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Surgery Clerkship - Pestana > Chapter 1 - Trauma > Flashcards

Chapter 1 - Trauma Flashcards

1
Q

How do you know if an airway is present?

A

Patient is conscious and speaking in a normal tone of voice

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2
Q

In a patient who is conscious and speaking in a normal tone of voice, the airway can soon be lost in what two situations?

A

Expanding hematoma or emphysema in the neck

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3
Q

What are 4 indications for an airway?

A

Unconscious (GCS of 8 or under)
Breathing is noisy or gurgly
Severe inhalation injury (breathing smoke)
If respirator is needed

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4
Q

If an indication for securing an airway exists in a patient with potential cervical spine injury, what should be done first?

A

Airway (before dealing with the cervical spine injury)

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5
Q

An airway is most commonly inserted by ___, under direct vision with use of a ___, assisted in the awake patient by rapid induction with monitoring of pulse oximetry, or less commonly with the help of topical anesthesia.

A

Orotracheal intubation; laryngoscope

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6
Q

When is the use of a fiberoptic bronchoscope mandatory?

A

When securing an airway if there is subcutaneous emphysema in the neck, which is a sign of major traumatic disruption

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7
Q

If for any reason (laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged, etc.) intubation cannot be done in the usual manner and we are running out of time, what becomes necessary?

A

Cricothyroidotomy (quickest and safest way to temporarily gain access before the patient sustains anoxic injury)

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8
Q

How is breathing assessed (ABCs)?

A

Hearing breath sounds on both sides of the chest and having satisfactory pulse oximetry

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9
Q

Clinical signs of shock?

A

Low BP (<90 systolic)
Fast feeble pulse
Low urinary output (<0.5 mL/kg/hr) in a patient who is pale, cold, shivering, sweating, thirsty, and apprehensive

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10
Q

In the trauma setting, shock is caused by either ___, ___, or ___.

A

Bleeding (hypovolemic-hemorrhagic most commonly)
Pericardial tamponade
Tension pneumothorax

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11
Q

How can you distinguish between the 3 common causes of shock in the trauma setting (bleeding vs. pericardial tamponade vs. tension pneumothorax)?

A

In shock caused by bleeding, the central venous pressure (CVP) is low (empty veins clinically).

In both tamponade and tension PT, CVP is high (big distended head and neck veins clinically).

In tamponade, there is no respiratory distress.

In tension PT, there is severe respiratory distress, one side of the chest has no breath sounds and is hyperresonant to percussion, and the mediastinum is displaced to the opposite side (tracheal deviation).

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12
Q

The treatment of hemorrhagic shock in the urban setting (big trauma center nearby), with penetrating injuries that will require surgery anyway, starts with the surgical intervention to stop the bleeding, and volume replacement takes place afterward. What is done in all other settings?

A

Volume replacement is the first step, starting with ~2L of Ringer lactate (without sugar), followed by packed red cells, FFP, and platelet packs, in a 1-1-1 ratio, until urinary output reaches 0.5-2 mL/kg/h, while not exceeding CVP of 15 mm Hg.

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13
Q

Uncontrolled massive bleeding is lethal, and os is untreated hemorrhagic shock. In the usual civilian setting, where one single patient arrives with a visible source of bleeding to an ER staffed by tons of people, that bleeding is best controlled with what?

A

Local pressure; gloved finger pushes and occludes the lacerated vessel until it can be repaired

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14
Q

In the trauma setting, what is the preferred route of fluid resuscitation? If these cannot be used? In children under 6?

A

2 peripheral IV lines (16-gauge); Percutaneous femoral vein catheter or saphenous vein cut-downs (alternatives); intraosseous cannulation of the proximal tibia (alternative)

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15
Q

Management of pericardial tamponade is based on clinical diagnosis (if unclear, choose ___ to diagnose) and centered on prompt evacuation of the pericardial sac. Fluid and blood administration while evacuation is being set up is helpful.

A

U/S

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16
Q

Management of tension PT is also based on clinical diagnosis. Start with ___ into the affected pleural space.. Follow with ___ connected to underwater seal (both inserted high in the anterior chest wall).

A

Big needle or big IV catheter; chest tube

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17
Q

Shock can be hypovolemic, from bleeding or other massive fluid losses (burns, pancreatitis, severe diarrhea). The classical clinical signs of shock will include a low ___. Treat the cause and replace the volume.

A

CVP

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18
Q

Intrinsic cardiogenic shock can happen with massive infarction or fulminating myocarditis. In this case, the clinical signs will come with ___, a key identifying feature. Treat with circulatory support.

A

High CVP

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19
Q

Vasomotor shock is seen in anaphylactic reactions and high spinal cord resection or high spinal anesthetic. Circulatory collapse occurs in patients who appear ___. CVP is ___. What is the main therapy?

A

Flushed “pink and warm”; low

Vasopressors to restore peripheral resistance; additional fluids will help

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20
Q

What are the three components of septic shock?

A

Early: low peripheral resistance and high cardiac output
Later: cardiogenic and hypovolemic features

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21
Q

Initial treatment of septic shock? Why?

A

ABX + steroid bolus; patients who respond beautifully at first then suffer a relapse may have adrenal insufficiency

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22
Q

Management of penetrating head trauma?

A

Surgical intervention and repair of the damage

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23
Q

Management of linear skull fractures?

A

Left alone if they are closed (no overlying wound)

Wound closure if open

Treat in the OR if comminuted or depressed

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24
Q

Management of anyone with head trauma who has become unconscious?

A

CT to look for intracranial hematomas

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25
Q

In anyone with head trauma who has become unconscious has a negative CT scan, can they go home?

A

They can go home if the family will wake them up frequently during the next 24 hours to make sure they are not going into coma

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26
Q

Signs of a fracture affecting the base of the skull?

A

Raccoon eyes, rhinorrea, otorrhea or ecchymosis behind the ear

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27
Q

Management of suspected fracture at the base of the skull?

A

Expectant management is the rule. The significance of a base of the skull fracture is that it indicates that the patient sustained very severe head trauma, and thus requires that we assess the integrity of the cervical spine with CT scan. Avoid nasal endotracheal intubation in these patients.

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28
Q

Neurologic damage from trauma can be caused by what three components? What is the management for each?

A

Initial blow -> no treatment
Subsequent development of a hematoma that displaces midline structures -> surgery
Later development of increased ICP -> medical measures to prevent or minimize

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29
Q

Classic presentation of acute epidural hematoma?

A

Modest trauma to the side of the head

Classic sequence of trauma, unconsciousness, lucid interval (completely asymptomatic patient who returns to previous activity), gradual lapsing into coma again, fixed dilated pupil (90% of the time on the side of the hematoma), and contralateral hemiparesis with decerebrate posture

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30
Q

CT scan findings of acute epidural hematoma?

A

Biconvex, lens-shaped hematoma

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31
Q

Management of acute epidural hematoma?

A

Emergency craniotomy -> dramatic cure

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32
Q

Classic presentation of acute subdural hematoma?

A 
Major trauma (relative to epidural)
Sicker (not fully awake and asymptomatic at any point)
Severe neurologic damage
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33
Q

CT scan findings of acute subdural hematoma?

A

Semilunar, crescent-shaped hematoma

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34
Q

Management of acute subdural hematoma?

A

If midline structures are deviated, craniotomy will help, but prognosis is bad. If there is no deviation, therapy is centered on preventing further damage from subsequent increased ICP -> monitor ICP, elevate head, hyperventilate (signs of herniation, goal PCO2 of 35), avoid fluid overload, give mannitol or furosemide.

Do not diurese to the point of lowering systemic arterial pressure (brain perfusion = arterial pressure - ICP).

Sedation and hypothermia have been used to decrease brain activity and oxygen demand.

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35
Q

Diffuse axonal injury occurs in more severe trauma. How does it appear on CT scan?

A

Diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages

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36
Q

Management of diffuse axonal injury?

A

Without hematoma, there is no role for surgery.

Therapy aims to prevent further damage from increased ICP

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37
Q

2 patient population often affected by chronic subdural hematoma?

A

Very old patients
Severe alcohol use disorder

(A shrunken brain is rattled around the head by minor trauma, tearing venous sinuses).

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38
Q

Presentation of chronic subdural hematoma?

A

Over several days or weeks, mental function deteriorates as hematoma forms.

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39
Q

Diagnosis and treatment of chronic subdural hematoma?

A

CT scan; surgical evacuation -> dramatic cure

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40
Q

True or false - hypovolemic shock cannot happen from intracranial bleeding.

A

True - there isn’t enough space inside the head for the amount of blood loss needed to produce shock. Look for another source.

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41
Q

Management of penetrating trauma to the neck?

A

Surgical exploration in all cases where there is an expanding hematoma, deteriorating vital signs, or clear signs of esophageal or tracheal injury (coughing or spitting up blood)

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42
Q

For gunshot wounds in the upper zone of the neck, what is the preferred management?

A

Arteriographic diagnosis and management

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43
Q

For gunshot wounds to the base of the neck, what is the preferred management?

A

Arteriography
Esophagogram (water-soluble, followed by barium if negative)
Esophagoscopy
Bronchoscopy

All before surgery to help decide the specific approach

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44
Q

Management of stab wounds to the upper and middle zones of the neck in asymptomatic patients?

A

Safe to observe

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45
Q

In all patients with severe blunt trauma to the neck, the integrity of the ___ has to be ascertained.

A

Cervical spine

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46
Q

If there are neurologic deficits in a patient with severe blunt trauma to the neck, the need to radiologically examine the neck with CT of the cervical spine is obvious, but it also has to be done in neurologically intact patients with what finding on exam?

A

Pain to local palpation over the cervical spine

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47
Q

Findings in a complete transection of the spinal cord?

A

No motor or sensory function below the lesion

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48
Q

Hemisection (Brown-Sequard) is typically from what kind of injury? How does it present?

A

Clean-cut injury (knife blade)

Paralysis and loss of proprioception distal to the injury on the injury side and loss of pain perception distal to the injury on the opposite side

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49
Q

Anterior cord syndrome is typically caused by what? How does it present?

A

Burst fractures of the vertebral bodies; loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional sense

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50
Q

Typical cause and presentation of central cord syndrome?

A

Elderly with forced hyperextension of the neck (rear-end collision)

Paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities

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51
Q

Management of cord injury?

A

Precise diagnosis with MRI; corticosteroids immediately after injury is no longer recommended

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52
Q

Rib fracture can be deadly in the elderly - why?

A

Progression of pain -> hypoventilation -> atelectasis -> pneumonia

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53
Q

Manage rib fracture?

A

Local nerve block and epidural catheter

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54
Q

Plain pneumothorax results from what type of trauma? Presentation?

A

Penetrating trauma; moderate SOB, absent breath sounds and hyperresonance unilaterally

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55
Q

Presentation of hemothorax compared to plain pneumothorax?

A

Affected side will be dull to percussion

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56
Q

Management of hemothorax?

A

Dx with CXR
Evacuate blood with chest tube (placed low) to prevent empyema development
Surgery to stop the bleeding is seldom required (usually lung, will stop by itself)

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57
Q

If we get 1,500+ mL of blood when a chest tube is inserted (or more than 600 mL in the ensuing 6 hours), what does this indicate and what is the management?

A

Systemic vessel is lacerated (typically an intercostal artery); video-assisted thoracotomy to control the bleeding

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58
Q

In severe blunt trauma to the chest, there may be obvious injuries, plus hidden injuries - how should these be monitored/sought out?

A

Blood gases and CXR to detect developing pulmonary contusion
Cardiac enzymes and EKG to detect myocardial contusion
Assess for traumatic transection of the aorta

59
Q

Untreated, a sucking chest wound will lead to a deadly ___. First aid?

A

Tension PT; occlusive dressing that allows air out (taped on three sides) but not in

60
Q

___ occurs with multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing).

A

Flail chest

61
Q

In the setting of flail chest, what is the real problem and how is it managed?

A

The underlying pulmonary contusion

Contused lung is very sensitive to fluid overload, so treat with fluid restriction and diuretics
Monitor blood gases, as pulmonary dysfunction may develop
If a respirator is needed, bilateral chest tubes are advisable to prevent tension PT
Search for transected aorta

62
Q

Myocardial contusion should be suspected in what type of injury?

A

Sternal fractures

63
Q

Treatment of myocardial contusion?

A

Focus on complications of the contusion, such as arrhythmias

64
Q

How does traumatic rupture of the diaphragm appear on imaging?

A

Bowel in the chest, always on the left side

65
Q

Evaluation and management of traumatic rupture of the diaphragm?

A

All suspicious cases should be evaluated with laparoscopy

Surgical repair is typically done from the abdomen

66
Q

What causes traumatic rupture of the aorta?

A

Happens at the junction of the arch and the descending aorta, requires big deceleration injury, totally asymptomatic until the hematoma contained by the adventitia blow sup

67
Q

What should trigger suspicion for traumatic rupture of the aorta?

A

Mechanism of injury (severe deceleration injury)
Fractures in chest bones that are very hard to break (first rib, scapular, sternum)
Presence of a wide mediastinum

68
Q

Non-invasive diagnostic tests for possible rupture of the aorta?

A

TEE
Spiral CT scan, aka CT angio (most practical in the trauma setting)
MRI angiography

69
Q

Treatment of traumatic rupture of the aorta?

A

Repair immediately, whenever possible, with endovascular prosthesis rather than open thoracotomy

70
Q

Traumatic rupture of the trachea or major bronchus is suggested by what findings?

A

Subcutaneous emphysema in the upper chest and lower neck

Large “air leak” from a chest tube

71
Q

Diagnosis and treatment of traumatic rupture of the trachea or major bronchus?

A

CXR confirms air in the tissues
Fiberoptic bronchoscopy identifies the lesion and allows intubation to secure an airway beyond the lesion
Surgical repair follows

72
Q

DDx - subcutaneous emphysema

A

Rupture of the esophagus (usually after endoscopy)

Tension PT

73
Q

___ should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator. It can also happen when the ___ vein is open to the air (as in supraclavicular node biopsies, CV line placement, CVP lines that become disconnected).

A

Air embolism

74
Q

Immediate management of air embolism?

A

Cardiac massage, with the patient positioned with the left side down

75
Q

Prevention of air embolism?

A

Trendelenburg position when the great veins at the base of the neck are to be entered

76
Q

Fat embolism may be seen in multiple trauma patients with several long bone fractures - how do they present?

A

Petechial rashes in the axillae and neck
Fever, tachycardia, thrombocytopenia
Full-blown respiratory distress with hypoxemia and bilateral patchy infiltrates on CXR

77
Q

Treatment of fat embolism?

A

Respiratory support using a respirator

78
Q

Rarely, fat droplets may reach the brain, producing unexpected coma. A ___pattern on MRI is diagnostic.

A

Star-field (note that spontaneous resolution is possible and one should not rush to declare irreversible damage and withdraw further care)

79
Q

Management of gunshot wounds to the abdomen (entrance or exit wound below the level of the nipple line is considered to involve the abdomen)?

A

Requires ex-lap for repair of intra-abdominal injuries (not necessarily to remove the bullet)

80
Q

In very select cases of abdominal trauma due to low caliber gunshot wounds involving the ___ (location), conservative therapy may be used if the patient is properly monitored with close follow-up of clinical signs and serial abdominal CT scans.

A

RUQ

81
Q

Management of stab wounds?

A

If it is clear that penetration has occurred (protruding viscera), ex-lap is mandatory. The same is true of hemodynamic instability or signs of peritoneal irritation develop. In the absence of the above, digital exploration of the wound in the ER and observation may be sufficient. If this is equivocal, a CT scan is diagnostic.

82
Q

Management of blunt trauma to the abdomen?

A

Ex-lap if acute abdomen develops; otherwise, one must determine whether there are internal injuries, whether there is bleeding into the peritoneal cavity, and whether the bleeding is likely to stop by itself or will require surgical intervention. Signs of internal bleeding trigger this investigation.

83
Q

List # signs of internal bleeding in a patient with blunt trauma.

A
  1. Drop in BP
  2. Fast thready pulse
  3. Low CVP
  4. Low urinary output
  5. Cold, pale, anxious patient who is shivering, thirsty, perspiring profusely
84
Q

Signs of hypovolemic shock occur when __% of blood volume is acutely lost.

A

25-30 (about 1500 mL in an average-size adult)

85
Q

List 3 places where 1500 mL of blood can “hide” in a blunt trauma patient with shock.

A
  1. Abdomen
  2. Thighs (2/2 femur fracture)
  3. Pelvis (2/2 pelvic fractures)
86
Q

The diagnosis of intra-abdominal bleeding can be made most accurately with what imaging? It allows a decision to be made for surgery or expectant therapy.

A

CT scan (will show blood, the injury from where the blood is coming, sense of how bad the injury is)

87
Q

The diagnosis of intra-abdominal bleeding in the patient who is hemodynamically unstable has to be made quickly in the ER or OR, at the same time that resuscitation efforts are underway. This is best down with what method?

A

Limited sonogram (FAST - Focused Abdominal Sonogram for Trauma)

88
Q

What is the most common source of SIGNIFICANT intra-abdominal bleeding in blunt abdominal trauma?

A

Ruptured spleen (if insignificant cases are counted, liver is most common)

89
Q

Every effort will be made to repair a lacerated spleen - why? What should be done if it cannot be saved?

A

Important immunologic function; post-operative immunization against encapsulated bacteria (Pneumococcus, Hib, meningococcus)

90
Q

Treatment for intraoperative development of coagulopathy during prolonged abdoinal surgery for multiple trauma with multiple transfusions?

A

Treat empirically with platelet packs and fresh-frozen plasma (~10 units each)

Note - if there is also hypothermia and acidosis, the laparotomy has to be promptly terminated, with packing of bleeding surfaces and temporary closure. This can resume later when the patient has been warmed and the coagulopathy treated.

91
Q

The ___ syndrome occurs when lots of fluids and blood have been given during the course of prolonged laparotomies, so that by the time of closure all the tissues are swollen and the abdominal wound cannot be closed without undue tension.

A

Abdominal compartment

92
Q

Management of abdominal compartment syndrome?

A

Temporary cover placed over the abdominal contents (either an absorbable mesh or non-absorbable plastic)

If post-op following closure -> open back up

93
Q

What is a damage control laparotomy?

A

Management of severly traumatized patient who is subject to consumption coagulopathy, hypothermia, and abdominal compartment syndrome

Clamp all bleeders, temporarily occlude damaged viscera, clean up contamination, and get out. Then do the rest of the resuscitation and go back in later.

94
Q

Management of pelvic hematomas?

A

Leave them alone if they are not expanding

95
Q

What associated injuries need to be ruled out in the setting of a pelvic fracture?

A

Rectum (rectal exam and proctoscopy)
bladder
Vagina in women (pelvic exam)
Urethra in men (retrograde urethrogram)

96
Q

Management of pelvic bleeding?

A

Site of blood loss is often inaccessible and not amenable to clamping or electrocoagulation -> immobilize the pelvis with binding or external fixation; angiographic management (embolization to minimize venous bleeding)

97
Q

What is the hallmark finding of urologic injuries?

A

Gross hematuria in the setting of sustained penetrating or blunt abdominal trauma

98
Q

Management of penetrating urologic injuries?

A

Surgically explored and repaired as a rule

99
Q

Blunt urologic injuries may affect the kidney, in which case the associated injuries tend to be ___ fractures. If they affect the bladder or urethra, the usual associated injury is ___ fracture.

A

Lower rib; peelvis

100
Q

Urethral injury occurs almost exclusively in men, is typically associated with a ___ fracture, and may present with blood at the ___. Other findings?

A

Pelvic fracture; meatus

Scrotal hematoma, sensation of wanting to void but not being able to do it (posterior injuries), “high-riding” prostate

101
Q

Key management in urethral injury?

A

Do NOT insert a Foley; do a retrograde urethrogram

102
Q

Dx bladder injuries?

A

Retrograde cystogram (x-ray study must contain postvoid fims to see extraperitoneal leaks at the base of the bladder that might be obscured by the bladder full of dye)

103
Q

Rx extraperitoneal leaks in the bladder? Intraperitoneal?

A

Extra - place a Foley

Intra - surgical repair, protect with a suprapubic cystostomy

104
Q

Assess and manage renal injury secondary to blunt trauma?

A

CT scan; most of the time can be managed without surgical intervention

105
Q

A rare but fascinating potential sequela of renal injuries affecting the renal pedicle is the development of an AV fistula leading to ___.

A

CHF

106
Q

Scrotal hematomas can attain alarming size but typically do not need specific intervention unless the ___ is ruptured (assess with U/S).

A

Testicle

107
Q

Fracture of the penis due to fracture of the ___ or ___ occurs to an erect penis, typically as an accident during vigorous intercourse.

A

Corpora cavernosa; tunica albuginea

108
Q

Management of fractured penis?

A

Emergency surgical repair (impotence will ensue as AV shunts develop)

109
Q

In penetrating injuries of the extremities, the main issue is whether a ___ injury has occurred or not. Anatomic location provides the first clue. When there are no major vessels in the vicinity of the injury tract, only ___ and ___ is required.

A

Vascular; tetanus prophylaxis; cleaning of the wound

110
Q

If a penetrating injury is near major vessels and the patient is asymptomatic, what should be done?

A

Doppler or CT angio

111
Q

If a penetrating injury results in an obvious vascular injury (absent distal pulses, expanding hematoma), what should be done?

A

Surgical exploration and repair (required)

112
Q

Combined injuries of arteries, nerves, and bone obviously need repair, but they pose the challenge of which one to do first. What is the usual sequence?

A

Stabilize the bone first. Then do the delicate vascular repair. Leave the nerve for last. A fasciotomy should be added because the prolonged ischemia could lead to a compartment syndrome.

113
Q

Management of high-velocity gunshot wounds that produce a large cone of tissue destruction?

A

Extensive debridement and potential amputation

114
Q

Crushing injuries of the extremities pose the hazard of what sequelae?

A 
Hyperkalemia
Myoglobinemia
Myoglobinuria
Renal failure
Compartment syndrome
115
Q

Management of crush injuries?

A

Vigorous fluid administration
Osmotic diuretics
Alkalinization of the urine
Fasciotomy later

116
Q

Management of chemical burns?

A

Require massive irrigation to remove the offending agent; begin as soon as possible at the site where the injury occurred

117
Q

Which is worse - an alkaline or acid burn?

A

Alkaline

118
Q

Management of high-voltage electrical burns?

A

Massive debridements or amputations may be required
Additional concerns include myoglobinemia-myoglobinuria-renal failure (give plenty of fluids and osmotic diuretics like mannitol, and alkalinize the urine), orthopedic injuries secondary to massive muscle contractions (posterior dislocation of the shoulder, compression fractures o f vertebral bodies), and late development of cataracts and demyelinization syndromes

119
Q

What are respiratory burns?

A

Inhalation injuries that occur with flame burns in an enclosed space (burning building, car, etc.) and are chemica lnjuries caused by smoke inhalation

120
Q

Suggestive clues that someone has experienced a respiratory burn?

A

Burns around the mouth, soot inside the throat

121
Q

Dx and management of respiratory burns?

A

Fiberoptic bronchoscopy
Key issue is whether respirator support is needed or not (blood gases are best to make that determination)
Intubate if there is any concern about airway
Monitor level of carboxyhemoglobin, if elevated, 100% oxygen will shorten its half-life

122
Q

Circumferential burns of the extremities can cause what problem?

A

Cutoff the blood supply as edema accumulates under the unyielding eschar; if affecting the chest, can cause breathing problems

123
Q

Management of circumferential burns?

A

Escharotomies at the bedside for immediate relief

124
Q

What is the most critical life-saving component of the management of extensive thermal burns and why?

A

Fluid replacement - underneath a deep burn, a lot of fluid accumulates. This is essentially plasma that has been temporarily lost from the circulating space and trapped at the burn site. In extensive burns, this shift is enormous and leads to hypovolemic shock and death without treatment. Large infusions of IV fluids are required.

125
Q

An appropriate predetermined rate of fluid infusion in the adult is to start at ___ of LR (without sugar) on anyone whose burns exceed 20% of body surface, and then adjust as needed to produce the desired urinary output (1-2 mL/kg/hr, avoiding CVP over 15 mm Hg)

A

1000 mL/hour

126
Q

Appropriate rate of initial fluid administration in babies with burns?

A

20 mL/kg/hr if the burn exceeds 20% of body surface

127
Q

List other important aspects of burn care.

A
  1. Tetanus prophylaxis
  2. Cleaning of the burn areas
  3. Use of topical agents (standard is silver sulfadiazine; if deep penetration is desired, mafenide acetate).
  4. Pain meds IV
  5. 1-2 days of NG suction, then intensive nutritional support via the gut, with high-calorie, high-nitrogen diets
  6. After 2-3 weeks of wound care and general support, the burned areas that have not regenerated are grafted.
  7. Rehab starting day 1
128
Q

Burns near the eyes are covered with ___.

A

Triple antibiotic ointment (not silver sulfadiazine, which is irritating to the eyes).

129
Q

When is early excision and grafting used?

A

Whenever possible to save costs and minimize pain, suffering, and complications; impleis removal in the OR on day 1 with immediate grafting; only done for fairly limited burns (under 20%) that are obviously third-degree

130
Q

What 2 things are required for all bites?

A

Tetanus prophylaxis and wound care

131
Q

Management of dog bites if provoked (dog petted while eating or otherwise teased)?

A

No rabies prophylaxis required, other than observation of the dog for developing signs of rabies

132
Q

Management of unprovoked dog bites or bites from wild animals?

A

If the animal is available, it can be killed and the brain examined for signs of rabies. Otherwise, mandatory prophylaxis (Ig + vaccine)

133
Q

Snakebites by crotalids (rattlesnakes) do not necessarily result in envenomation, even if the snake is poisonous. The most reliable signs of envenomation?

A

Severe local pain, swelling, and discoloration developing within 30 minutes of the bite.

134
Q

Management of possible envenomation by snakebite?

A

Draw blood for typing and crossmatch, coag studies, and liver/renal function
Treat based on antivenin (current preferred agent is CROFAB)
Rarely need surgical excision of the bite site of fasciotomy
First aid - splint the extremity (do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet)

135
Q

How is antivenin dosed?

A

Based on the size of the envenomation (not size of the patient)

136
Q

Management of bites by brightly colored coral snakes?

A

Neurotoxin needs prompt neutralization with specific antivenin (don’t wait for signs of envenomation)

137
Q

Management of bee stings causing anaphylaxis?

A

Epinephrine

Remove stingers without squeezing them

138
Q

Management of black widow spider bites?

A

IV calcium gluconate

Muscle relaxants help

139
Q

Presentation of brown recluse spider bite?

A

Within a day, a skin ulcer develops with necrotic center and a surrounding halo of erythema

140
Q

Management of brown recluse spider?

A

Dapsone
Surgical excision, but delay until the full extent of the damage is evident
Grafting may be needed

141
Q

Management of human bites?

A

Extensive irrigation and debridement in the OR

142
Q

Preventing surgical infection

A
  1. Prevent multiplication with elimination of foreign material and dead tissue, along with massive irrigation
  2. Suction
  3. Leave a wound open to help healing
143
Q

Colon contents require a combination of ABX to cover what categories of organisms? Options?

A

GP, GN, anaerobes; ciprofloxacin and metronidazole, Pip/tazo, imipenem

Surgery Clerkship - Pestana (17 decks)

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