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ORAL BOARDS > CRIT CARE/TRAUMA > Flashcards

CRIT CARE/TRAUMA Flashcards

1
Q

Splenectomy - OR

A

Divide splenophrenic, splenorenal, splenocolic attachments
Divide short gastrics using energy device
Divide hilum with endo GIA vascular stapler

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2
Q

Duodenal hematoma in child - mgmt (blunt trauma)

A

Leave alone
NGT for decomp
TPN
Consider feeding access

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3
Q

Size ETT in kid

A

Size of pinky
Check breslow tape***
Age/4 + 4

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4
Q

Tx of fat embolism

A

Supportive care

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5
Q

Ideal filling volume/CVP

A

10

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6
Q

Ideal CO

A

3-5

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7
Q

Ideal PA pressures

A

25/10

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8
Q

Ideal PAWP

A

16-18

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9
Q

Ideal SVR

A

1000

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10
Q

Forearm fasciotomy

A

Incision in the biceps groove and cross antecubital fossa in s-shaped fashion
Travel down forearm along border of brachioradialios
Veer medial towards middle of wrist, stop halfway in the middle of the palm of the hand

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11
Q

Plateau pressure goals in ARDS

A

<30

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12
Q

Optimize oxygenation/ventilation in ARDS

A

Paralysis
Recruitment maneuvers
Reverse I:E ratio
APRV

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13
Q

SVT mgmt

A

Awake, nonintubated: valsalva
Adenosine 6 mg –> short asystolic pause
Esmolol

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14
Q

Afib with RVR - unstable

A 
Activate code team
Amio bolus 150 mg 
Synchronized CVN @ 200J - requires sedation
Phenyl gtt
2 g Mg sulfate 
Crystalloid boluses
\+/- intubation
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15
Q

Afib with RVR - stable

A

Replete lytes PRN esp K, Mg, Ca
5 mg IV metop x 3 every 5 min
Cardizem gtt (ensure HD stable)
Amiodarone gtt @ 1mg/min after bolus 150 mg over 10 min

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16
Q

Any time you intubate remember ..

A

order confirmation CXR

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17
Q

How to monitor argatroban gtt

A

PTT

goal 60-90 just like heparin

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18
Q

Assess fluid status

A

Bedside US (IVC monitoring)
Passive leg raise esp if aline
UOP
Lactate

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19
Q

Hypovolemia –> SVR?

A

High

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20
Q

Low SVR, Low CVP, High CO

A

Septic shock

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21
Q

High CVP, Low CO, High SVR

A

Cardiogenic shock

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22
Q

Low CVP, Low CO, Low SVR

A

Neurogenic shock

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23
Q

Once afib with RVR has stablilized on amio gtt

A

Extubate ASAP
Cont infusion over 24 hours then transition to PO
Repeat EKG, echo, trops
F/u with cards

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24
Q

Pt is coding as you arrive

A

Organize team, initiate ACLS
Attach AED
Intubate and connect to end tidal CO2 monitor
Ensure adequate IV access and send off stat labs incl ABG

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25
Q

Chest compressions in adult - goals

A

ET CO2 > 10
100-120 compressions/min
2 cm depth
Allow for complete chest recoil

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26
Q

Rhythm shows PEA

A 
Redose 1 mg epi q3-5 min
Check pulses q2 min
Start checking for reversible causes incl bleeding 
Consider cardiac and pulmonary US
Addn adjunts: Ca, Mg, Amio, Lidocaine
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27
Q

Hs & Ts - reversible causes of arrest

A 
Hypothermia
Hypovolemia
Hypoxia
Hypo/hyperkalemia
H+ (acidosis)

Toxins
Tension PTX
Tamponade
Thrombosis (pulm and cardiac)

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28
Q

V fib on monitor

A

Unsynchronized defibrillation at 150 J

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29
Q

V tach on monitor

A

Synchronized defib at 125-200J

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30
Q

Post-MI care

A

Stat EKG, CXR, echo
Consult cards
Initiate levo gtt PRN
Cath lab

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31
Q

Basics of VA ECMO

A

Provides cardiac and pulmonary support
Blood is removed from venous drainage cannula, oxygenated, pumped back into arterial cannula placed into descending aorta which perfuses brain and UE via retrograde flow

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32
Q

VA ECMO Cannulation

A

Access contralateral femoral a and vein
via US guidance
Admin heparin
Insert approp size venous drainage and arterial cannulas over a wire using fluoro guidance
Insert venous drainage cannula to just below RA and arterial cannula to just below descending aorta
With circuit primed, initiate flow and adjust to support cardiac function
Once stabilized, insert distal perfusion cannula just below arterial cannula insertion site to ensure distal perfusion to extremities

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33
Q

Post-ECMO monitoring

A

Transfer back to ICU
Start continuous heparin gtt
Frequent Xa monitoring
Hourly neurovascular checks of LE
First wean pressor support then slowly wean blood flow
Daily echos, once heart improves can decannulate in OR with primary repair

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34
Q

Hx of alcoholic cirrhosis found down - h&p?

A

recent alcohol/drug use
previous cirrhosis complications - UGIB, heart and kidney problems, encephalopathy, ascites
medications?

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35
Q

Hx of alcoholic cirrhosis - labs/imaging?

A

CBC, CMP, coags, type and screen, blood cx, UA, alcohol level, drug screen, acetaminophen level, ammonia
CXR (volume status, pleural effusions)
Ensure 2 large bore IVs

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36
Q

Best determinant of intrinsic liver function (lab)

A

INR

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37
Q

How are SBP and UGIB related?

A

Infection –> coagulopathy

Large volume ascites –> incr portal pressure –> coagulopathy

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38
Q

UGIB + cirrhosis - abx?

A

Ceftriaxone

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39
Q

Major complications of TIPS

A

new or worsening encephalopathy

in-stent stenosis (correct w/dilation)

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40
Q

Abdom pain + large volume ascites

A

R/o SBP
CT scan
Paracentesis with culture, neutrophil count, protein count, LDH and glucose

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41
Q

Diagnostic of SBP (fluid analysis)

A

Neutrophils >250

Exclude 2ndary BP which is dx when 2+ of following: total protein >1, gluc<50, LDH > upper limit of normal for serum

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42
Q

Mgmt of large volume ascites/UGIB in cirrhotic

A 
Paracentesis
IV high dose PPI BID
Ceftriaxone 
Octreotide 
Consider hepatologist consult
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43
Q

Prep for trauma pt

A

Prepare team - ID roles, get equipment in the room
Detailed primary and secondary surveys, obtain 2 large bore IVs, send comprehensive labs, obtain vitals, perform FAST exam, order CXR and pelvic XR

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44
Q

Basics of neurogenic shock mgmt

A

Replace volume
Avoid overresuscitation
Pressors to support distributive shock
MAP goals 85-90

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45
Q

Bradycardia in neurogenic shock - tx?

A

Atropine

Consider external or internal pacing if no response

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46
Q

Delirium tx

A 
Awake and interactive during day, min stimulation at night
Engage his family and friends
Review meds including narcotics, benzos
R/o infection
Check thyroid, blood glucose and LFTs
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47
Q

Delirium/agitation tx (meds)

A

Melatonin
Quetiapine
IV haldol
Monitor daily EKGs for QT prolongation

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48
Q

Dx AKI - next steps?

A

Check FENA/urine lytes
ID any nephrotoxic medications
Renal US to r/o hydronephrosis
D/w surgeon re: ureter

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49
Q

Urine Na >40

A

Intrinsic AKI

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50
Q

Urine Na <20

A

Prerenal AKI

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51
Q

Muddy casts

A

ATN

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52
Q

RBC cast

A

glomerulonephritis

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53
Q

WBC cast

A

AIN, pyelonephritis

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54
Q

+Hgb but no RBC in UA

A

Rhabdo

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55
Q

K+ of 8 - next steps?

A 
EKG
3g of IV calcium
10U Insulin
1 amp D50
Monitor glucose hourly
Start albuterol nebulizer tx
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56
Q

Norepi MOA

A

Lots of alpha 1, some beta 1 agonism

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57
Q

Vaso MOA

A

V1 and V2 agonism

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58
Q

Epi MOA

A

Some alpha 1, lots of beta 1 agonism

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59
Q

Phenyl MOA

A

Lots of alpha 1 agonism

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60
Q

ARDS - additional workup

A

BAL
Echo
CT PE?

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61
Q

Berlin Criteria (ARDS)

A

Sx within 1 week of known insult
Bilateral opacities c/w pulm edema NOT fully explained by cardiac failure or fluid overload
Moderate to severe impairment of oxygenation

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62
Q

ARDS management

A 
Lung protective ventilation
Treating ventilator dyssynchrony
Proning
Paralyzing
Consider use of steroids, APRV, NO
Consider ECMO
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63
Q

Decreased mortality and time on vent in ARDS (vent changes)

A

Lower tidal volumes and plateau pressures

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64
Q

How to check plateau pressure

A

Inspiratory hold

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65
Q

Ways to improve ventilator synchrony

A

Additional sedation
Change mode
Incr inspiratory pause
Incr tidal volume

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66
Q

Dose of steroids in ARDS

A

50 mg IV hydrocortisone q6h

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67
Q

Neck exploration (vascular injury)-OR

A

Anterior border of SCM from angle of mandible down to sternal notch
Divide platysma, retract SCM and IJ laterally
Proximal control of common carotid
Follow proximally into hematoma
Control with finger over injury and continue dissection to obtain distal control around CCA and ECA
Prior to clamp, anesthesia admin heparin and place argyle shunt in common carotid into ICA

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68
Q

<50% defect common carotid artery

A

Patch angioplasty with bovine pericardium

Low threshold to do reverse interposition bypass with saphenous vein

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69
Q

Following carotid artery repair in trauma

A

Continue exploring neck for airway or esophageal injury

Ensure flow with doppler

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70
Q

ICA transection

A

Reverse saphenous vein interposition graft

OR 6 mm PTFE

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71
Q

Distal ICA stump - no backbleeding

A

Gently pass 2 Fogarty and inflate it and pull back until adequate backbleeding
Should be done at time of shunt placement if no good backbleeding evident

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72
Q

Pseudoaneurysm with extrav at base of CCA - options?

A

If vascular available for endovascular and/or stenting of proximal CCA
Otherwise partial or complete sternotomy to get control of base of carotid artery

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73
Q

Intimal flap 1 cm in size to ICA, neurologically intact

A

Antiplatelet

Re-image in 1 week to ensure lesion does not degenerate into pseudoaneurysm

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74
Q

R sided Zone 1 hematoma - Exposure of IVC

A

Confirm w/anesthesia they are ready for blood loss/all caught up
R sided medial visceral rotation starting at white line of toldt at cecum and following all the way up
Kocher maneuver
Distal control of IVC
Open hematoma, evacuate blood, use spongesticks to get proximal and distal control

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75
Q

Complete injury IVC below renal vv

A

Longitudinal venotomy along anterior wall of IVC through injured segments to allow access to posterior wall of IVC
Eval injuries - if posterior segment is easily approximated with 3-0 prolene
If anterior segment cannot be closed without stricture, use patch angioplasty once debrided to healthy edges

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76
Q

Unable to primarily repair IVC injury

A

If HD unstable - ligate IVC, prophylactic fasciotomies

If stable - attempt to construct ringed PTFE graft slightly smaller than IVC to keep flow rates high

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77
Q

Injury at confluence of IVC - how to help visualize?

A

Right to left medial visceration
May have to divide R common iliac artery to fully expose problem (repair or reconstruct at end of case, make sure patient is heparinized)

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78
Q

If there is a need for ex fix and concomitant vascular injury, what is the order of steps?

A

Shunt first
Ex fix (ortho)
Definitive repair

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79
Q

GSW to LE with high suspicion for arterial injury - OR plan?

A

Longitudinal incision just below inguinal ligament
Follow down to CFA, loop it out proximally for inflow control
Dissect distally to get control of SFA and profunda
Heparinize pt
Clamp all 3 inflow vessels
Long incision over area of concern based on trajectory of bullet
Isolate SFA proximally and distally to lesion
Same with femoral vein

80
Q

2 cm defect of SFA with small piece of backwall intact, distal vessel thrombosed - OR plan?

A

Interposition bypass of SFA
Contralateral reverse greater saphenous vein
Prior to doing so, place shunt to regain distal perfusion to extremity
Prior to shunt, fogarty embolectomy to outflow tract using 3 fogarty
Ensure good inflow, place argyle shunt into inflow, tie silk sutures to hold in place
Confirm shunt with doppler

81
Q

Interposition bypass - OR

A

Harvest long segment of gr saphenous vein
Remove shunt, ensure good forward and backbleeding
Debride vessel to healthy portion and spatulate ends
Reverse vein and sew proximally and distally with 5-0 prolene once shunt is removed
Check pulses
Evaluate total time til revascularization to determine if fasciotomy is needed

82
Q

Compromised outflow of all 3 below-knee vessels - next step in OR?

A

Below knee pop a cutdown
Selective embolectomy of tibial vessels
Patch pop a

83
Q

Injury to right ventricle

A

Use finger or foley catheter to control bleeding
Repair defect with pledgeted 3-0 prolene suture in horizontal mattress fashion, taking care to ID and protect coronary vessels q

84
Q

About to start resuscitative thoracotomy

A

Ask team to place chest tube on R side
Intubate pt
Obtain central venous access
Begin massive transfusion

85
Q

Indications for resuscitative thoracotomy in penetrating trauma

A

Pulseless + CPR <15 min

86
Q

Contraindications to resuscitative thoracotomy

A

W/o signs of life at scene of injury

PResent in asystole without pericardial tamponade

87
Q

Indication for resuscitative thoracotomy in blunt trauma

A

Pulseless + CPR <10 min and/or signs of life

88
Q

Signs of life

A 
pupillary response
presence of carotid pulse
extremity movement
cardiac electrical activity
spontaneous ventilation
measurable or palpable BP
89
Q

Resuscitative thoracotomy - steps

A

Position pts left arm above their head
Scalpel to incise medial aspect of sternum across to bed
With chest wall exposed, heavy scissors to cut intercostal musculature staying along superior aspect to avoid neurovascular bundle
Place finochietto retractor and open chest widely
Open pericardial sac avoiding phrenic nerve and start cardiac massage, make repairs as needed
Cross clamp aorta
Address any injuries to lung

90
Q

Zone 1 hematoma near duodenum - OR/exposure

A

Ensure good IV access, plenty of blood on hand, anesthesia is ready, and call for 2nd partner to help
ID supraceliac aorta and have vascular clamp on hand
Right–>left medial visceral rotation by taking down white line and performing kocher maneuver

91
Q

How to determine if CBD involved in duodenum & identify ampulla

A

Pass a fogarty catheter into duo via cystic duct

92
Q

Unable to perform primary closure of duodenum and injury distal to CBD

A

Perform duodenoduodenostomy or roux en y duodenojejunostomy and leave drains adjacent to repair
Pass NJ while in OR

93
Q

Upper esophageal injury exposure- OR

A

Bump under shoulders
Head turned away from injury
Prep entire neck and chest prior to incision along anterior border of SCM
Transect platysma, retract SCM and open carotid sheath to allow for visualization of IJ, vagus and carotid a
Medialize thyroid and laryngeotracheal complex and ligate middle thyroid v., inf thyroid a and omohyoid muscle
Can place NG to help ID esophagus

94
Q

2 cm defect to lateral esophagus - OR

A

40Fr Bougie
2 layer primary repair using absorbable suture
Ensure to expose entire mucosal defect (may need to enlarge muscular defect)
Leave multiple drains in area

95
Q

Tracheal injury (+ esophageal injury) - OR

A

Repair with absorbable suture

Use muscle buttress to separate repairs (strap muscle)

96
Q

CT scan shows thickened thoracic esophagus with small flecks of air adjacent to it + loculated collections in pleural space - concern of?

A

Missed aerodigestive injury - start w/esophagram + water soluble contrast

97
Q

Fluid collection s/p angioembolization for liver trauma - ddx?

A

Bile leak

Hematoma

98
Q

Large laceration involving R lobe of liver - next steps (OR)?

A

Manually compress liver to allow anesthesia time to catch up

Extend incision to xiphoid process, divide falciform ligament and place self retaining retractor

99
Q

Ways to control liver bleeding

A 
Energy devices (argon beam, electrocautery)
Vessel clips
Tissue staplers 
Suture ligation of vessels 
Packing
Hemostatic agents - combat gauze
Approximation of parenchyma by suturing capsule together using large chromics 
Pringle maneuver for inflow control
100
Q

Preperitoneal packing - OR

A

lower midline incision that doesnt violate peritoneum
retract the bladder
pack preperitoneal space and pelvis with lap pads
3 on each side (6 total)
close skin

101
Q

Continued pelvic bleeding s/p ex lap without identified source

A

Stabilize fracture - bedsheet, pelvic binder, etc
IR - stat angio + embolization
zone 3 reboa
expose and ligate hypogastric a

102
Q

REBOA - OR

A

Insert fem a line
Upsize to reboa insertion catheter by exchange over wire
flush catheter and ensure balloon deflated
connect pressure port of catheter to pressure transducer
advance peel away sheath to cover curled tip of catheter and advance to approx 46 cm for zone 1 and 26 cm for zone 3
inflate with saline - 8 cc for zone 1, 2 cc for zone 3, carefully incr volume as needed to ensure occlusion
secure
mark time and proceed to OR or IR

103
Q

REBOA - anatomic landmarks for estimation

A

mid sternum for zone 1

umbilicus for zone 3

104
Q

Physiol changes in pregnancy (3rd trimester)

A

mild tachycardia
plasma volume expands
tachypnea
hypotension

105
Q

Special H&P trauma eval for pregnancy pt

A

Check fundal height, assessing for uterine tenderness
Check for vaginal bleeding, amniotic fluid
Type and screen, fibrinogen
Notify OB team and plan for fetal monitoring and HR/contractions

106
Q

At what age is fetus considered viable

A

23 weeks

107
Q

Type & screen in preg patient - Rh negative

A

1 dose of anti d immunoglobulin and have KB test sent ( to see if additional rhogam needed)

108
Q

how to perform retrograde cystography

A

foley inserted
400 cc of dilute contrast instilled into bladder by gravity
foley clamped
xray or CT image obtained

109
Q

3 cm laceration through dome of bladder- repair?

A

carefully examine bladder -esp neck and urethral orifices
close defects in 2 layers using running absorbable suture
foley to stay x 2 weeks

110
Q

workup for rectal injury - secondary survey to include?

A

DRE

111
Q

imaging to eval for renal injury

A

CT pyelography - 3 phases
non contrast
corticomedullary phase
delayed expiratory phase *best for urinary leak

112
Q

options for coumadin reversal

A

4 factor PCC
FFP
vitamin K

113
Q

Quickly assess severity of TBI

A

GCS + pupillary exam

Ask about last time received sedatives/paralytics (which dont affect pupillary response!)

114
Q

Rocuronium - onset, duration

A

30 sec onset, 30 min duration

115
Q

ETomidate - onset, duration

A

60 sec on set, 5 min duration

116
Q

Etomidate - onset, duration

A

60 sec on set, 5 min duration

117
Q

Ketamine - onset, duration

A

30 sec onset, 10 min duration

118
Q

reversal of xarelto, eliquis, arixtra

A

PCC or adnexa

119
Q

reversal of pradaxa

A

praxibind

120
Q

TBI + spleen injury - what do you fix first?

A

spleen

121
Q

traumatic splenectomy - OR

A

ex lap
place lap pads behind spleen to elevate and medialize, carefully taking down attachments to diaphragm, kidney and colon in the process
once medialized, ID, control and transect hilar vessels with laparoscopic stapler (or clamp and suture ligate individually)
transect short gastrics with vessel sealers
carefully examine hilar and short gastrics to ensure hemostasis

122
Q

Assess brainstem function

A

testing respiratory drive, pupillary light, corneal cough and gag reflexes

123
Q

Brain death pre-requisites

A

American academy of neurology 2010 guidelines
prerequesites must be met: coma 2/2 known cause, neuroimaging that explains coma, SBP >100 mm Hg for which pressors may be used,absence of CNS depressing drugs in system, core temp >36 celsius, absence of spontaneous respirations

124
Q

Pt doesnt meet criteria for brain death testing - other options?

A

Ancillary testing, such as brain perfusion scan, cerebral angiography, transcranial doppler, CTA, MRA

125
Q

PE consistent with brain death

A

nonreactive pupils, absent corneal, oculovestibular, oculocephalic, gag and cough reflexes, absent motor response to noxious stimuli in all 4 limbs, absent facial movements to noxious stimuli at supraorbital and TMJ
apnea testing confirms absence of spontaneous respirations in the setting of documented pCO2 rise which includes pCO2 >60 or increase in baseline >20 mmHg

126
Q

qSOFA score components

A

AMS
SBP < or = 100 mmHg
RR > or = 22 breaths/min

127
Q

Goals of resuscitation to be attained during first 6 hours after recognition of sepsis

A 
CVP 8-12
MAP >65
UOP >0.5 mL/kg/hr
ScvO2 of 70% or SvO2 of 65%
Normalization of lactate
128
Q

% of calories that should come from carbs

A

60%

129
Q

% of calories that should come from fat

A

25-30%

130
Q

% of calories from protein

A

10-15%

131
Q

how many kcal is dextrose

A

3.4 kcal/g

132
Q

how many kcal is protein

A

4 kcal/g

133
Q

how do you calculate nitrogen balance

A

protein intake divided by 6.25 - (UUN + 4)

134
Q

Post op oliguria - H&P, first step s

A 
Assess volume status (CVP, swan, echo)
Baseline renal function/trend
Perioperative events - large volume resusc/transfusions?
HoTN (ptx, MI, PE?)
Review meds potentially toxic to kidneys
Is foley patent 
check bladder pressure
135
Q

REason for decreased ventilator volumes and elevated airway pressures in ACS

A

Pulmonary compliance suffers as PVR increased due to increased intrathoracic pressures

136
Q

Open pelvic fx - surgical tx for the belly?

A

Diverting sigmoid colostomy regardless of rectal injury

137
Q

Late finding in compartment syndrome

A

absence of pulses

138
Q

Sensory finding corresponding to anterior compartment

A

first web space (deep peroneal nerve)

139
Q

sensory finding corresponding to lateral compartment

A

dorsum of foot (superficial peroneal nerve)

140
Q

sensory finding corresponding to deep posterior compartment

A

sensation of plantar surface (tibial nerve)

141
Q

How to measure compartment pressure

A

use solid state rtransducer intracompartmental cathteer
attach 16-g needle to an A line setup with 3 way stopcock
using sterile saline, xero monitor, and inject 1 cc into compartment

142
Q

surgical decompression for compartment syndrome of extremity when compartment pressures are > than?

A

40 mm Hg

or within 30 mm Hg of distalic BP

143
Q

LE fasciotomy

A

Make 2 incisions
1st incision from knee to ankle, centered between anterior and lateral compartments
Divide fascia 1 cm above and below intermuscular septum to free anterior and lateral compartments
Avoid superficial peroneal n in lateral compartment
2nd incision from knee to ankle and 2 cm posterior to the posteromedial border of the tibia
Avoid saphenous vein
Divide fascia overlying gastroc and soleus muscles (medial compartment)
Detach soleus from posterior tibia to reach fascia of deep compartment and incise

144
Q

Surgical treatment for duodenal injury - exposure

A

R/o injury to pancreas and adjacent ductal and major vascular structures
Extended Kocher fro mporta hepatis to superior mesenteric vessels (posterior duo)
Extended mobilization from L side as well to divide LoT in order to see D3/D4
Add Cattell-Braasch maneuver (mobilize entire right colon out of retroperitoneum to look at ureter, vena cava, right kidney)

145
Q

Intraoperatively diagnosed intramural hematoma of duodenum

A

explore and rule out full thickness laceration ro leak

146
Q

simple laceration of duodenum - repair?

A

primary with two layer closure transversely +/- omental patch

147
Q

large laceration to seocnd portion of duodenum or unable to do primary repair

A

roux en y reconstruction

148
Q

Lower 1/3 ureteral injury

A

ureterneocystostomy +/- psoas hitch

149
Q

middle 1/3 ureteral injury

A

end-to-side ureteroureterostomy to other ureter

150
Q

proximal 1/3 ureteral injury

A

nephrostomy tube in ipsilateral kidney

151
Q

injury to renal vein - stable vs unstable pts

A

repair in stable

otherwise ligate

152
Q

renal a injury - stable vs unstable

A

repair in stable

otherwise nephrectomy

153
Q

what must you remember to check on PE in a pelvic fx

A

meatus, rectum

154
Q

deep liver laceration - OR

A

finger fx and ligation of indivdual vessels
liver suture to reapproximate injured area
pack laceration with vascularized tongue of omentum mobilzied from transverse colon

155
Q

ext3ensive liver injury (bilobar, hepatic venous injury ,retrohepatic cava) - OR

A

mobilize liver
gauze packing anteriorly and posteriorly to tamponade bleeding
temporary abdominal wall closure
angioembolization via IR
return to OR in12-36h after resuscitation
plan to ask for help and have amble blood products available
offer to transfer with open abdomen to higher level of care at level 1 trauma center

156
Q

hepatic v injury - OR

A

pringle maneuver to control INFLOW - if bleeding stops, its from hepatic artery and/or portal vein
consider total hepatic isolation and/or atriocaval shunt
Place tourniquet around infrahepatic IVC, perform median sternotomy, open pericardium, place Rummel tournqieut around intrapericardial IVC then try an atriocaval shunt by placing chest tube down through hole in RA and below level of liver injury

157
Q

Post op liver trauma mgmt

A

Consider ERCP esp if bile leaking from drains

fever is common so work up for all infectious causes

158
Q

Blood at urethral meatus - next step?

A

urethrogram first - if positive, suprapubic cystostomy

if negative, cystogram

159
Q

zone 1 neck

A

clavicles to cricoid

proximal carotid, subclavian, vertebrals, esophagus, trachea, brachial plexus, spinal cord, thoracic duct, upper lung

160
Q

zone. 2 neck

A

cricoid to angle of mandible

carotid, vertebral, jugular, larynx, esophagus, trachea, vagus, recurrent laryngeal, spinal cord

161
Q

zone 3 neck

A

angle of mandible to base of skull

pharynx, distal carotid, vertebrals, parotid, cranial nn

162
Q

incision/mgmt of zone 1 injury to neck

A

typically requires median sternotomy to access R subclavian and innominate
Trap door may be needed to access left subclavian artery if left of midclavicular line

163
Q

incision/mgmt of zone 2 injury to neck

A

cervical incision like CEA along anterior border of SCM

isolated trachea injury can do collar incision

164
Q

incision/mgmt of zone 3 injury to neck

A

cephalad extension of unilateral cervical neck incision

non operative mgmt and IR embolization preferred if possible

165
Q

Indications for IVC filter

A

pts with recurrent PE despite therapeutic anticoagulation
pts who have undergone mechanical thrombolysis or surgical embolectomy
pts who cannot be anticoagulated

166
Q

alternative to abthera

A

ioban over drains hooked to suction

167
Q

alternative to abthera

A

ioban over drains hooked to suction

168
Q

right subclavian - proximal exposure

A

takeoff of innominate

median sternotomy

169
Q

right subclavian - distal control

A

axillary

170
Q

6 steps for vascular OR scenario

A 
diagnose the rpoblem
locate the problem - CTA is ideal 
heparinize pt 
fix the problem
completion angiogram
consider fasciotomy
171
Q

left subclavian - proximal exposure

A

anterolateral thoracotomy in 2nd intercfostal space

172
Q

left subclavian - distal control

A

axillary

173
Q

suprahepatic IVC - where do you put your clamp

A

between diaphragm and heart
can do thoracotomy
ID where phrenic nerve/artery are and lacerate diaphragm parallel to that and access with satinsky clamp

174
Q

infrahepatic IVC - be mindful of?

A

renal vein

175
Q

principals in repair of kidney

A

use pledgets

leave drain

176
Q

zone 3 penetrating - explore?

A

yes

177
Q

exposure: ascending aorta

A

median sternotomy

178
Q

exposure: transverse aortic arch

A

median sternotomy +/- neck extension

179
Q

exposure: descending thoracic aorta

A

left posterolateral thoracotomy (4th ICS)

180
Q

exposure: innominate artery

A

media nsternotomy with right cervical extension

181
Q

exposure: left CCA

A

median sternotomy with leftcervical extension

182
Q

exposure: pulmonary artery (main, intrapericardial)

A

median sternotomy

183
Q

exposure: pulmonary artery (right or left hilar)

A

ipsilateral posterolateral thoracotomy

184
Q

exposure: pulmonary vein

A

ipsilateral posterolateral thoracotomy

185
Q

undiagnosed injury to the chest: exposure

A

left anterolateral thoracotomy

186
Q

conduit of choice in vessels >5 mm

A

prosthetic graft

187
Q

tracheostomy - OR

A

Vertical midline incision
Divide platysma and straps
Develop pretracheal space at leve lof cricoid cartilage
Divide isthmus using electrocautery
Place 2-0 prolene through 3rd tracheal ring laterally on each side (deflate your ETT cuff)
Use scalpel to incise between rings 2&3 and 3&4, divide 3rd ring to make H shape
Tracheal spreader
Withdraw ETT and insert tracheostomy tube
Confirm ET CO2
2-0 prolene to reapproximate above and below tube and secure to skin

188
Q

cricothyroidotomy - OR

A

Use a 10 blade to make vetrtical incision from prominence of thyroid cartilate to below level of cricoid
Use curved hemostat to pop through cricothyroid membrane
Advance a 15 Fr Bougie through opening into trachea
6-0 ETT over the bougie into trachea and inflate balloon
Confirm ET CO2
Use 0 silk to secure ETT

189
Q

Total inflow occlusion to heart

A

SVC and IVC at intrapericardial location

Can only do so for 1-3 min

190
Q

Repair of atrial injury - what suture

A

2-0 monofilament in running or interrupted

Make sure to debride

191
Q

Repair of ventricular injury - what suture

A

2-0 monofilament with pledgets

192
Q

Rapid sequence intubation

A

Preoxygenate
Etomidate 0.3 mg/kg
Succinylcholine 1 mg/kg

193
Q

RSBI goal in SBT

A

<105

194
Q

Indications for RRT in ARF

A 
Volume overload
Hyperkalemia
Metabolic acidosis
Uremia
Azotemia
195
Q

Electrolyte disturbances in adrenal dysfunction in ICU

A

hypoglycemia
hyponatremia
hyperkalemia

196
Q

supraceliac aorta control

A

lesser sac opened by dividing gastrohepatic ligament, dissect down onto superior aspect of pancreas
Mobilize pancreas
Divide crura

ORAL BOARDS (11 decks)

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