Emma Holliday for Surgery: Part III Flashcards
Review GCS scoring
Best Eye Response. (4) No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously.
Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated
Best Motor Response. (6)
No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localising pain. Obeys Commands
3 causes of increased ICP
Hematoma, edema, tumor
Symptoms of increased ICP
Headache, vomiting, altered mental status
How do we treat increased ICP
Elevate HOB, hyperventillate to pCO2 28-32, give mannitol (watch renal fxn)
Surgical intervention: Ventriculostomy
We can get trauma to the neck in a question stem by a gunshot wound or stab wound. The problem is that we treat differently based on the zone we are in.
What are the neck zones and what do we due with a wound like this
Zone 3 is above the angle of the mandible. Do an aortography and triple endoscopy
Zone 2 is between the angle of the mandible and the cricoid. Do a 2D doppler +/- exploratory surgery
Zone 1 is below the cricoid. Do an aortography
What do we do with a GSW to the abdomen?
Exploratory lap. No matter what.
If we get a stab wound to the abdomen things get more complicated. When do we do an ex lap in this case?
If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration? Do an ex-lap and give tetanus prophylaxis.
If stab wound but pt is stable? Do a FAST exam, DPL if FAST is equivocal. Ex-lap if either is positive.
If someone has a blunt trauma to the abdomen, what do we do?
Hypotensive and tachycardic? Do an Ex-Lap.
Stable? Abdominal CT
On AXR, black underneath the diaphragm =
Go directly to ex-lap, they have fluid, and you don’t know where it is coming from.
Lower rib fracture and bleeding into the abdomen s/p blunt abdominal trauma =
Spleen or liver laceration
If lower rib fracture plus hematuria s/p blunt abdominal trauma =
Kidney lac
If Kehr sign (what is this) and viscera in the thorax on CXR s/p blunt abdominal trauma =
Diaphragm rupture
Kehr’s sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr’s sign in the left shoulder is considered a classic symptom of a ruptured spleen.[1] May result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury or ruptured ectopic pregnancy.
Kehr’s sign is a classic example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is because the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.
If handlebar sign (what is this) s/p blunt abdominal trauma =
Pancreatic rupture
The pancreas may be injured in abdominal trauma, for example by laceration or contusion.[5] Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children and vehicular accidents in adults, usually occur in isolation in children and accompanied by other injuries in adults.[5] Indications that the pancreas is injured include enlargement and the presence of fluid around the pancreas
If patient is stable with epigastric pain s/p blunt abdominal trauma…
Still do an abdominal CT since they are stable. If retroperitoneal fluid is found, consider a duodenal rupture.
If hypotensive and tachycardic after pelvic trauma…
FAST and DPL to r/o bleeding in abdominal cavity.
If blood at the urethral meatus and a high riding prostate after pelvic trauma?
Consider pelvic fracture w/ urethral or bladder injury.
Next best step is Retrograde urethrogram (NOT FOLEY!)
If retrograde urethrogram is normal with blood at the urethral meatus and a high riding prostate after pelvic trauma?
Retrograde cystogram to evaluate bladder
Check for extravasation of dye. Take 2 views to ID trigone injury
If extraperitoneal extravasation, do bed rest and foley.
If intraperitoneal extravasation, do ex-lap and surgical repair.
When do fractures of any kind go to the OR?
–Depressed skull fx
–Severely displaced or angulated fx
–Any open fx (sticking out bone needs cleaning)
–Femoral neck or intertrochanteric fx
Shoulder pain s/p seizure or electrical shock
Post. shoulder dislocation
Arm outwardly rotated, & numbness over deltoid
Ant. shoulder dislocation
old lady FOOSH, distal radius displaced
Colle’s fracture
young person FOOSH, anatomic snuff box tender.
Scaphoid fracture
–“I swear I just punched a wall…”
Metacarpal neck fracture “Boxer’s fracture”. May need K wire
Clavicle most commonly broken where?
Between middle and distal 1/3s. Need figure of 8 device
Fever POD 1
Low fever under 101 with productive cough? What do we do about it?
Atelectasis.
Do a CXR and treat with mobilization and incentive spirometry
Fever POD 1
High fever to 104, very ill
Necrotizing fasciitis that spreads along scarpas fascia in sub Q.
Most commonly GABHS or c. perfringens
Tx with IV PCN, go to OR and debride skin until it bleeds
Fever POD 1
High fever > 104 with muscle rigidity
Malignant hyperthermia from succinyl Choline or halothane anesthesia, usually also secondary to a genetic defect in ryanodine receptor
Treat with Dantrolene Na which blocks the RYR and decreased intracellular calcium
Two options for fever POD 3-5
Pneumonia - Fever, productive cough, diaphoresis. Treat with sputum culture for abx, cover with moxicillin to cover strep pneumo in the meantime.
UTI - Fever, dysuria, frequency, urgency, particularly in a foley patient. Get a UA and culture. Treat with a new foley and wide spec abx until culture returns
Fever after POD 7 with pain at IV site
Central line infection. Do blood cx from the line site, pull it, and give abx to cover staph