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MRCS Critical care > Burns, wound healing and orthopaedics > Flashcards

Burns, wound healing and orthopaedics Flashcards

1
Q

Describe possible reasons for low gcs in burns patient

A

-Hypoxia
-Inhalation injury
-Head injury

Possible:
–> drug/alcohol overdose
–> hypoglycaemia

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2
Q

When would you expect inhalation injury from history?

A

-Burns occuring in enclosed space
-Smoke during incident
-Injury from blast
-Pt brought in unconcious/decreased GCS

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3
Q

What are the signs of smoke inhalation injury?

A

-Facial +/- neck burns
-Singed hairs (eyebrows, nose hairs)
-Soot in airway
-Hoarseness/stridor
-Carbonaceous sputum
-Hypoxia
-Low GCS

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4
Q

How would you initially manage burns pt?

A

-Manage according to ATLS guidelines
-A-E
-Analgesia, tetanus, investigations, fluid resuscitation

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5
Q

What investigations would you request in burns pt?

A

-FBC, U + E, coag, G + S
-ABG, COHb levels
-CT head
-CT trauma if evidence of trauma

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6
Q

What is half life of carbon monoxide?

A

-Room air: 250 mins
-100% O2: 40 mins

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7
Q

How would you clinically assess depth of a burn?

A

-Colour
-Cap refill
-Presence/abscence of blisters
-Sensation

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8
Q

How would you estimate the extent of the burn as mesaured by TBSA?

A

-Hand surface area = 1% (patient’s hand)
-Rule of 9’s
-Lund and browder chart

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9
Q

Describe rule of 9s

A

Head = 9%
Arm = 9%
chest = 9%
abdomen = 9%
Back: 18%
Leg = 18%
Genitals = 1%

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10
Q

What are the indications for fluid resuscitation in burns?

A

->10% deep partial/full thickness in children
->15% deep partial/full thickness in adults ?? 20% according to new atls guidelines

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11
Q

What fluid resuscitation is given? When is it indicated?

A

New ATLS guidelines:
-2ml x body weight Kg x % TBSA
-Half over 8 hrs, subsequent over 16
-Indicated if over 20% deep partial thickness or full thickness burn

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12
Q

What would you expect in a deep dermal burn?

A

-Dry, blotchy red cherry skin
-Absence of a capillary refill
-Loss of sensation

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13
Q

What emergency treatment is required for circumferential burns?

A

Escharotomy

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14
Q

What are the indications/criteria for referring to the burns unit?

A

-5% TBSA full thickness burn in adults
-5% TBSA in children (any depth)
-10% TBSA in adults (any depth)
-Burns + inhalation
-Burns + trauma
-Electrical and chemical burns
-Burns in certain anatomical areas e.g. face, hands, feet, perineum and genitals
-Circumferential full thickness burns

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15
Q

Healing by primary intention

A

-Wound edges are approximated by sutures, glue, staples or steristrips
-Healing occurs in an orderly manner
-Good cosmetic outcome

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16
Q

Healing by delayed primary intention

A

-Used in bites (human/animal) or contaminated wounds
-Following thorough debridement, the wound is left open for 24-48 hrs and then primary closure is performed

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17
Q

Healing by secondary intention

A

-The wound edges cannot be approximated (tissue loss)
-Wound heals by contraction
-Poorer cosmetic outcome compared to healing by primary intention
-Myofibroblasts are the predominant cell type in this type of healing

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18
Q

Healing by re-epithelialisation

A

-Only epiderms and superficial part of the dermis are injured
-Adnexal structures are intact and the wound heals by re-epithelialisation
-Seen in abrasions and split-skin donor sites

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19
Q

What are the stages of wound healing?

A
  1. Haemostasis
  2. Inflammation
  3. Proliferation
  4. Re-modelling
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20
Q

Haemostasis

A

-Vasoconstriction
-Platelet aggregation and activation
-Fibrin clot formation

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21
Q

Describe inflammation stage of wound healing

A

-Early phase (first 24 hrs) - neutrophils are the predominant cell type
-Late phase (>24 hrs) - lymphocytes and macrophages are seen

22
Q

Proliferation

A

-Extracellular matrix formation
-Collagen deposition
-Fibroblast proliferation
-Angiogenesis
-Epithelialisation

23
Q

Re-modelling

A

-Decresased fibroblast formation. Collagen is rearranged along tension lines
-Gradual increase in tensile strength of wound

24
Q

What is the fundamental difference between a ‘graft’ and a ‘flap’?

A

-A graft relies on recepient wound bed for vascularity and nutrition
-A flap brings its own blood supply

25
Q

How would you classify skin grafts?

A

-SSG
-Full thickness

26
Q

Describe split thickness graft

A

-Used for large surface area e.g. extensive burns
-Epidermis and part of dermis taken, donor site left to heal by re-epithelialisation
-Common donor sites: lateral aspects of thigh, buttocks, back

27
Q

Describe full thikness grafts

A

-Used in areas e.g. digits of hand or over joints to minimise contractures
-FT skin grafts have better colour match and are therefore preferred in exposed areas e.g. face
-Common donor sites for FT graft: pre and post-auricular region, supraclavicular region, medial surface of forearm/arm

28
Q

How would you classify ‘flaps’?

A

-Random patterns (does not have named blood vessel)
-Pedicled (has named blood vessel)
-Free (blood supply is disconnected from one part of body and connected to a vessel at recipient site)

29
Q

What types of flaps are used in which locations?

A

-Face: mostly random pattern flaps
-Breast recon: pedicled flaps (LD) and free flaps (DIEP) is used
-Pedicled and free flaps also used in variety of recons following trauma (e.g. gracillis musculocutaneous free flap to cover defect over dorsum of foot)

30
Q

Name some types of dysfunctional wound healing

A

Non-Healing wounds
Healing with hypertrophic scar
Healing with formation of keloid

31
Q

What are the differences between hypertophic and keloid scar?

A

Borders
–> confined to original wound
–> outgrows wound area

Incidence
–> usually develops in weeks following surgery/injury
–> can develop months or years from original injury

Site
–> usually in flexor surfaces
–> predilection for sternum, shoulder and ear lobes

Aetiology
–> Usually related to wound factors (e.g. infection/haematoma/dehiscence) and those crossing tension lines
–> unknown

Racial predisposition
–> Not race related
–> non whites >whites

32
Q

How would you manage hypertrophic scars?

A

-Subside with time and respond to conservative measures e.g. pressure treatment/silicone gel/plasters

33
Q

How would you manage keloid scars?

A

-No effective treatment
-Conservative: steroid injections, pressure treatment, silicone gel
-Surgery rarely advocated, only if severe/for cosmetic purposes

-Rarely subside, do not have established treatment option
-No treatment is proven to be effective, recurrence is common following excision
-Commonly used symptom control measures include pressure treatment, intra-lesional steroid + silicone gel/plasters
-Surgery rarely advocated and is performed if symptoms severe/for cosmetic purposes
-Surgery includes debulking keloid by ensuring incision is kept within margin of keloid and does not overrun into normal skin

34
Q

What is the aetiology of septic arthritis?

A

-Micro-organisms invade joint by direct penetration into joint, spread from adjacent soft tissue infection or via blood stream

35
Q

What micro-organisms are known to cause septic arthritis?

A

Bacterial
-Staph
-Haemophilus
-E.coli

Viruses
-Heptatitis A, B, C
-Herpes viruses

Fungi
-Histoplasma

36
Q

What are risk factors for developing septic arthritis?

A

-previous joint disease/injury/surgery
-IV drug abse
-Immune deficiency/immunosuppression

Underlying medical illness:
-Diabetes
-Alcoholism
-Rheumatic diseases

37
Q

Which investigations would you perform in septic arthritis?

A

-Bloods: FBC, CRP, Urate
-X-ray
-joint aspiration for M, C and S

38
Q

How would you manage a pt with septic arthritis?

A

-Bloods including urate, CRP, FBC
-Analgesia, immobilisation
-Aspirate joint
-IV abx
-Washout of joint
-Surgery to remove prosthesis (if present)

-IV abx
-Analgesia
-Immobilisation
-Washout/aspiration of joint
-Surgery to remove prosthesis (if present)

39
Q

What are the complications of septic arthritis?

A

-Soft tissue injury
-Degenerative joint disease
-Osteomyelitis
-Sepsis

40
Q

Can you differentiate between septic arthritis and other inflammatory joint diseases e.g. gout or reactive arthritis?

A

-Septic arthritis is mono-articular, inflammatory arthropathies can be mono or poly-articular

41
Q

What is the difference between gout and pseudogout

A

Joints
–> affects smaller joints
–> affects larger joints

Investigations
–> Associated with high serum urate levels
–> not associated with high serum urate levels

Crystals
–> monosodium urate crystals, needle shaped crystals, negatively birefringent on polarised light microscopy with rhomboid shaped crystals
–> Positively birefringent on polarised light microscopy

42
Q

How would you treat gout?

A

During acute flare up: Colchicine, NSAIDs or corticosteroids (intra-articular or systemic)

To induce remission: allopurinol, dietary advise (reduce alcohol intake, reduce red meat consumption, good hydration)

43
Q

Define compartment syndrome

A

-Increase in interstitial fluid pressure within osseo-fascial compartment with sufficient magnitude to cause compromise of microcirculation leading to myoneural necrosis

44
Q

What are the signs and symptoms of compartment syndrome?

A

-Pain on passive stretch of affected compartment
-Paraesthesia
-Paralysis
-Pallor
-Pulslessness
-Perishingly cold leg

45
Q

What is the normal compartment pressure in the lower leg?

A

Normal resting pressure 0-6mmhg

46
Q

What happens to this pressure in compartment syndrome?

A

-Pressure is >30mmhg or difference in diastolic pressure and compartment pressure is <30mmhg

47
Q

Name the compartments in the lower leg

A

-Anterior
-Lateral
-Superficial posterior
-Deep posterior

48
Q

Name structures present in deep posterior compartment of lower leg

A

-Tibialis posterior
-Flexor hallucis longus
-Flexor digitorum longus
-Popliteus

Nerve
-Tibial nerve

Artery
-Posterior tibial artery
-Peroneal artery

49
Q

How would you treat compartment syndrome in this pt?

A

-Immediate fasciotomies
-Address underlying cause

50
Q

Describe incisions for fasciotomies

A

Two longitudinal incisions on medial and lateral sides of leg
–> medial longitudinal incision 1-2cm posterior to medial border of tibial to release superficial and deep posterior compartments

–> Lateral longitudinal incision 2cm lateral to anterior border of tibia releases anterior and lateral compartments

MRCS Critical care (11 decks)

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