ER, TRAUMA, ICU, SURGERY Flashcards
2 components of disability portion of trauma assessment
Glasgow coma scale and finger-stick blood glucose.
4 classic findings in a basilar skull fracture
Raccoon eyes
Battle sign (bruises on mastoid process)
Bloody TM
CSF coming out of nose or ears
Cushing’s triad
HTN + bradycardia + bradypnea
Rx involved in treatment of anterior spinal cord syndrome following a traumatic injury
Immediate high-dose IV steroids, ideally within 8 hours of methylprenisolone
Zone 1 of the neck
Clavicle – > cricoid cartilage. Includes great vessels, aortic arch, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots.
Zone II of the neck
Cricoid cartilage –>angle of the mandible. Carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, cervical spine, and spinal cord
Zone III of the neck
Angle of the mandible –>base of the skull. Salivary and parotid glands, esophagus, trachea, cervical spine, carotid arteries, jugular veinS*, major cranial nerves.
Penetrating injury to zone I: initial assessment
4 vessel CTA
Penetrating injury to zone II: initial assessment
surgical exploration or doppler US + selective exploration
Penetrating injury to zone III: initial assessment
4 vessel CTA + triple endoscopy
If chest tube placement is delayed in tension ptx, what should be done in the meantime?
Needle decompression on the affected side at the 2nd or 3rd IC space at midclavicular line or 5th IC space at midaxillary line
Important part of treatment in flail chest
ANALGESIA! otherwise, patient may become hypoxic from limiting breathing due to pain.
What are the next steps in mgmt of blunt abdominal trauma in a patient with STABLE vital sings?
ABC, establish IV access at 2 sites with large bore IV, NG tube and Foley, CT And/Pelvis, Stat H&H +/- blood type and cross.
What are the next steps in mgmt of patient with blunt abdominal trauma and UNSTABLE vitals?
Primary and secondary survey, asses for and manage pelvic fx, FAST, if no blood in pelvis and angio is normal, CT Abd/pelvis + observation +/- admission
If blunt trauma without blood in abdomen, next steps?
Follow H+H. If hemodynamically unstable or falling H+H, angio with possible embolization.
What are the classic signs for a urethral injury?
Look for blood at urethral meatus, high riding “blamable” prostate, or absence of palpable prostate. If signs of injury, perform retrograde urethrogram to rule out injury prior to Foley cather placement.
Criteria that must be met prior to discharge of pregnant woman after traumatic event?
Contractions occurring no more often than >1 q 10 min.
Normal fetal heart tracing
No vaginal bleeding
No abdominal pain
Chest trauma + hypotension + JVD + distant heart sounds –>next step?
Pericardiocentesis
Pelvic fracture + DPL shows blood in pelvis
Emergent lap
Pelvic fracture + DPL shows urine in the pelvis
Urgent lap
Pelvic fx + DPL shows nothing + hemodynamic instability
Angio with poss embolization
Blunt abdom trauma + unstable vital signs + FAST shows fluid in pelvis
Emerg lap
Blunt abdom trauma + unstable vital signs + FAST shows NO fluid in pelvis
Angio with possible embolization
Blunt abdominal trauma + unstable vital signs + FAST inconclusive
DPL
1-4 points in Eye Opening category of GCS
Spontaneous = 4
To voice = 3
To pain = 2
None = 1
1-5 points in Verbal Response category of GCS
Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible = 2 None = 1
1-6 points in Motor response category of GCS
Obeys commands = 6 Localizes pain = 5 Withdraws from pain = 4 Flexion with pain = 3 Extension with pain = 2 None = 1
While the head of an unconscious patient is turned, a patient’s eyes follow the movement, rather than being fixed at a point in space. This is suggestive of which injuries?
Vestibular, cranial nerve, pontine, or medullary.
Important part of treatment in neck trauma (penetrating injury)
Prophylactic abx due to increased risk of contamination by oropharyngeal flora.
Anatomic differences in post-traumatic pregnant patient
IVC compression by uterus makes pregnant women more susceptiblle to poor CO following injury.
Decreased risk of GI injury from lower and trauma because of superior displacement of bowel by the uterus (but greater risk of GI injury from upper abdominal or chest trauma)
Who gets examined first – mother or fetus?
Mother
Describe superficial partial thickness burn
FIRST DEGREE. It is painful. There is erythema and BLISTERS. Capillary refill is INTACT.
Describe signs and symptoms of second degree burn
Painful with blisters. Does NOT blanch with pressure.
%BSA of palm
1%
What is unique to mgmt of electrical burn patients as compared to heat burn patients
Aggressive IVF to prevent myoglobinuria, renal failure n and acidosis in the face of muscle necrosis.
High index of suspicion for compartment syndrome.
Obtain an EKG and monitor for dysrhythmias.
When should a burn patient be transferred to a burn center
Full thickness burn >5% BSA Partial thickness >10% BSA Any burn to face, genitals, perineum, or major joints Circumferential burns Electrical or lightning injury Inhalation injury Fracture or other trauma assoc with burn Pre-existing medical problems (e.g. DM, sickle cell) or special psychosocial or rehab needs.
5 Common life threatening complications in pt with substantial burns
Hypovolemia -- > shock Sepsis due to PNA or pseudomonas Inhalation Cardiac dysrhythmia Renal failure
In heat stroke, what is the best method of cooling
Via evaporation, so continuous fanning and spraying of skin with lukewarm water
Treatment for black widow spider bite with mild skin reactions
Tetanus toxoid ppx
Treatment for black widow spider bite with necrotic center >2 cm
5-7 days corticosteroids
Abx if signs of infection in black widow spider bite
Erythromycin
How can we possibly reduce extent of local necrosis in black widow spider bite
Consider dapsone due to leukocyte inhibitory properties. But obviously r/o G6PD deficiency first due to risk of hemolytic anemia
If systemic symptoms after black widow spider bite ..
Calcium gluconate q2 hrs for muscle pain Benzos for AMS Steroids Nitrates for HTn Methocarbamol for muscle spasm Analgesia with acetaminophen +/- opioids Antivenom ideally within 30 min
Higher likelihood of infection after dog/cat bite if ..
Cat bite Eats wet food Presents >6-12 hrs post-bite Presents >12-24 hrs post-bite to face Immunocompromised host
When do pts get rabies ppx after animal bite
If animal cannot be observed for 10 days or if animal is suspected to be rapid
Abx choices for animal bites
Amp/sulbactam then Amox/clav
Clinda + FQ
Clinda + Bactrim DS
Anticholinergic sx and antidote
Hot as a hare, dry as a bone, red as a beet, blind as a bat (mydriasis, cycloplegia) and mad as a hatter, bloated as a toad, tachycardia, decreased or absent BS.
Antidote: pralidoxime, atropine
S&S of organophosphate poisoning
Diarrhea, urination, miosis, bronchospasm, bradycardia, emesis and excitation of skeletal muscle, lacrimation, sweating, salivation, and abdominal cramping.
Describe phases of iron toxicity
GI phase 30 min - 6 hrs post ingestion
Latent/stable phase 6-24 hrs post ingestion
Shock and metabolic acidosis 6-72 hrs post ingestion
Hepatotoxicity/hepatic necrosis 12-96 hrs post ingestion
Bowel obstruction 2-8 wks post ingestion
Treatments tO NOT USE ** for ingestion of alkali plumbing liquid
Ipecac, a neutraliz agent which will improve nothing but amy result in thermal injury
NG tube which may lead to perf or emesis of caustic
Surveillance EGD after ingestion of alkali plumbing liquid
Beginning 15-20 yrs after ingestion at interval of q1-3 yrs to evaluate for esophageal SCC
Almond scented breath
Cyanide poisoning
Ingestion can cause delayed onset parkinsons
Cyanide ingestion as basal ganglia is sensitive to cyanide
Accelerated junctional rhythm or bidirectional ventricular tachycardia suggests?
Digoxin toxicity until proven otherwise
Characteristic EKG changes in digoxin at therapeutic levels
Prolonged PR interval
“scooping” of ST segments
Most freq vital sign abnormality in digoxin toxicity
Bradycardia. Atrial tach with AV block is less common.
How do we indicate severity of digoxin toxicity?
Hyperkalemia.
When should hyperkalemia be treated in cases of dig toxicity?
Only if its causing EKG disturabnces. Avoid calcium which can worsen intracellular hyperkalemia.
Acid base disturbance in aspirin OD
Resp alkalosis from hyperventilation THEN a mixed res alkalosis and metabolic acidosis with elevated anion gap.
Why do pts that OD on aspirin often get tachypneic?
ASA stimulates medullary respiratory center
Why do pts that OD on aspirin often get hyperthermic?
ASA uncouples mitochondrial oxidative phosphorylation.
MCC of acute hemolytic transfusion reaction
ABO incompatibility
Treatment of chronic mesenteric iscehmia
Bypass, angioplasty
S&S of chronic mesenteric ischemia
“intestinal angina”
Dull crampy post prandial epigastric pain within first hour after eating then subsiding over 2 hours
Weight los d/t food aversion to avoid postprandial pain
N/V early satiety
Abdominal bruit in 50%
When is greatest risk for postop MI?
48 hours post op
What is recommended perioperatively for pts with known CAD?
Peri op beta blockers and telemetry monitoring
High doses of which vasopressor optimize alpha 1 vasoconstriction
epinephrine
Best vasopressor for septic shock
norepi
Best vasopressor for cariogenic shock
dobutamine
Which vasopressorr causes vasoconstriction and bradycardia
Phenylephrine
Which blood product is most appropriate in DIC
FFP with or without platelets
Which blood product is most appropriate in severe anemia due to autoimmune hemolytic anemia
PRBC
Which blood product is most appropriate in shock due to trauma or post partum hemorrhage
Whole blood or PRBC
Which blood product is most appropriate in hemorrhage due to warfarin overdose
FFP
Which blood product is most appropriate when you need a vWF rich blood product
Cryo
Preferred vessels in placement of Swan Ganz
Right IJ or left subclavian
Some interventions to protect kidneys in times of anticipated insult
N-acetylcysteine 24 hours before and after
IVF
Sodium bicarb 1 hr before and about 6 hrs after
