogenic shock
What do you see with an epidural hematoma?
Heat CT shows CONVEX lens hematoma; presents as LOC –> lucid interval –> LOC –> ipsilateral fixed/dilated pupil, tx craniotomy
What do you see with a subdural hematoma?
Head CT shows CRESCENT MOON hematoma, high risk for brain herniation; tx head elevation, hyperventilate, sedate, mannitol + furosemide
What do you see with diffuse axonal injury?
Head CT shows blurred gray-white junction and small punctate hemorrhages; management is prevention of increase in ICP
What are the signs of a basal skull fracture?
raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear
What are the zones in trauma?
Zone 1: below cricoid (includes lung)
Zone 2: between mandible and cricoid
Zone 3: above mandible
Surgery indicated if stab wound in zone 2
What are you at risk for if there is blunt trauma to the neck?
At risk of carotid dissection (tx anticoagulation) or laryngeal edema (tx intubation)
What is hemisection syndrome?
Always due to stab wounds in posterior neck area, presents as ipsi DCML/motor loss and contra ACL loss
What is anterior cord syndrome?
Usually seen with vertebral burst fractures, presents as bilateral ALS/motor loss but intact DCML
What is central cord syndrome?
Usually seen with whiplash, presents as UE burning pain and paralysis, but LE nerves intact
What is your suspicion if you have a stab and hemiparesis?
Suggests injury to the carotid artery
What is at risk following a rib fracture?
Painful breathing leads to shallow breaths –> atelectasis –> pneumonia, tx local nerve block
What do you suspect with a chest stab wound?
Suspect HTX or PTX, chest tube insertion is indicated
Infraclavicular stab wound: suspect injury to the subclavicular artery or vein, dx angiogram if pt is stable or urgent exploration if unstable
Nipple-level stab wound: suspect additional injury to diaphragm/abdominal organs, ex lap indicated for abdominal organ damage
What do you suspect if you see continuous air leak into a chest tube?
Major airway injury with disruption of bronchus or trachea
What do you see clinically if there is a tension PTX?
Mediastinal shift, hypotension, JVD, absent breath sounds, and hyperresonant to percussion; tx emergent needle aspiration and chest tube insertion
What do you suspect with thoracic blunt trauma?
Suspect HPTX, chest tube insertion is indicated; emergent thoracotomy if >1.5 L or >200 mL/hr blood is extracted from tube
What do you see on CXR with an aortic transection?
Presents as widened mediastinum, confirm with aortic angiography or chest CT
What is a flail chest?
Presents with paradoxic chest wall movements due to multiple rib fractures, suspect lung contusions and aortic transection; manage by inserting bilateral chest tubes and serial ABGs
How do pulmonary contusions present?
Present as deteriorating ABGs and “white out” of lungs on CXR; tx colloid + diuretics + fluid restriction
How does a ruptured trachea/bronchi present?
Presents as continuous air leak into chest tube and subcutaneous emphysema
How does an air embolus present?
Presents as sudden death in an intubated/respiratory patient; management is immediate Trendelenburg position + cardiac massage
How does a fat embolus present?
Presents as RDS and petechiae in neck/axilla due to bone marrow embolization from long bone fx; management is respiratory support
What do you do for abdominal trauma?
GSW: mandatory OR for ex lap below nipple level
stab wound: mandatory OR if stab wound penetrates peritoneum (e.g. protruding viscera, peritonitis, hemodynamic instability)
blunt trauma: mandatory OR if signs of peritonitis or hemodynamic instability despite transfusion
What do you do if there is a trauma who is hypotensive?
indicated for FAST –> ex lap in OR if positive; CT scan inappropriate for unstable pts
What do you suspect in a trauma patient who is hypotensive with a pelvic fracture?
Suspect vascular injury from branch of internal iliac, dx FAST
How do you manage a splenic laceration?
Ex lap if unstable, preserve spleen if possible to avoid post-splenectomy sepsis, avoid blood transfusion if possible, splenectomy requires vaccination for SHiN bacteria
What do you suspect with a hematoma in the SMA region?
Suggests major injury to abd aorta, major aortic branches, pancreas, or duodenum; stable –> angiography and assessment before operation unless unstable –> urgent ex lap
How do you manage a pancreatic transection?
Mandatory ex lap; minor injury –> debride and drain, major injury –> resection of devitalized pancreatic tissue and repair of duodenal injury
What are you concerned about with a duodenal hematoma?
Common in kids hitting abd on bicycle handlebars, hematoma causes GI obstruction
Tx: NPO/IVF, will resolve spontaneously in 5-7d
How do you treat a liver laceration or a renal laceration?
Liver laceration: ex lap if unstable, observe if stable
Renal laceration: stable –> angiography and planned operative repair
unstable –> IV pyelo to detect if two kidneys present, then OR for nephrectomy
What is the triad of death?
Acidosis, coagulopathy, and hypothermia
What can hemorrhage and hypothermia lead to?
Coagulopathy due to platelet dysfunction and PT/PTT prolongation; rewarming indicated
What do you suspect if there is hemorrhage and metabolic acidosis?
Results from decreased tissue perfusion causing lactic acidosis; crystalloid infusion indicated
What do you suspect if there is hemorrhage and abdominal distention?
Bleeding into abd cavity can lead to abd compartment syndrome, which can cause decreased renal blood flow and dyspnea (elevated diaphragm)
What do you suspect if there is decreased cardiac output and decreased CVP?
Hypovolemic shock, neurogenic shock (e.g. spinal cord trauma, anaphylaxis)
What do you suspect if there is decreased cardiac output and increased CVP?
Cardiogenic shock
What are the retroperitoneal zones?
Central is zone 1, flank is zone 2, pelvis is zone 3
Surgery is indicated in all zone 1 hematomas, zone 2 and zone 3 hematomas only if penetrating trauma
What are urologic surgery indications?
All GSW, stab wounds, and other penetrating injuries
What do you see with urethral injury?
Presents as blood on meatus, scrotal hematoma, and “high-riding” prostate; get a retrograde urethrogram and suprapubic catheter instead of Foley
How do you manage a bladder injury?
Associated with seatbelt trauma in adults; get a retrograde cystogram and post-void films, then surgical repair
What is the order of repair in combined limb trauma?
Order of repair is bone first, then vascular repair, nerve last; fasciotomy is required to prevent compartment syndrome
What is the risk of crushing limb trauma?
High risk of myoglobinuria, leading to acute renal failure
Tx IV fluids + mannitol + acetazolamide to maintain a high urine output
What are the types of burns?
First degree: epidermis only, painful
Second degree: extends into dermis, causes pain and blistering, may develop into third-degree burns without proper management
Third degree: full thickness, painless
How do you manage burns?
Tetanus PPx, IV pain meds, topical agents (silver sulfadiazine is default, mafenide actate for deep penetration, triple abx ointment for the eyes)
What is the rule of 9’s?
estimates % BSA burned; head and upper extremities are 9% each; anterior trunk, posterior trunk, and lower extremities are 18% each; and perineum is the last 1%
How do you manage chemical burns?
Alkaline burns are worse than acids
Massive tap water irrigation, don’t try acid-base neutralization except in ingestion
How do you manage electrical burns?
May appear benign on surface, but masks large amounts of interior damage to muscles, nerves, and vessels; at risk of cardiac injury (arrhythmias) and muscle injury (myoglobinuria)
Manage with IV fluids + mannitol + acetazolamide to maintain a high urine output
When do you suspect inhalation burns?
Suspected with carbonaceous sputum, facial burns, signed facial/nasal hairs, hoarseness, etc. due to smoke inhalation
Confirm with fiberoptic bronchoscopy and order serial ABGs
High COHb levels –> tx with 100% O2
What are you concerned about with circumferential burns?
Rapidly become thick and contracted, causing restricted ventilation in the chest and ischemia in extremities
tx escharotomy
What are the sx of burns with methemoglobinemia?
chocolate-brown blood, central cyanosis of trunk, arrhythmias, seizures, coma; Dx ABGs, tx IV methylene blue
How do you manage bites?
All require tetanus PPx
dog: rabies PPx only required if bite was unprovoked and dog isn’t available for brain bx
snake: don’t always result in envenomation; if signs of venom evident, then draw blood for labs and tx anti-venin
human: requires extensive irrigation and debridement due to high amounts of bacteria
When is TPN indicated?
Indicated for nutrition when gut is non-functional or not available, requires personalization of formula for nutrition status
