Clinical Flashcards
1
Q
When may a MP take the blood of a suspect for DUI? (3)
A
- with consent
- by order of police officer (SAP 308 a)
- if dr is of opinion that it will be required in further criminal procedures (criminal procedure act 51 of 1977 section 2)
2
Q
How should a blood sample be obtained for a DUI? (4)
A
- collect at least 5 ml, preferable 20
- sterilise arm with sterile water, not alcohol swab
- Place specimen in special prepared container with anticoagulant and preservative
- record time and site
3
Q
Name 7 red flags indicating child abuse
A
1 treated at different hospitals or different doctors
- Delay in seeking medical help
- Discrepancy in history
- Abnormal affect and behaviour of parents
- Abnormal affect and behaviour of child
- Different injuries in different stages of healing
- Specific injuries: skull fractures ( more than 1, in more than 1 place), subdural haemorrhage, retinal haemorrhage, rib fractures especially if history doesn’t support injury.
4
Q
What damage does the light component of lightning cause?
A
Eyes! Most commonly cataract with posterior subscapular haemorrhage
5
Q
What damage can the electrical component of lightning cause? (2)
A
Abrupt cerebral salt wasting syndrome, delayed onset psych and cognitive symptoms
6
Q
What are the 4 primary targets for blast overpressure (barotrauma) injury?
A
Hollow organs, ear, lung, GIT
Lightning: pneumomediastinum (bubbles on post wall)
7
Q
Name 3 causes of hyperthermia ( 2 drugs, 1 endocrine)
A
- Cocaine
- amphetamine
- Hyperthyroidism
8
Q
What is mild hypothermia?
A
Core temp 32-35
9
Q
What is moderate hypothermia?
A
Core temp 30-32
10
Q
What is severe hypothermia?
A
Core temp below 30
11
Q
Name 3 illnesses included in high altitude illness
A
- Acute mountain sickness
- High altitude cerebral oedema
- High altitude pulmonary oedema
(Due to hypobaric hypoxia)
12
Q
What causes epidural haematoma ?
A
Traumatic rupture of middle meningial artery over parieto -temporal area with associated skull #
Arterial bleed therefore develops rapidly
13
Q
What causes subdural haematoma? (5)
A
Trauma to communicating veins with no associated skull fracture. By rotational/shearing forces applied to brain
Other: rupture of cerebral aneurysm or arteriovenous malformation, cerebral hypotension, rarely malignancy
14
Q
What is needed for a subdural haematoma present clinically?
A
Venous bleed. Needs enough volume of about 35 ml to become a space occupying lesion /cortical irritant to be clinically apparent.
15
Q
Complication of epidural or subdural haematomas?
A
Brain herniation
16
Q
Which 3 arteries, in order, are common sites of aneurysm in the brain?
A
- ant communicating
- int carotid/post communicating
- Middle cerebral
17
Q
Name 3 causes of spontaneous subarachnoid haemorrhage
A
Cerebral aneurysms (85 % ), cocaine, amphetamines
18
Q
What is Duret haemorrhage?
A
Primary brainstem haemorrhage secondary to raised ICP
19
Q
What is and causes pontomedullary runt?
A
Brainstem snaps. Hyperextension injury associated with ring fractures, fractures - dislocations to c1 -c2
20
Q
Is diffuse axonal injury traumatic brain injury?
A
No. But is most common path feature noted in TBI
21
Q
Define diffuse axonal injury and give cause
A
Damage to axons of any etiology which traumatic axonal injury (tai) is example.
Primarily a non-impact rotational acceleration-deceleration phenomenon, deformation by stretching probably being most significant factor.
22
Q
How diagnose TAI?
A
Special stains (B APP ) to demonstrate subtle microscopic damage to nerve fibres: axonal bulbs/ retraction balls or globes
23
Q
What is a “coup” lesion? How acquired?
A
Mobile head struck with object, maximum cortical contusion site is beneath or at least on same side as blow.
24
Q
How is “contrecoup” lesion acquired?
A
Moving head is suddenly decelerated eg fall, cortical damage on opposite side of head to blow.
25
See picture 3 and label the brain herniations.
```
A: subfalcine hernia
B. Lateral transtentorial DTH /uncal hernia
C. central DTH (transtentorial)
D. Transcalvarial (extracranial)
E.tonsillar hernia
```
26
How old is a bruise that is red to purple- black?
Day 0-1 (haemoglobin)
27
Name 4 types skull vault fractures
1. Base of skull
2. Facial fractures
3. Open skull #
4. GSW to skull
28
Name 5 complications of assault /injuries
1. Haemorrhage
2. Infection
3. Haemo/ pneumo thorax
4. Bronchopneumonia
5-pulmonary thromboembolism
6. Metabolic disturbances
7. Renal failure
8. Air and fat embolism
29
Name 11 differentials for altered level of consciousness, with 2 examples of each
1. Toxicologic: carbon monoxide, opioids, alcohol,
2. Trauma: intracranial haemorrhage, diffuse cerebral oedema, concussion, anoxic brain injury,
3. Neurologic.: seizures, encephalopathy, complicated migraine, ruptured av malformation or aneurysm, stroke, CSF shunt malfunction, cns vasculitis, post-infec disorders eg acute disseminated encephalomyelitis
4. Cardiac: syncope, dysrhythmias, hypertensive crisis, posterior reversible encephalopathy syndrome, hypotension, mi
5. Pulmonary: hypoxia, hypercarbia
6. Endocrinology: hypoglycaemia, DKA, hyperglycemic hyperosmolar state, hashimoto encephalopathy
7. Git: intussusception, acute abdomen
8. Renal/genetic / metabolic: electrolyte abnormal, dehydration, uraemia, inborn errors of metabolism
9. Haematologic/oncologic: hyperleukocytosis, space occupying lesion, severe anemia
10. Infections: meningitis, encephalitis, intracranial abscess, tick- borne diseases, sepsis
11. other: psych delirium, shock ( hypovolaemic, cardiogenic, distributive, obstructive), hyper/hypo- thermia, porphyria, thiamine def / wernicke encephalopathy
30
Classify wound picture 18
Sliding abrasion
31
Classify wound picture 19
Pressure abrasion
32
Classify wound picture 20
Patterned abrasion and tramline contusion
33
Classify wound picture 21
Contusion
34
Classify wound picture 22
Tramline contusion
35
Classify wound picture 23
Tramline contusion
36
Classify wound picture 24 and what it indicates
Raccoon eyes - basal skull fracture
37
Classify wound picture 25
Laceration: irregular edges
38
Name 6 types abrasions
```
DIG FLIP
Dicing (small edged/rectangular caused by fragments of glass, usually from mva)
Imprint
Gravel
Friction
Linear
Post mortem insect bites,
Also scratches and brush abrasions.
```
39
Name 3 conditions that mimic death
1. Hypoglycaemia (hyper)
2. Hypothermia
3. Barbiturate coma (sodium thiopentone)
4. Depressant drugs eg narcotics, hypnotics, tranquilizers
5. apnea due to neuromuscular blocking agents
40
How do CPR chest injuries usually present (3)
Anterior, lateral, symmetrical.
41
How old is a bruise that is bluish - brown?
2 days (haemosiderin)
42
How old is a bruise that is greenish-brown?
3 days ( haemosiderin and biliverdin)
43
How old is a bruise that is green?
4-5 days (biliverdin)
44
How old is a bruise that is yellow?
7-10 days (bilirubin)
45
How old is a bruise that is fading/disappearing?
12-15 days
46
Properties of first degree burns- description, appearance, capillary refill, sensation/pain, healing
* Superficial thickness: only epidermis
* erythematous
* fast cap refill
* sensation and pain present
* 7-14 days to heal
47
Properties of second degree burns superficial and deep - description, appearance, capillary refill, sensation/pain, healing
* Either superficial partial thickness or deep partial thickness: epidermis and part of dermis
* wet, pink, blisters vs less wet, red, with or without blisters
* fast cap refill vs sluggish/absent
* extreme pain vs with or without sensation
* 2-4 weeks healing vs 3-8 weeks with severe scarring, need grafting
48
Properties of third degree burns- description, appearance, capillary refill, sensation/pain, healing
* Full thickness: epidermis and entire dermis and fat
* dry, white
* absent cap refill
* absent sensation or pain
* needs grafting to heal
49
Name 4 cold injuries
* Frostbite
* trench foot
* chilblains
* hypothermia (core <35, hide and seek phenomenon)
50
Bright Red abrasion age?
Fresh
51
Bright scabs abrasion age?
12-24 hours , after lymph and blood dried
52
Red-brown scab abrasion age?
2 to 3 days
53
Epithelium covering scab abrasion age?
4 to 7 days
54
How long does it take abrasion scab to fall off?
After 7 days
55
Name 5 symptoms subdural haematoma
```
• Headache
• drowsy
. Weakness
• paraesthesia / numb
• nausea vomiting
. Confusion
• poor balance
```
56
Location of extradural haemorrhage?
Between skull bone and dura
57
Pathophysiology of extradural haemorrhage?
mostly Rupture middle meningeal artery on temporal surface of skull - associated fracture skull
Rarely by venous bleeding from perforating veins or dural sinuses
58
Clin presentation extradural haematoma?
History trauma
Skull fracture
Lucid interval followed by unconciousness
59
appearance ct extradural haematoma?
Convex
60
Location subdural haemorrhage?
Between dura and arachnoid
61
subdural haemorrhage pathophysiology ?
Rupture bridging communicating cranial veins - shearing or rotational injury , no skull fracture
62
subdural haemorrhage clin presentation
```
History trauma
Older
Alcohol misuse
Child non accident. injury
Gradual deterioration
```
63
Subdural haematoma ct appearance?
Concave or crescent shaped
64
Subarachnoid haemorrhage location
Between arachnoid and pia
65
Subarachnoid haemorrhage pathophysiology
Rupture berry aneurysm
66
Subarachnoid haemorrhage clin presentation
History trauma
Thunderclap headache
Sudden onset symptoms
67
Subarachnoid haemorrhage ct appearance
Hyper-attenuation around circle of willis
68
Intracerebral haemorrhage location
Within brain parenchyma
69
Intracerebral haemorrhage pathophysiology
Haemorrhagic stroke
70
Intracerebral haemorrhage clin presentation
Sudden onset neuro deficits
71
Intracerebral haemorrhage ct appearance
Hyper- attenuation in brain parenchyma
72
Describe brush/sliding/friction/ graze or gliding abrasion appearance
Uneven, longitudinal parallel lines with epithelium heaped up at the ends of these lines, which indicates direction applied force
73
Describe appearance of scratch/linear abrasions.
Length but no significant width. Caused by sharp/pointed objects eg fingernail , pin,. Thorn
74
Explain and name the rule of nines. (6)
```
To identify body surface area burnt
• head 9%
• genitalia 1%
• arm 9%
• leg 18%
• torso 36%
```
75
Characteristics Pressure abrasion?
Caused by crushing superficial layers epidermis. Associated bruise. Eg ligature mark from hanging or strangulation, teeth Bite
76
Pathophysiology tramline bruises?
Skin struck with rod-like object , squeezing blood from vessels at point of impact thus emptying them and preventing them from leaking blood . edges of wound are stretched, and blood vessels torn, causing blood to leak to surrounding tissues. 2 parallel linear bruises separated by paler, undamaged skin results.
77
Name 10 types skull fractures
1. comminuted
2. Ring or foramen fracture
3. Simple linear most common or fissured
4. Depressed
5. Pond or indented
6. Gutter:long, narrow fracture caused by gunshot wound
7. Penetrating
8. Basilar fracture
9. Diastatic: along suture lines of skull in infants
10. Hinge: separate floor of skull into 2 halves ( 9 and 10 types of linear)
11. Mosaic or spider web fracture: comminuted depressed fracture
12. Contre-coup fractures: usually from hard surface striking occipital region of mobile head causing coup damage, - transmitted force may be sufficient to fracture thin bone on floor of ant fossa.
78
What is a pond or indented skull fracture?
Seen only in infants - like depressed fracture but in infants
79
What is a Gutter skull fracture?
Caused by gunshot wound
80
What causes split laceration?
Blunt object makes perpendicular contact with skin and skin is tightly stretched over bones, causing skin to split eg scalp
81
Name the 4 classes of electrical injuries
* True electrical injuries: person becomes part of the electrical circuit and has an entrance and exit site.
* flash injuries: superficial burns caused by arcs that burn the skin, no electrical injury travels through skin.
* flame injuries: caused by ignition of clothing by arc , electricity may or may not flow through body
* lightning injuries: extremely high voltages for shortest duration, majority of electrical flow occurs over body
82
Name 3 major mechanisms of electricity induced injury
1. Electrical energy causing direct tissue damage alternating cell membrane resting potential and eliciting muscle tetany.
2. Conversion into thermal energy, causing massive tissue distruction and coagulative necrosis
3. Mechanical injury with direct trauma resulting from falls or violent muscle contraction
83
Is ac or dc current more dangerous?
Ac
84
How protect eyes after lightning injury?
Keep them wet and closed
85
Name, in order, the appearance of contusions over time. (6)
* Day 0-1: red to purple black due to haemoglobin
* 2: bluish-brown due to haemosiderin
* 3: greenish brown- haemosiderin and biliverdin
* 4-5: green - biliverdin
* 7-10: yellow-bilirubin
* 12-15: fading to disappear
86
What is a mosaic or spider web's fracture?
Comminuted depressed fractures with fissures radiating away from fracture
87
Name 3 distinct structural abnormalities in pathology of TAI
* Corpus callosum lesions
* brain-stem lesions
* diffuse axonal damage
88
Describe characteristics of superficial or first degree burn by depth, appearance, pain and prognosis
• Epidermis only
. Dry, blanching erythema
. Painful very
• heals without scarring in 5-10 days
89
Describe characteristics of superficial partial thickness or second degree burn by depth, appearance, pain and prognosis
* upper dermis
* blisters, wet, blanching and erythema
* painful
* heals without scarring <3 weeks
90
Describe characteristics of deep partial thickness or second degree burn by depth, appearance, pain and prognosis
• lower dermis
. Yellow or white dry, nonblanching
• decreased sensation
• Heal in 3-8 weeks, likely to scar if heal >3 weeks
91
Describe characteristics of full thickness or third degree burn by depth, appearance, pain and prognosis
• Subcutaneous structures
• white or black/brown, nonblanching
. Decreased sensation
• heal by contracture >8 weeks. Will scar.
92
What are six penny bruises?
Bruises left by fingers usually, round or discoid shape. Usually in manual strangulation or tight gripping in child abuse
93
What is a butterfly bruise?
Pinch marks
94
Name 5 microscopic changes of skin in electrothermal burn.
1. Metallization
2. Homogenization, fuzziness of stratum corneum (melt)
3. Honeycomb vacuolisation
4. Demarcation zone _ separation dermis and epidermis
5. Streaming of nuclei
