Clinical Flashcards
Incidence of compartment syndrome in tibial fracture?
Up to 45%
Is compartment syndrome excluded in open injury?
No - There could be compression on another compartment
Causes of compartment syndrome
Fracture Plaster compression Burns Crush injury Bleeding Haematoma Postischaemic swelling
Compartments of lower limb
Anterior
Posterior
Deep posterior
Perineal (Lateral)
Signs and symptoms of compartment syndrome?
Main symptom I look out for is pain out of proportion to injury, despite adequate analgesia, and pain on passive stretch of a muscle.
Later signs may include pallor, paraesthesia and pulseless
Management of compartment syndrome
If in backslab —> Elevate, Cut the backslab on soft part to skin, or if full plaster then split, keeping it partially intact for support
Provide analgesia
Check distal pulse and sensation and skin
Keep NBM
If available could check compartment pressures
Inform my registrar what i have just done and check on patient again in 20 minutes
If settled, continue as is, if no better book for theatre, take bloods, inform anaesthetist and senior and mark consent for fasciotomy
Measuring compartment in CS
- Sterile conditions
- Probe inserted into each compartment
- Within 5 cm of fracture site
Normal compartment pressure?
0-10 mmHg
Pressure indicative of CS?
within 30 of Diastolic BP or absolute pressure of >30
Signs of Critical Ischaemia
Pain Pallor Pulseless Paraesthesia Perishingly cold Paralysis
Low urine output post op (AKI)
Causes?
Pre renal
- Hypovolemia/haemorrhage
- Renovascular
Renal
- Acute tubular necrosis
- Glomerulonephritis
- Necrosis
Post renal
- Obstruction
- Extrinsic compression
- Iatrogenic
- Trauma
Define acute tubular necrosis
Renal failure resulting from injury to the tubular epithelial cells
Two types of Acute Tubular necrosis
Ischaemic
Nephrotoxic
E.g. drugs, toxins or myoglobin
Medications that cause AKI
NSAIDS ACE-I Diuretics Antibiotics e.g. Gentamicin, trimethoprim Paracetamol
Complications of AKI?
Hyperkalemia
Flash pulmonary oedema
Indications for dialysis?
- Refractory or persistent Hyperkalemia
- Metabolic acidosis
- Refractory pulmonary oedema
- Signs of uraemia encephalopathy
- Signs of Uraemic pericarditis
Risk factors for UGI bleed?
Drugs - NSAIDS, anticoagulants
Oesophasgus - Vacrices, Mallory Weiss tear
Gastric - Ulcer, gastritis, drugs, malignancy
Duodenal - ulcer, drugs, malignancy, injury
Scoring system for UGI bleed?
Rockall Score
- Pre and Post endoscopy
Age
BP
HR
Co-morbidity
Post endoscopy —> Diagnosis and signs of recent haemorrhage
High risk score for UGI Bleed?
> 3
Types of Stoma
Colostomy
Ileostomy
End
Loop
Ileostomy
End of ileum to the abdomen.
Spouted.
Loop is double barrelled (diverts away from obstruction)
Greenish, loose product
Crohns vs. UC
Crohns
- Rose thorn ulcers
- Skip Lesions
- Throughout alimentary tracts
- Can involve all layers of bowel wall
- Deep ulceration
- Fistula formation
- Cobblestone appearance
- Worsened by smoking
Consequence of multiple bowel resections?
Short gut syndrome.
Malabsorption.
Malnutrition.
Complications of Crohn’s?
- Abscesses
- Fistula
- Small bowel obstruction
- Toxic Megacolon
- Short bowel
- Malignancy
- Primary Sclerosing Cholangitis
- Gall stones
Management of DKA
Fixed rate insulin infusion 0.1 units/kg/hr
IV Fluids 4-6 litres/24 hours
First 2 in 3 hours
Resolution Criteria for DKA
pH >7.35
HCO3 >18
Serum Ketones <0.3
Define HONK
Hyperosmolar Non-Ketotic Coma
Hypersomolar hyperglycemia
Hormone excess with relative insulin deficit
Tests for HONK
Glucose >40
Electroluytes suggest dehydration
Serum osmolality >350
Normal ketones and ph
Treat HONK
IV Fluids to correct dehydration
3-5 units/hr insulin
Manage Hypoglycemia in conscious patient
Fast acting oral carbohydrate e.g. gel (20-30 grams)
Manage hypoglycaemia in unconscious patient
IM Glucagon 1 mg
IV Dextrose (20%, 100 ml)
Consequences of poorly controlled T2DM
- PVD
- Heart disease
- Neuropathy
- Retinopathy
- Nephropathy
AKI Classification
R- Risk I- Injury F- Failure L- Loss of function E- End stage
AKIN Criteria AKI
Stage 1 - 1.5x Cr
Stage 2 - 2x Cr
Stage 3 - 3x Cr
Virchow’s Triad
- Haemostasis
- Endothelial Damage
- Hypercoagualability
Embolus vs. Thrombus
Embolus:
More acute
Painful
Risk factors e.g. AF, Surgery, Endocarditis, Prosthetic heart valves
Left iliac fossa pain
Septic
61 year old
DDX?
Abdominal: AAA, Diverticulitis, Ischaemic bowel, Volvulus, Perforation
Gynae: ovarian torsion
Urinary: Renal calculus, Urine infection, Pyelonephritis
SIRS
SIRS: Two or more of:
- Raised or low WCC
- Temp 38, < 36
- HR >100
- Tachynpneoa
- Altered Mental State
- BM >6.6
Sepsis
SIRS with a known source of infection Severe when there is end organ dysfunction
Septic Shock
Sepsis with refractory hypotension
Sepsis Six
1) Take Cultures
2) Take Bloods inc. Lactate
3) Take urine culture
4) Give abx
5) Give O2
6) Give fluids
Lethal Triad in ATLS
- Metabolic Acidosis
- Coagulopathy
- Hypothermia
Signs of Urological Injury in trauma?
- Blood at meatus
- Difficulty passing catheter
- Suprapubic bruising
- Extravasation of urine
Metabolic Acidosis
Kidneys unable t excrete hydrogen ions or increased lactate
Body Compensates by increasing respiratory drive to blow off CO2
Intra-operative findings of Nec Fasc
- Necrotic tissue
- Fascial oedema
- Vessel Thrombosis
- Dishwater-colour fluid
- Pus
Charcot Triad
RUQ Pain
Jaundice
Fever/Rigors
Charcot Triad indicates?
Ascending cholangitis
Glasgow score for pancreatitis
PO2 <8 Age >55 Neuts >15 Ca <2 (Renal) Urea >16 Enzymes (LDH >600/AST >2000) Albumin <32 Sugar >10
Causes of acute pancreatitis?
- Gall Stones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hypothermia, hyperlipidemia, hypercalcemia
- ERCP
- Drugs (e.g. NSAIDS)
Fat embolism
Fat molecule that enters the circulation, to a distant location. Often associated with trauma, fractures and limb surgery.
Pneumothorax compromises Cardiovascular function
Obstructs venous return to the heart
Investigating tension pneumothorax
ABG, Examination
NOT CHEST X RAY
Risk factors for DVT
- Previous DVT
- Family history
- Lower limb surgery
- Prolonged period of immobility
- Lower limb fracture requiring plaster cast and NWB
- Malignancy
- Medication e.g. Oral contraceptive pill
Three factors for VTE
1) Hypercoagulability
2) Endothelial damage
3) Haemostasis
Risks for secondary pneumothorax
- Trauma
- Ruptured bullae due to emphysema
- Cystic fibrosis
- infection
- Malignancy
- Iatrogenic
- Asthma
Ruptured bullae
- Pressure changes
- Trauma
- Intubation
- Iatrogenic
- Infection
CT Head indications in trauma
- Focal Neurology
- Evidence of base of skull fracture
- Seizure
- Vomiting (>1 episode)
- GCS <13 on admission
- GCS <15 after 2 hours
GLASGOW Score severity
> 6 Severe, high mortality
Signs of base of skull fracture
- CSF Rhinorrhea
- Otorhoea
- Bilateral echymosis
- Battle sign (Bruising around mastoid process)
- Depressed skull fracture
