inflammation, wound healing, trauma/ICU/Burn

Question 1

phases of inflammation

Answer 1

injury-> exposed collagen-> plt activating factor release and tissue factor release from endothelium-> platelets bind collagen-> release growth factors (ie-ptl-derived GF PDGR)-> PMN and macrophage recruitment

Question 2

role of macrophages in wound healing- what do they release

Answer 2

dominant role, release PDGF (plt derived GF) and cytokines (IL-1 and TNF-alpha)

Question 3

Growth and activating factors in inflammation: role of the following

1) PDGF (platelet derived growth factor)
2) EGF (epidermal growth factor)
3) FGF (fibroblastic growth factor)
4) PAF (platelet-activating factor)

Answer 3

1) chemotactic and activates inflammatory cells (PMNs and macrophages) and activates fibroblasts-> ECM proteins and collagen. Imp for angiogenesis and epithelialization. Chemotactic for smooth muscle cells. accelerates wound healing
2, 3) Chemotactic, activates fibroblasts, angiogenesis, epithelialization
4) generated by phospholipase in endothelium (a phospholipid) which is chemotactic for inflam cells and inc adhesion mlqs

Question 4

1) what are the chemotactic factors for inflammatory cells
2) for fibroblasts
3) angiogenesis factors
4) epithelialization factors

Answer 4

1) PDGF, IL-8, LTB-4, C5a and C3a, PAF
2) PDGF, EGF, FGF
3) PDGF, EGF, FGF, IL-8 and hypoxia
4) PDGF, EGF, FGF

Question 5

1) How long do PMNs last in tissues and in blood
2) how long do platelets last
3) lymphocyte role in inflammation

Answer 5

1) 1-2 days in tissues, 7 days in blood
2) 7-10 days
3) involved in chronic inflammation (T cells) and Ab production (B cells)

Question 6

Type 1 hypersensitivity rx:

1) role of eosinophils
2) what type of infections have increased eosinophils
3) role of basophils, where aren’t they found
4) Mast cells role
5) role of histamine
6) role of bradykinin
7) what inactivates bradykinin and where is it found

Answer 6

1) release major basic protien once bound to allergin-> stimulates basophils and mast cells to release histamine
2) parasitic
3) main source of histamine in blood (not in tissue)
4) main source of histamine in tissues, primary cell in type 1 hypersensitivity
5) vasodilation, tissue edema, postcapillary leakage; primary effector type in type I hypersensitivity rxs (allergic rxs)
6) peripheral vasodilation, increased permeability, pain, pulm vasoconstriction
7) Angiotensin-converting enzyme located in lung

Question 7

Nitric oxide

1) what is its precursor
2) what does it activate and end effect
3) another name for it
4) what has the opposite effect of NO

Answer 7

1) Arginine
2) guanulate cyclase-> inc cGMP-> vascular smooth muscle dilation
3) endothelium-derived relaxing factor
4) Endothelin-> vascular smooth muscle constriction

Question 8

cytokines

1) main initial cytokine resonse to injury and infection is release of

Answer 8

1) TNF-alpha and IL-1

Question 9

cytokines

1) largest producer of TNF
2) role of TNF-alpha
3) what can high concentrations of TNF-a cause
4) largest producer of IL-1
5) effects of IL-1 and what does it synergize with
6) which cytokine causes cachexia in CA pts
7) which cytokine is responsible for fever and how?
8) how do NSAIDS reduce fever
9) role of IL-6

Answer 9

1) Macrophages
2) increases adhesion mlqs, procoagulant, activates neutrophils and macs-> more cytokine production and cell recruitment
3) circulatory collapse and multisystem organ failure
4) macs
5) same as TNF-alpha, synergizes with TNF-alpha
6) TNF-alpha
7) IL-1 (how alveolar macs cause fever with atelectasis), PGE2 mediated in hypothalamus
8) reduce PGE2 synthesis
9) increases hepatic acute phase proteins (CRP, amyloid A -> activate complement), decreases albumin, pre-albumin and transferrin

Question 10

Interferons

1) what are they released by
2) what stimulates release
3) effect of release

Answer 10

1) lymphocytes
2) viral infection or other stimulants
3) activate macs, NK cells and cytotoxic T cells-> inhibit viral replication

Question 11

Cell adhesion mlqs- where are they located, what they bind and type of adhesion

1) Selectins
2) Beta-2 integrins (CD11/18 molecules)
3) ICAM, VCAM, PECAM, ELAM

Answer 11

1) L-selectins on leukocytes bind E- (endothelial) and P-(platelet) selectins-> rolling adhesion
2) on leukocytes, bind ICAM etc-> anchoring adhesion
3) on endothelial cells, bind beta-2 integrin mlqs located on leukocytes and platelets. Also involved in transendothelial migration

Question 12

Complement- what activates the following pathways and what factors are only in each one

1) classic pathway
2) alternative pathway
3) what complement factor is common to both pathways
4) what electrolyte is required for both pathways

Answer 12

1) (IgG or IgM) Ag-Ab complex activates. Factors C1, C2, C4
2) endotoxin, bacteria, other stimuli activate. Factors B, D and P (properdin)
3) C3
4) Mg

Question 13

Complement

1) factors that are anaphylatoxins and actions
2) membrane attack complex factors and actions
3) opsonization factors and action
4) factors involved in chemotaxis for inflammatory cells

Answer 13

1) C3a, C4a, C5a. increase vascular permeability, bronchoconstriction and activate mast cells and basophils
2) C5b-9b-> cell lysis (usually bacteria) by creating hole in the membrane
3) C3b and C4b- targets Ag for immune response
4) C3a and C5a

Question 14

Prostaglandins

1) precursor
2) LTC4, LTD4, and LTE4 actions
3) LTB4 actions

Answer 14

1) arachidonic precursors
2) slow-reacting substances of anaphylaxis, bronchoconstriction, vasoconstriction followed by increased permeability
3) chemotactic for inflammatory cells

Question 15

Catecholamines

1) when after injury do they peak
2) where is norepinephrine released?
2) where is epinephrine released?

Answer 15

1) 24-48hours
2) sympathetic postganglionic neurons and adrenal medulla
3) adrenal medulla (neural response to injury)

Question 16

T/F thyroid hormone plays a major role in injury/inflammation

Answer 16

false

Question 17

neuroendocrine response to injury

Answer 17

afferent nerves from site of injury stimulate CRF, ACTH, ADH, growth hormone, epi and norepi release

Question 18

CXC chemokines

1) what are they
2) what is their role
3) what does CXC stand for

Answer 18

1) IL-8 and platelet factor 4
2) chemotaxis, angiogenesis, wound healing
3) C=cysteine, X= another amino acid

Question 19

1) what oxidants are generated in inflammation

2) what are cellular defenses against oxidative species

Answer 19

1) superoxide anion radical (NADPH oxidase), hydrogen peroxide (xanthine oxidase)
2)superoxide anion radical- defense is superoxide dismutase
hydrogen peroxide- defence is glutathione peroxidase, catalase

Question 20

primary mediator of reperfusion injury

Answer 20

PMNs

Question 21

Chronic granulomatous disease:

1) enzyme defect and result

Answer 21

NADPH-oxidase system enzyme defect in PMNs-> decreased superoxide radical formation-> increased infection from bacteria and fungi

Question 22

stages of wound healing- cells involved, what happens during each and time frame

1) Inflammation
2) proliferation
3) remodeling

Answer 22

1) days 1-10. PMNs, macs. Epithelialization (1-2mm/day)
2) 5days-3wks. fibroblasts. collagen deposition, neovascularization, granulation tissue formation; type III collagen replaced with type 1
3) 3wk to 1 year. decreased vascularity. net amount of collagen unchanged despite sig production and degradation

Question 23

rate of

1) epithelialization
2) peripheral nerve regeneration

Answer 23

1) 1-2 mm/day

2) 1mm/day

Question 24

order of cell arrival in wound: PMNs, lymphoctes, macs, fibroblasts, platelets

Answer 24

1) platelets
2) PMNs
3) Macrophages
4) lymphocytes
5) fibroblasts

Question 25

role of the following in wound healing 1) macrophages 2) fibronectin 2) fibroblasts

Answer 25

1) release growth factors, cytokines, etc 2) chemotactic for macs; anchors fibroblasts 3) replace fibronectin-fibrin with collagen

Question 26

predominant cell type by day: 1) day 0-2 2) days 3-4 3) days 5+

Answer 26

1) PMNs 2) macrophages 3) fibroblasts

Question 27

1) composition of the platelet plug 2) composition of provisional matrix 3) what wounds show accelerated wound healing

Answer 27

1) platelets and fibrin 2) platelets, fibrin and fibronectin 3) reopened wounds bc healing cells already present

Question 28

Open wounds 1) most imp factor in healing open wounds 2) where does epithelium migrate from

Answer 28

1) epithelial integrity 2) hair follicles (#1 site), wound edges and sweat glands - dependent on granulation tissue in wound - unepithelialized wounds leak serum and protein and promote bacteria

Question 29

closed wounds | 1)most imp factor in healing

Answer 29

tensile strength- depends on collagen eposition and cross-linking of collagen

Question 30

1) which layer of bowel provides the strength | 2) what is weakest time point for small bowel anastamosis

Answer 30

1) submucosa | 2) 3-5days

Question 31

myofibroblasts- what are they, how do they communicate and what part of wound healing are they involved in

Answer 31

smooth muscle cell fibroblast. communicate by gap junction. Involved in wound contraction and healing by secondary intention.

Question 32

t/F: perineum has better wound contraction than leg

Answer 32

true

Question 33

which type of collagen is: 1) MC type, found in skin, bone and tendons. Primary collagen in healed wound 2) widepread, particularly found in cornea 3) increased in healing wound, also in blood vessels and skin 4) basement membranes 5) cartilage

Answer 33

1) type I 2) type V 3) type III 4) type IV 4) type II

Question 34

1) what aa improves wound tensile strength 2) which of the following are not required for hydroxylation and subsequent cross-linking of proline residues: Alpha-ketoglutarate, Magnesium, Vitamin C, Oxygen and Iron

Answer 34

1) proline cross-linking. collagen has proline every 3rd aa. | 2) Magnesium

Question 35

cause of scurvy

Answer 35

Vit C deficiency

Question 36

1) max tensile strength of healed wound compared to pre-wound skin 2) what is predominant collagen over days 1-2 3) collagen over days 3-4 4) at what point has all of the type of collagen in #2 been replaced by the collagen in #3 5) when does wound reach max tensile strength 6) what inhibits collagen cross-linking

Answer 36

1) 80% 2) III 3) I 4) 3 weeks 5) 8 weeks 6) d-Penicillamine

Question 37

optimal wound healing 1) is dry or moist environment better 2) how to inc O2 delivery 3) effect of edema 4) which vitamin counteracts the effects of steroids on wound healing 5) what amount of bacteria impedes wound healing and why 6) what drugs impair wound healing in 1st 14d after injury

Answer 37

1) moist 2) optimize fluids, no smoking, pain control, supp O2, arterial revascularization 3) avoid it by leg elevation 4) vit A 5) >10^5 2/2 dec O2 content, collagen lysis, prolonged inflammation 6) cytotoxic drugs- 5FU, methotrexate, cyclosporin, FK-506

Question 38

1) how does DM contribute to poor wound healing 2) what albumin level sig risk for poor wound healing 3) mechanism via which steroids inhibit wound healing

Answer 38

1) impedes early-phase inflammation response (hyperglycemia causes poor leukocyte chemotaxis) 2) dec tensile strength

Question 39

Diseases associated with abnormal wound healing- name the defect 1) Osteogenesis Imperfecta 2) Ehlers-Danlos syndrome 3) Marfan's syndrome 4) Epidermolysis bullosa and rx 5) Scurvy 6) what extraintestinal manifestation of IBD is associated with abnl wound healing

Answer 39

1) Type I collagen defect 2) 10 types identifies, all collagen 3) fibrillin defect (connective tissue protein) 4) excessive fibroblasts. rx- phenytoin 5) vit C def 6) Pyoderma gangrenosum

Question 40

Diabetic foot ulcers 1) where they most commonly occur 2) 2/2 what? 3) cause of 90% of leg ulcers and rx

Answer 40

1) Charcot's joint (2nd MTP joint) MC, also on toes 2) peripheral neuropathy (can't feel-> pressure from walking-> ischemia) 3) venous insufficiency. rx- Unna boot (elastic wrap)

Question 41

1) what are scars made of 2) when to do scar revisions 3) what pts heal with little to no scarring

Answer 41

1) proteoglycans, hyaluronic acid and water 2) wait 1 year to allow for maturation, may improve with age 3) infants

Question 42

1) how does cartilage get nutrients and oxygen 2) does denervation effect wound healing 3) does chemo affect wound healing

Answer 42

1) diffusion. Doesn't have blood vessels 2) no 3) no effect on healing after 14 days

Question 43

Keloids 1) inheritance pattern 2) difference bw them and hypertrophic scars 3) rx 4) rx hypertrophic scars 5) when do hypertrophic scars occur

Answer 43

1) autosomal dominant, more common in dark skinned ppl 2) in keloids collagen goes beyond original scar where as hypertrophic scar collagen is confined to original scar 3) intra-lesion steroid injection, silicone, pressure garments, XRT 4) steroid injection, silicone, pressure garments 5) burns or wounds that take a long time to heal

Question 44

Platelet granules: 1) what are the alpha granules and what is their role 2) dense granules 3) platelet aggregation factors

Answer 44

1) platelet factor 4- aggregation beta thrombomodulin- binds thrombin platelet derived growth factor- chemoattractant Transforming growth factor beta (TGF-beta)- modulates above responses 2) adenosine, serotonin and Ca 3) TXA2, thrombin, platelet factor 4

Question 45

Trauma deaths by time after injury 1) when does 1st peak occur and associated injuries 2) when does 2nd peak occur and associated injuries 3) when does 3rd peak occur and associated injuries

Answer 45

1) 0-30min- lac of heart, aorta, brain, brainstem, spinal cord. no hope to save 2) 30min-4hr-head injury (#1), hemorrhage (#2)- golden hour. pts can be saved with rapid assessment 3) days to weeks-multi system organ failure and sepsis

Question 46

1) what % of trauma is blunt injury and what is most commonly injured organ 2) most commonly injured organ in penetrating injury 3) biggest predictors of survival after fall 4) what is the median lethal dose for fall (LD50)

Answer 46

1) 80%. Liver (although some texts say spleen) 2) small bowel (some texts say liver 3) age and body orientation 4) 4 stories

Question 47

kinetic energy calculation

Answer 47

1/2 MV^2; M=mass, V=velocity

Question 48

1) when will you see a change in BP with hemorrhage? | 2) resuscitation- when to switch to blood

Answer 48

1) >30% blood loss | 2) 2L LR then switch to blood

Question 49

MC cause of 1) death after reaching ER alive 2) death long term 3) upper airway obstruction

Answer 49

1) head injury 2) infection 3) tongue

Question 50

1) injuries from seat belts 2) best site for cutdown for venous access 3) positive DPL- what makes it + 4) what does DPL miss 5) where to do DPL if pelvic fracture 6) when might you get a false negative FAST

Answer 50

1) small bowel perf, lumbar spine fx, sternal fx 2) saphenous vein at ankle 3) >10cc blood, >100,000 RBCs/cc, food particles, bile, bacteria, >500WBC/cc 4) retroperitoneal bleeds, contained hematomas 5) supraumbilical 6) free fluid

Question 51

1) where might pts with hypoTN and neg FAST be bleeding 2) when do you need a CT scan following blunt trauma 3) what might a CT scan miss in trauma 4) when to go to OR for laparotomy (which doesn't require it: peritonitis, evisceration, positive DPL, uncontrolled visceral hemorrhage, free air, diaphragm injury, indeterminant FAST, intraperitoneal bladder injury, contrast extravasation from hollow viscus, specific renal/pancreas/biliary tract injuries

Answer 51

1) pelvic fx, chest, extremity 2) abdominal pain, need for gen anesthesia, closed head injury, intoxicants on board, paraplegia, distracting injury, hematuria, negative DPL 3) hollow viscus or diaphragm injury 4) negative FAST

Question 52

1) abdominal injuries- when do you need to go to the OR 2) first step after pt with penetrating anterior abd trauma, no obv peritonitis/eviscer and local wound exploration shows fascial violation or equivocal

Answer 52

1) any penetrating abd injury (GSW, evisceration), local wound exploration with fascial violation or equivocal. If no fascial violation can observe 2) diagnostic laparoscopy. If peritoneal violation-> explore. if no peritoneal violation-> d/c after recovery

Question 53

Abdominal compartment syndrome 1) when do you see it 2) bladder pressure 3) cause of decreased cardiac output 4) result of low Cardiac output 5) effect on ventilation/why? 6) rx

Answer 53

1) after massive fluid resuscitation, trauma or abdominal surgery 2) >25-30 3) IVC compression 4) visceral and renal malperfusion-> dec UOP 5) upward displacement of diaphragm affects ventilaton 6) decompressive laparotomy

Question 54

1) when to use Pneumatic antishock garment 2) when to do ER thoracotomy after a-blunt trauma b-penetrating tauma 3) how to perform thoracotomy 4) when should pt be transfered to OR after ED thoracotomy

Answer 54

1) pts with SBP70mmHg, if not situation is futile

Question 55

1) when do catecholamines peak after injury 2) change in ADH, ACTH and glucagon after trauma 3) type specific blood- why do ppl get reactions to it 4) What should you do for all GCS

Answer 55

1) 24-48 hours 2) fight or flight response-> increase ADH, etc 3) blood is nonscreened, non cross-matched so can get effects from abs to HLA minor Ag in the donated blood 4) Head CT 5) Intubate 6) ICP monitor

Question 56

Epidural hematoma 1) artery injured MC 2) shape on head CT 3) clinical picture 4) when to operate

Answer 56

1) middle meningeal artery 2) lenticular deformity 3) LOC-> lucid interval-> sudden deterioration (vomiting, LOC, restlessness) 4) significant neurologic degeneration or significant mass effect (shift >5 mm)

Question 57

subderal hematoma 1) vessel injured 2) shape on CT 3) when to go to OR 4) who gets chronic subdural hematomas

Answer 57

1) tearing of venous plexus (bridging veins bw dura and arachnoid) 2) crescent-shaped 3) sig neurologic degeneration or mass effect (>1cm shift)

Question 58

intracerebral hematoma- 1) where does it usually occur 2) when to operate 3) type of injury with coup and countrecoup lesions

Answer 58

1) frontal or temporal 2) significant mass effect 3) cerebral contusion

Question 59

1) treatment for traumatic intraventricular hemorrhage | 2) how to dxs diffuse axonal injury, treatment and prognosis

Answer 59

1) ventriculostomy if causing hydrocephalus | 2) MRI better than CT. Tx- supportive, craniectomy if elevated ICP, very poor prognosis

Question 60

How to calculate Cerbral Perfusion Pressure (CPP)

Answer 60

CPP=MAP- ICP (intracranial pressure)

Question 61

When to use an ICP monitor

Answer 61

GCS<=8, suspected inc ICP (dec ventricular size, loss of sulci, loss of cisterns) or pt with moderate to severe head injury and inability to follow clinical exam (ie- intubated pt)

Question 62

1) Normal ICP 2) When to treat ICP 3) where to keep CPP

Answer 62

1) 10 2) >20 3) >60

Question 63

``` How to increases Cerbral perfusion pressure? which of the following won't: sedation and paralysis lower head of bed relative hyperventilation (CO2 30-35) Mannitol Barbituate coma ventriculostomy with CSF drainage craniotomy decompression ```

Answer 63

must RAISE the head of the bed to increase CPP

Question 64

1) which side is the temporal pressure increased in for a dilated pupil 2) when does peak ICP occur 3) what can be given prophylactically to prevent seizures with moderate to severe head injury 4) how to dose mannitol 5) what level to keep Na and serum Osm in head injury pts

Answer 64

1) same side (CNIII, oculomotor compression) 2) 48-72hr after injury 3) keppra and fosphenytoin 4) load 1g/kg, give 0.25mg/kg q4hr after that (draws fluid from brain) 5) Na 140-150. Serum Osm 295-310 (may need to use hypertonic saline)

Question 65

1) What do Racoon eyes signal? 2) Battle's sign? and what is management 3) Nerve injured in basal skull fracture 4) nerves injured in temporal skull fx 5) what kind of blows are associated with temporal skull fx 6) when to operate for skull fx 7) cause of coagulopthy in traumatic brain injury 8) most common site of fascial nerve injury

Answer 65

1) per-orbital ecchymosis, anterior fossa fx 2) mastoid echymossis- middle fossa fx; can injure facial nerve CNVII. rx-if acute facial nerve injury, need exploration and repair. if delayed, likely 2/2 edema and exploration not needed 3) CN VII 4) CNVII and VIII (vestibulocochlear nerve) 5) orbital or lateral skull blows 6) if signficantly depressed (>1cm), contaminated, or persistant CSF leak no responding to conservative therapy (lumbar CSF drainage) 7) release of tissue factor 8) geniculate ganglion

Question 66

Spine trauma 1) Jefferson fracture- what level, cause, rx 2) Hangman's fracture- level, cause, rx 3) odontoid fx- level, 3 types and rx 4) Facet fx/dislocation- how they occur and what else can be injured?

Answer 66

1) C1 burst 2/2 axial loading. Tx- rigid collar 2) C2- caused by distraction and extension. rx- traction and halo 3) C2. Type 1- above base, stable; Type 2- at base, unstable (need fusion or halo); Type 3- extends into vertebral body (needs fusion or halo) 4) Can cause cord injury; associated with hyperextension and rotation with ligamentous disruption

Question 67

Thoracolumbar Spine 1) what comprises the 3 columns of the thoracolumbar spine? 2) when is thoracolumbar spine considered unstable 3) what column is affected by compression (wedge) fx? 4) what fx is unstable and rx 5) what fx is stable

Answer 67

1) Anterior- anterior logitudinal ligament and anterior 1/2 of vertebral body Middle- posterior 1/2 of vertebral body and posterior logitudinal ligament Posterior- facet joints, lamina, spinous processes, interspinous ligament 2) if >1 column disrupted 3) anterior column only, stable 4) Burst fractures (>1 column) require spinal fusion 5) Compression (wedge) fx

Question 68

1) bones that are at risk for injury in upright fall 2) when in spinal injury should you get an MRI? 3) indications for emergent spinal decompression

Answer 68

1) calcaneous, lumbar, wrist/forearm 2) neuro defects w/o bony injury to eval for ligamentous injury 3) fracture/dislocation not reducible with distraction, open fx, soft tissue or bony compression of cord, progressive neuro dysfnc

Question 69

1) most common cause of facial nerve injury in trauma 2) technique for repairing facial lacerations 3) Le Fort Classification of Facial Fractures I-III. describe. what is the rx

Answer 69

1) temporal bone fx 2) preserve skin and don't trim edges 3) Le Fort I- maxillary fx straifht across (-). rx- reduce, stabilize, intramaxillary fixation (IMF) +/- circumzygomatic and orbital rim suspension wires. Le Fort II- lateral to nasal bone, underneath eyes, diagonal toward maxilla (/ \). rx same as I Le Fort III-lateral orbital walls (- -). rx-suspension wiring to stablize frontal bone, may need external fixation

Question 70

1) what type of facial fx have a 70% CSF leak and rx of CSF leak 2) rx of nose bleeds

Answer 70

1) nasoethmoidal orbital fx. conservative therapy for up to 2 weeks. Can try epidural catheter to dec CSF pressure and help leak close, may need surgical closure of dura if above fail 2) anterior- packing posterior- try balloon tamponade 1st. May need angioembolization of internal maxillary artery or ethmoidal artery

Question 71

1) rx of orbital blowout fx and who needs repair 2) Tripod fx- what is it and how to repair 3) T/F: pts with maxillofacial fx are at high risk for cervical spine injuries

Answer 71

1) repair pts with upward gaze or diplopia with upward vision. rx- restoration of orbital floor with bone fragments or bone graft 2) Zygomatic bone fx- ORIF for cosmesis 3) True

Question 72

1) what is the #1 indicator of Mandibular injury 2) how to diagnose mandibular injury 3) rx

Answer 72

1) malocclusion 2) fine0cut facial CT with reconstruction 3) IMF (intramaxillary fixation- metal arch bars to upper and lower dental arches for 6-8wks) or ORIF

Question 73

Neck Trauma 1) 3 neck zones of injury 2) study to get in asymptomatic pt with blunt injury 3) in asymptomatic penetrating (by 3 neck zones) 4) in symptomatic blunt or penetrating injury (shock, bleeding, expanding hematoma, losing or lost airway, subq air, stridor, dysphagia, hemoptysis, neuro defect

Answer 73

1)ZOne I- clavical to cricoid cartilage. Zone II- Cricoid to angle of mandible. Zone III- angle of mandible to base of skull 2) neck CT 3) Zone I- (greater potential for intrathoracic great vessel injury) angiography, bronchoscopy, esophagoscopy and barium swallow. pericardial window may be indicated. May need medium sternotomy to reach lesions ZOne II-neck exploration in OR Zone III-angiography and laryngoscopy. May need jaw subluxatin/digastric and SCM muscle release/mastoid sinus resection to reach vascular injuries in this location 4) neck exploration in OR immediately

Question 74

``` Esophageal injury 1) how to diagnose 2) rx of contained injuries 3) rx of non-contained injuries if: a- small injury, minimal contamination b- extensive injury or contamination 4) Approach to esophageal injuries in: a- the neck b- upper 2/3 of thoracic esophagus c- lower 1/3 of thoracic esophagus ```

Answer 74

1) hardest neck injury to find. Do esophagoscopy and esophagogram (finds 95% of injuries when combined) 2) observe 3) a-primary closure. b-if in neck- just place drain (will heal). if in chest- chest tubes to drain injury and place spit fistula in neck (eventually will need esophagectomy) 4) a-left side, b- right thoracotomy, c- left thoracotomy

Question 75

Laryngeal fracture and tracheal injuries 1) sx 2) are these non-urgent, urgent or emergent? 3) rx

Answer 75

1) stridor, crepitus, resp compramise 2) emergent 3) secure airway in ER (usually cricothydoidotomy). then primary repair (can use strap muscle for airway support) _ tracheostomy for most to allow edema to subside and check for stricture (convert the cric to a trach)

Question 76

1) rx of thyroid gland injury 2) rx of recurrent laryngeal nerve injury 3) management of shotgun injures to neck 4) of vertebral artery bleeds 5) common carotid bleeds and complication

Answer 76

1) control bleed and drain (NOT thyroidectomy) 2) try to repair or reimplant in cricoarytenoid muscle) 3) get angiogram and neck CT, esophagus and trach evaluation 4) embolize or ligate without any sequela 5) ligation causes stroke in 20%

Question 77

Chest trauma: 1) when to go to OR for thoracotomy after CT placement 2) how quickly do you need to drain blood in hemothorax and why 3) management of unresolved hemothorax after 2 well-placed drains

Answer 77

1) >1500 cc after initial insertion in one side, >250cc/hr for 3 hours, >2500cc/24 hr or bleeding with instability 2)

Question 78

Sucking chest wound 1) how big does it need to be to be clinically significant 2) rx

Answer 78

1) >2/3 diameter of trachea | 2) cover wound with dressing that has tape on 3 sides to prevent tension pneumo

Question 79

1) what should you think about if pt has worsening oxygenation after chest tube placement 2) T/F Bronchus injuries are more common on the right 3) dx of thracheobronchial injury 4) rx- indications for repair and how to repair (type of incision)

Answer 79

1) tracheobronchial injury. one of the few indications to clamp NGT 2) True 3) bronchoscopy 4) may need to mainstem intubate pt on unaggected side repair if large air leak and respirator compromise or after 2 weeks of persistent air leak. - right thoracotomy for right mainstem, trachea and and proximal left mainstem injuries (avoids aorta) - left thoracotomy for distal left mainstem injuries

Question 80

Injuries of the diaphragm 1) where are they more common? 2) more common in blunt or penetrating trauma? 3) signs on CXR 4) type of approach for repair

Answer 80

1) on left 2) blunt trauma 3) air-fluid level in chest from stomach herniation 4) transabdominal if 1wk bc will have to take down adhesions in the chest. May need mesh

Question 81

1) what am I: widened mediastinum, 1st or 2nd rib fx, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to the right

Answer 81

1) aortic transection

Question 82

1) where is aortic transection most common 2) how good is CXR at diagnosing? 3) when should you do aortic evaluation if nl CXR 4) Dx of aortic transection 5) operative approach 6) if pt has aortic transection and + DPL twhat should be addressed first

Answer 82

1) ligamentum arteriosum (just distal to subclavian takeoff) is MC. also seen near ortic valve and where aorta traverses diaphragm 2) nl in 5% 3) significant mechanism (head on car crash >45 mph, fall >15ft) 4) CT angio chest 5) left thoracotomy and repair with left heart bypass of place covered stent endograft (distal transections only) 6) abdominal ex-lap first. Rx other life-threatening injuries first.

Question 83

What am I?: widened mediastinum, 1st or 2nd rib fx, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, trachea deviation to the right

Answer 83

aortic transection

Question 84

Aortic transection 1) MC place for tear and other places 2) How good is CXR at detecting 3) Diagnostic study 4) operative approach 5) T/F: you can not defer treatment to treat other life-threatening injuries or positive DPL first

Answer 84

1) ligamentum arteriosum just distal to subclavian takeoff (MC). Also, near aortic valve where aorta traverses diaphragm 2) misses 5%, need evaluation of aorta for pts with sig mech (head on car crash >45mph or fall >15ft 3) CT angio chest 4) left thoracotomy and repair with partial L heart bypass or place a covered stent endograft (distal transections only) 5) false, you can defer for other life-threatening injuries

Question 85

what operative approach should you use for the following injuries: 1) ascending aorta, innominate artery, proximal right subclavian artery, inominate vein, proximal left common carotid 2) left subclavian artery, descending aorta 3) distal right subclavian artery

Answer 85

1) median sternotomy 2) left thoracotomy 3) midclavicular incision with removal of medial clavical

Question 86

Myocardial contusion 1) what is MC cause of death 2) MC arrhythmia seen 3) how long to monitor and when is risk highest

Answer 86

1) v-tach and v-fib 2) SVT 3) risk highest in 1st 24 hours, monitor for 24-48hrs

Question 87

1) flail chest ddefinition and rx and biggest pulm impairment 2) T/F: aspiration produces immediate CXR findings

Answer 87

1) 2+ consecutive rib fx with 2+ break sites. rx- occlusive dressing taped at 3 sides. can result in underlying pulm contusion 2) false- may not be immediate

Question 88

Penetrating Chest injuries 1) first imaging study in stable pts 2) penetrating "box" injuries- location and studies to do to dx injuries 3) penetrating chest wound outside box w/o pneumo or hemothorax- what to do 4) what to do if find blood on doing pericardial window? 5) when do you need to go to OR for laparoscopy or laparotomy

Answer 88

1) CXR (if pneumothorax or hemothorax place a chest tube) 2) borders are clavicles, xiphoid process, nipples - do pericardial window, bronchoscopy, esophagoschopy, barium swallow 3) need chest tube if pt req intubation otherwise just follow serial CXR 4) median sternotomy to fix possible injury to heart or great vessels, place pericardial drain 5) penetrating injuries anterior-medial to midaxillary line below the nipples (may also need penetrating box injury eval)

Question 89

1) traumatic causes of cardiogenic shock 2) tension pneumo: what do you see for BP, airway pressures, breath sounds, neck veins, trachea 3) cause of cardiac compromise in tension pneumo 4) pts with what type of fx are at high risk for cardiac contusion 5) what fx put pt at high risk for aortic transection

Answer 89

1) tension pneumo, cardiac tamponade, cardiac contusion 2) hypotension, inc airway pressures, dec breath sounds, bulging neck veins, tracheal shift 3) 2/2 ICV/SVC compression-> dec venous return 4) sternal 5) 1st and 2nd rib fx

Question 90

Pelvic trauma 1) what to do with hemodynamically unstable with pelvic fx and negative DPL, CXR and not other signs of blood loss or reason for shock 2) what other structures may be injured 3) 3 types of fx, mortality and bld loss

Answer 90

1) stabilize pelvis (C-clamp, external fixator, sheet) and go to angio for embolization 2) genitourinary and abdominal injuries 3) Type I- crush, unstable, mortality 20-30%, blood loss >10units Type II- verticle incision completely transecting, unstable, mortality 8-12%, blood loss 2-10u Type III- fx in rami, etc that doesn't transect entire pelvis. stable.

Question 91

Pelvic trauma 1) can repair be delayed for other injuries 2) Intra-op management of penetrating injury pelvic hematomas 3) Intra-op management of blunt injury pelvic hematomas

Answer 91

1) yes 2) open (can angio) 3) leave. if expanding or unstable-> stabilize fx, pack if in OR and go to angio for embolization. remove packs after 24-48hr

Question 92

Duodenal Trauma 1) MC cause of injury 2) MC area injured 3) MC rx 4) for what section is segmental resection with primary end-to-end closure not possible 5) mortality 6) MC source of morbidity

Answer 92

1) blunt (crash or deceleration injury) 2) 2nd portion (descending portion near ampulla of Vater) 3) 80% get debridement and primary closure 4) second portion of duodenum 5) 25% 6) fistulas

Question 93

1) rx of intra-op paraduodenal hematomas and where they are located with blunt injury 2) presentation, dx and rx of paraduodenal hemotomas

Answer 93

1) 2+cm is significant- open for both blunt and penetrating (usually in third portion of duodenum overlying spine in blunt injury) 2) SBO 12-72 hrs after injury, UGI shows stacked coins or coiled spring appearance (make sure no contrast extravasation). rx- conservative (NGT, TPN)- cures 90% over 2-3wk (hematoma resorbed)

Question 94

1) what to do if at laparotomy and duodenal injury suspected

Answer 94

1) Kocker maneuver (to mobilize the duodenum) and open lesser sac through omentum. Chekc for hematoma, bile, succus and fat necrosis and if you see any do formal inspection of entire duodenum

Question 95

1) how to diagnoses suspected duodenal injury

Answer 95

1) CT abd with contrast-1st then UGI (best) CT- bowel wall thickening, hematoma, fre air, contrast leak or retroperitoneal fluid/air. If CT worrisome but non diagnostic, can repeat CT in 8-12 hours

Question 96

1) Tx of duodenal trauma | 2) What to do if in 2nd portion of duodenum and can't do primary repair->

Answer 96

try to get primary repair/anastamosis - may have to divert with pyloric exclusion and gastrojejunostomy to allow healing. - place distal feeding jejunostomy and possibly proximal draining jejunostomy tube that threads back to injury site. Place drains. 1) place jejunal serosal patch over hole (may need whipple in future), do pyloric exclusion and gastrojejunostomy, consider feeding and draining jejunostomies, leave drains -Trauma whipple rarely if ever indicated (v high mortality)

Question 97

1) when to remove drains after duodenal injury repair | 1) rx of fistulas

Answer 97

1) when pt tol diet without increasing drainage | 2) bowel rest, TPN, octreotide, conservative management for 4-6wks.

Question 98

``` Colon trauma 1) MC type of injury 2) repair for: a- right colon b- transverse colon c-left colon d-paracolonic hematomas ```

Answer 98

1) penetrating injury 2) a and b- perform primary repair/anastomosis c-primary repair/anastamosis, diverting ileostomy d-both blunt and penetrating need to be opened

Question 99

rectal trauma 1) MC type of injury 2) repair of high rectal injuries 3) repair of low rectal injuries (<5cm) 4) when to place diverting ileostomy

Answer 99

1) penetrating 2) extraperitoneal- generally not repaired bc of inaccessibility. can do serial debridement or consider diverting ileostomy intraperitoneal- rx- repair defect, presacral drainage, consider diverting ileostomy 3) repair transanally 4) shock, gross contamination, extensive injury

Question 100

Liver trauma 1) T/F- often need to do lobectomy 2) can you ligate the common hepatic artery? 3) what is the pringle maneuver? does it stop bleeding from hepatic veins? 4) when to use an atriocaval shunt? 5) management of portal triad hematoma

Answer 100

1) F 2) yes- gastroduodenal artery has collaterals 3) clamping portal triad. Does not stop bleeding from hepatic veins 4) for retrohepatic IVC injury. Allows for control while performing repair 5) explore

Question 101

Liver trauma cont 1) ideal repair of common biled duct injury 2) repair of portal vein injury and should you ligate portal vein 3) when to use omental graft 4) should you leave drains?

Answer 101

1) if 50% circumference or complex injury- do choledochojejunostomy. May need intraop cholangiogram to define injury. ALSO- place drains bc 10% of duct anastamoses leak 2) if you need to transect through pancreas to get to the injury in the portal vein need to perform distal pancreatectomy. Ligation of portal vein is associated with 50% mortality 3) place in liver lac to help with bleeding and prevent bile leaks. 4) yes!

Question 102

Conservative management of blunt liver injuries 1) activity level allowed for pt 2) when should you go to the OR

Answer 102

1) bedrest for 5 days 2) -if pt becomes unstable despite aggressive resucitation (HR>120 or SBP4u needed to keep HCT>25) - if active blush on CT abd or pseudoaneurysm: if posterior may be better going to angiogram (but if doubt go to OR), if anterior go straight to OR

Question 103

spleen injury 1) how long does it take spleen to fully heal 2) when is postsplenectomy sepsis risk greatest 3) T/F splenic salvage is associated with increased transfusions 4) when to go to the OR/when has conservative management failed 5) activity level with conservative management 6) in what pts is threshold for splenectomy much higher 7) what immunizations do you need after trauma splenectomy

Answer 103

1) 6 weeks 2) greatest within 2 years of splenectomy 3) true 4) -pt unstable despite aggressive fluid resucitation (HR>120 or SBP2u needed to keep HCT>25) - if active blush on CT abd or pseudoaneurysm 5) bedrest x 5days 6) children 7) Strept pneumo (pneumococcal), H flu (Hib), meningococcal

Question 104

Pancreatic Trauma 1) MC injury type 2) what type of injury can cause pancreatic duct fractures and typical orientation of fx 3) what are CT signs of injury 4) rx of pancreatic contusion 5) rx of distal pancreatic duct injury 6) rx of pancreatic head injury that is not reparable 7) how do you decide bw a whipple vs distal pancreatectomy

Answer 104

1) penetrating accounts fo 80% 2) bunt injury-> fx perpendicular to duct 3) edema or necrosis of peripancreatic fat 4) leave if stable, place drains if in OR 5) distal pancreatectomy (can take up to 80% of the gland) 6) place drains initially. delayed whipple or possible ERCP with stent may eventually be necessary 7) based on duct injury in relation to SMV

Question 105

Pancreatic Trauma 1) should you leave drains? 2) what maneuver helps evaluate the pancreas operatively 3) rx for pancreatic hematoma 4) what lab value should make you suspect missed pancreatic injury 5) when to use ERCP

Answer 105

1) YES! 2) Kocher 3) both blunt and penetrating need to be opened 4) rising or persistent amylase 5) good at finding ductal injuries and may be able to treat with temporary stent

Question 106

Vascular Trauma 1) repair before or after ortho repair? 2) when to go to the OR 3) when to go to angio 4) indications for saphenous vein graft 5) what vein injuries need repair? 6) what should you consider doing if ischemia>4-6hr

Answer 106

1) repair vascular injury 1st (or vascular shunt) 2) if major signs of injury go to OR: active hemorrhage, pulse deficit, expanding of pulsatile hematoma, distal ischemia, bruit, thrill (may need to go to angio to define injury) 3) if moderate/soft signs of injury go to angio: h/o hemorrhage, deficit of anatomically related nerve, large stable/nonpulsatile hematoma, ABI 2cm missing (use vein from contralateral leg when fixing lower extremity arterial injuries 5) vena cava, femoral, popliteal, brachiocephalic, subclavian and axillary 6) fasciotomy

Question 107

1) rx for transection of single artery in the calf in otherwise healthy pt 2) at what compartment pressure should you consider compartment syndrome 3) clinical signs of compartment syndrome 4) most common injuries leading to comp syndrome 5) how to rx

Answer 107

1) ligate 2) >20mmHg or clinical exam 3) pain-> paresthesia-> anesthesia-> paralysis-> poikliothermia-> pulselessness (late finding) 4) suprachondylar humeral, tibial, crush injuries or injuries with disruption and then restoration of blood flow after 4-6hr 5) fasciotomy- incisions are anterolateral and posteromedial

Question 108

IVC injury 1) how to best control bleeding, should you clamp it? 2) how to repair

Answer 108

1) proximal and distal pressure- don't clamp bc can tear 2) primary repair if residual stenosis is <50% the diameter of the IVC, otherwise do saphenous vein graft or synthetic patch. - posterior wall injury repaired through anterior wall (may need to cut through anterior IVC to access)

Question 109

Ortho trauma 1) how much blood can be lost from femur fx 2) which of the following is not an ortho emergency: pelvic fx in unstable pt, spine injury with deficit, open fx, dislocations or fx with vascular compromise, compartment syndrome, calcaneal fx 3) pt w femoral neck fx are at high risk for? 4) rx of long bone fx or dislocation with loss of pulse or weak pulse a-first step b- if pulse doesn't return-> c- if pulse is weak -> 4) rx monogram for knee dislocations 5) fx associated with upright falls

Answer 109

1) >2L 2) calcanear fx, unless associated with lumbar fx with neuro impairment 3) avascular necrosis 4) a- Immediate reduction and reassessment of pulse b- go to OR for vascular bypass or repair (may need OR angio to define injury) c-go to antio 4) all knee dislocations go to angiogram unless pulse is absent in which case you go to OR 5) lumbar, distal forearm (radial ulnar), calcaneous

Question 110

what is the concomitant nerve/artery injury UE 1) Anterior shoulder disloc 2) Posterior shoulder disloc 3) Proximal humerus fx 4) midshaft humerus fx (or spiral humerus fx) 5) distal humerus fx (supracondylar 6) Elbow dislocation 7) Distal radius fx

Answer 110

1) axillary nerve 2) axillary artery 3) axillary nerve 4) radial nerve 5) brachial artery 6) brachial artery 7) median nerve

Question 111

what is the concomitant nerve/artery injury LE 1) anterior hip disloc 2) posterior hip disloc 3) distal (supracondylar) femur fx 4) posterior knee disloc 5) fibula neck fx

Answer 111

1) femoral artery 2) sciatic nerve 3, 4) popliteal artery 5) common peroneal nerve

Question 112

what is the concomitant nerve/artery/organ injury 1) temoral or parietal bone fx 2) maxillofacial fx 3) sternal fx 4) 1st or 2nd rib fx 5) scapula fx 6) Left ribs 8-12 fx 7) Right ribs 8-12 fx 8) pelvic fx

Answer 112

1) middle meningeal injury-> epidural hematoma 2) cervical spine fx 3) cardiac contusion 4) aortic transection 5) pulmonary contusion, aortic transection 6) spleen lac 7) liver lac 8) bladder rupture, urethral transaction

Question 113

Renal trauma 1) best indicator of kidney injury 2) what imaging study should all pts with hematuria have 3) if you are going immediately to the OR without abdominal CT scan, what other study is useful to identify the presence of a functional contralateral kidney

Answer 113

1) hematuria 2) abd CT 3) intravenous pyelogram

Question 114

Renal trauma 1) T/F the left and right renal vein can be ligated near the IVC 2) what are the renal hilum structures from anterior to posterior 3) T/F- 95% of injuries are treated nonperatively 4) T/F- all urine extravasation injuries require operation 5) indications for operation in acute injury 6) indications for OR after acute phase

Answer 114

1) False, only the left renal vein can be ligated near IVC because it has adrenal and gonadal collaterals. The Right renal vein doesn't have these collaterals 2) VAP= vein artery pelvis 3) True 4) false 5) ongoing hemorrhage with instability 6) major collecting system dysruption, non-resolving urine extravasation, severe hematuria

Question 115

Renal Trauma 1) with exploration in OR what should you try to get bleeding control of first 2) should you place drains intra-op? 3) how to check for leak at end of case How would you treat if at exploration for another blunt injury or penetrating trauma you find: 4) blunt renal injury with hematoma 5) Penetrating renal injury with hematoma How do you rx: 6) Trauma to flank and IVP shows no uptake in stable pt

Answer 115

1) vascular hilum control 2) yes! especially if collecting system is injured 3) methylene blue die 4) leave unless pre-op CT/IVP shows no function or significant urine extravasation 5) open unless pre-op CT/IVP shows good function without significant urine extravasaton 6) angiogram (can stent if flap present)

Question 116

Bladder Trauma 1) best indicator that the bladder is injured 2) common associated injury 3) signs and sx 4) dx 5) cystogram findings and rx of extraperitoneal bladder rupture 6) cystogram findings and rx of intraperitoneal bladder rupture

Answer 116

1) hematuria 2) >95% have associated pelvic fx 3) meatal blood, sacral or scrotal hematoma 4) cystogram 5) cysto shows starbursts, foley for 7-14d 6) cysto shows leak (more likely in kids) . rx- operate and repair defect followed by foley drainage

Question 117

Ureteral trauma 1) best diagnostic studies 2) best repair if > 2cm of ureteral segment missing and can't reanastamose a- if injury in upper and middle 2/3 of ureter (above pelvic brim that won't reach bladder b- lower 1/3 injuries 3) repair if small ureteral segment a- upepr and middle 1/3 injuries b-lower 1/3 injuries 4) does a one-shot IVP evaluate the ureters sufficiently? 5) where is blood supply in relation to the ureter 6) what can be used to check for leaks

Answer 117

1) IVP and retrograde urethrogram (RUG) 2) a- temporize with perc nephrostomy and tie off both ends of ureter, later do ileal interposition or transureteroureterostomy b- reimblant in bladder, may need bladder hitch procedure 3) a-mobilize ends of ureter and perform primary repair over stent b- re-implant in bladder *leave drains for all injuries 4) no 5) blood supply is medial in upper 2/3 of ureter and lateral in lower ureter 6) IV indigo carmine or IV methylene blue

Question 118

urethral trauma 1) best signs 2) T/F: place a foley to allow for healing 3) best study to dx and area most at risk for transection 4) rx of significant tears 5) rx of small, partial tears 6) rx of genital trauma (fx in erectile bodies from vigorous sex 7) testicular trauma- first study to get

Answer 118

1) hematuria, blood at meatus are best. also free-floating prostate gland suggests, usually associated with pelvic trauma 2) false- DON'T place foley for urethral trauma 3) retrograde urethrogram (RUG); membranous portion is most at risk for transection 4) suprapubic cystostomy and repiar in 2-3 months (early repair can lead to stricture and impotence) 5) may get away with just bridging urethral catheter across tear area and repairing in 2-3mo 6) repair the tunica and Buck's fascia 7) get US to see if tunica albuginea is violated. if it is-> repair

Question 119

Pediatric trauma 1) T/F: blood pressure is a good indicator of blood loss in kids 2) what are the best indicators of shock in children 3) T/F: Kids have same risk of hypothermia as adults 4) T/F: Kids have increased risk of head injury 5) normal vital signs for kids 10yo

Answer 119

1) false, last resort 2) HR, RR, mental status, clinical exam 3) false, kids have increased risk bc increased BSA compared with weight 4) True 5) Infant (10yo: HR 120, SBP 100, RR 20

Question 120

Trauma during pregnancy 1) ethics: who to save? mother or child 2) T/F: pregnant pts can have up to a 1/3 total blood volume loss without signs 3) how to estimate pregnancy week 4) Can you get a CT scan in early prgnancy? 5) what special physical exam findings should you look for 6) lab tests to determine fetal maturity

Answer 120

1) mother at all costs 2) True 3) based on fundal height. 20 cm=20wk=umbilicus. place fetal monitor 4) try to avoid unless life-threatening and needed 5) vaginal discharge- blood, amnion. check for effacement, dilation, fetal station 6) lecithin: sphingomyelin (LS) ratio >2:1 and positive phosphatidylcholine in amniotic fluid

Question 121

Placental abruption 1) signs 2) causes 3) tests 4) prognosis for fetus

Answer 121

1) uterine tenderness, contractions, fetal HR sign of placental abruption 4) >50% result in fetal demise

Question 122

Uterine rupture 1) MC location of rupture 2) rx

Answer 122

1) posterior fundus 2) if after delivery of child, aggressive resuscitation even in the face of shock. eventually uterus will clamp down after delivery

Question 123

Indications for C-section during trauma ex-lap

Answer 123

- persistent maternal shock or severe injuries and pregnancy near term (>34wks) - pregnancy a threat to mothers life (hemorrhage, DIC) - mechanical limitation to life-threatening vessel injury - risk of fetal distress exceeds risk of immaturity - direct intra-uterine trauma

Question 124

``` Management of hematomas: 1) what size is considered significant? 2)Management of hematoma following penetrating/blunt injury in the a- pelvis b-paraduodenal c- portal triad d-retrohepatic e- midline supramesocolic f- midline inframesocolic g- pericolonic h- perirenal ```

Answer 124

1) >/= 2 cm 2) a-open/leave b-open for both c- open for both d- leave for both if stable e, f, g- open for both h- open unless CT/IVP shows no injury/ leave unless preop CT/IVP shows injury

Question 125

1) what injuries should you leave drains in for

Answer 125

pancreatic, liver, biliary, urinary and duodenal injuries

Question 126

Snake bites 1) symptoms 2) rx

Answer 126

1) (depend on species)-> shock, bradycardia, arrhythmia | 2) stabilize pt, anti-venin, tetanus shot

Question 127

Zones of the peritoneum and associated injuries 1) Zone 1 2) Zone 2 3) Zone 3 - and hematoma management for each

Answer 127

1) central retroperitoneum- pancreaticoduodenal injuries or major vascilar injury (usually open hematomas in these areas) 2) flank or periphephric- GU and colon injuries (often penetrating trauma, usually open hematomas in these areas) 3) pelvis- pelvic fractures- usually leave hematomas in these areas

Question 128

Cardiovascular System: Normal Values 1) Cardiac output (CO) L/min 2) Cardiac index (CI) L/min 3) Systemic vascular resistance (SVR) 4) Pulmonar Capillary wedge pressure (PCWP) 5) Central venous pressure (PAP) 6) mixed venous oxygen saturation

Answer 128

1) 4-8 2) 2.5-4 3) 800-1400 4) 11 +/- 4 5) 25/10 +/- 5 6) 75 +/- 5

Question 129

MAP=

Answer 129

SVR x CO

Question 130

C.I.=

Answer 130

CO/BSA

Question 131

1) what % of C.O. does kidney get 2) what % of C.O. does brain get 3) what % of C.O. does heart get

Answer 131

1) 25% 2) 15% 3) 5%

Question 132

relation of left ventricular end-diastolic length to left ventricular end-diastolic volume and filling pressure

Answer 132

linear relationship

Question 133

explain the relation of preload to stroke volume seen in the starling curve

Answer 133

as preload increase, the increase in stroke volume for equivalent increases in preload is less. At the far left (steep) part of the curve a small increase in preload will sig increase stroke volume. At the right (flat) portion of the curve, the same increase in preload will only create a slight increase in stroke volume

Question 134

What are the following a measure of: 1) Afterload 2) stroke volume (3 things that determine SV) 3) ejection fraction 4) end-diastolic volume (EDV) 5) end-systolic volume (ESV) 6) effect of HR on C.O.

Answer 134

1) resistance against the ventricle contracting (SVR) 2) determined by left ventricular end diastolic volume, contractility and afterload SV= LVEDV - LVESV 3) stroke volume/LVEDV 4) determined by preload and distensibility of the ventricle 5) determined by contractility and afterload 6) C.O. increases with HR up to 120-150bpm then starts to go down bc of decreased diastolic filling time

Question 135

1) how much of LVEDV does the atrial kick account for 2) Anrep effect 3) Bowditch effect

Answer 135

1) 20% 2) automatic increase in CONTRACTILITY 2/2 inc afterload 3) auromatic increase in contractility 2/2 inc HR

Question 136

Equation for arterial O2 content | CaO2=

Answer 136

Hgb x 1.34 x O2 sat x (Po2x0.003)

Question 137

Equation for O2 delivery=

Answer 137

COx arterial O2 content (CaO2) x 10

Question 138

Equation for O2 consumption (VO2)=

Answer 138

CO x (CaO2-CvO2); where CvO2= venous O2 content

Question 139

1) What is the normal O2 delivery to consumption ratio and how is it kept constant 2) does consumtion change with O2 supply

Answer 139

1) 5:1. CO2 increases to keep this ratio constant | 2) O2 consumption usually supply independent (doesn't change until low levels of delivery are reached)

Question 140

Causes of right shift on oxygen- Hgb dissociation curve

Answer 140

inc CO2, dec pH, inc temperature, inc ATP production, inc 2,3-DPG production all lead to O2 unloading

Question 141

1) What is normal p50 (O2 at which 50% of O2 receptors are saturated) 2) normal SvO2

Answer 141

1) 27 mmHg | 2) 75% +/- 5%

Question 142

1) what causes SvO2 to increase | 2) to decrease

Answer 142

1) occurs with inc shunting of blood or dec O2 extraction (ie- sepsis, cirrhosis, cyanide toxicity, hyperbaric O2, hypothermia, paralysis, coma, sedation) 2) occurs with inc O2 extraction or dec O2 delivery (ie- dec O2 saturation, dec C.O., malignant hyperthermia)

Question 143

what can throw off the pulmonary wedge pressure

Answer 143

pulmonary HTN, aortic regurg, mitral stenosis or regurg, high PEEP, poor LV compliance

Question 144

Swan-Ganz catheter 1) Where to place 2) management of hemoptysis after flushing swan-ganz catheter 3) relative contraindications to placing 4) distances for placing swan-ganz catheter to wedge from a- R SCV, b- R IJ, c- L SCV, d- L IJ 5) what pulmonary value can only be measured w Swan Ganz catheter 6) when should wedge pressure measurements be taken

Answer 144

1) Zone III, lower lung 2) increase the PEEP->taponade of pulmonary artery bleed. Then mainstem intubate the non-affected side (can try to place fogarty balloon down non-effected side) 3) previous pneumonectomy, L bundle branch block 4) a-45cm, b-50cm, c-55cm, d-60cm 5) PVR pulmonary vascular resistance (ECHO does not meausre) 6) at end-expiration for both ventilated and non-vent

Question 145

1) what are primary determinants of myocardial O2 consumption 2) why is LV blood 5mm Hg lower PO2 than pulmonary capillaries 3) what is a notmal alveolar-arterial gradient in nonventilated pt 4) what blood has the lowest venous saturation

Answer 145

1) increased ventricular wall tension (#1) and heart rate 2) unsaturated bronchial blood empties into pulmonary veins-> LV blood 5mmHG lower 3) 10-15mmHg 4) coronary sinus blood (30% saturated)

Question 146

1) definition of shock 2) Change in CVP&PCWP/CO/SVR in a-hemorrhagic shock b- septic (hyperdynamic shock)- early c- septic shock late d-cardiogenic shock e- neurogenic shock f- adrenal insufficiency

Answer 146

1) inadequate tissue oxygenation 2) a-D/D/I b-D (or nml)/I/D c-D/D/I d-I/D/I e-D (or nml)/D/D f-D (or nml)/D/D

Question 147

Adrenal insufficiency 1) MCC 2) sx of acute insuf 3) rx of acute insuf 4) steroid potency bw cortisonek, hydrocortisone, prednisone, prednisolone, methylprednisolone, dexamethasone

Answer 147

1) withdrawl of exogenous steroids 2) cardiovascular collapse, typically unresponsive to fluids and pressors, N/V, abd pain, fever, lethargy, hypoglycemia 3) Dexamethasone 4) 1x= cortisone, hydrocortisone 3x=prednisone, prednisolone, methylprednisolone 5x= dexamethasone

Question 148

Neurogenic shock 1) associated injury 2) vitals, skin temp 3) rx

Answer 148

1) spinal or head injury 2) dec HR and BP, warm skin 3) volume 1st then phenylephrine after resuscitation

Question 149

1) initial alteration in hemmorhagic shock

Answer 149

1) increased diastolic pressure

Question 150

Cardiac tamponade 1) mech of cardiogenic shock 2) Beck's triad 3) Echo findings 4) does pericardiocentesis blood form clot 5) rx

Answer 150

1) decreased ventricular filling due to fluid in the pericardial sac around the heart 2) hypotension, JVD, muffled heart sounds 3) impaired diastolic filling of right atrium initially (1st sign of tamponade) 4) no 5) fluid resuscitation to temporize the situation. need pericardial window or pericardiocentesis

Question 151

1) Early Sepsis triad 2) insulin and glucose levels in a- early GN sepsis b- late GN sepsis 3) what is a typical lab finding in a pt just before they become clinically septic

Answer 151

1) hyperventilation, confusion, hypotension 2) decreased insulin, increased glucose (impaired utilization) 3) increased insulin and glucose (2/2 to insulin resistance) 4) hyperglycemia

Question 152

Neurohormonal response to hypovolemia 1) rapid response 2) sustained response

Answer 152

1) epinephrine and norepi release (adrenergic release) -> vasoconstriction and inc cardiac contractility 2) renin released from kidney-> renin-angiotensin pathway activated resulting in vasoconstriction and water resorption - ADH released from pituitary-> water reabsorption - ACTH release from pituitary-> inc cortisol

Question 153

``` Emboli 1) Fat emboli- a- sx b-MC cause c- special stain that can show fat in sputum and urine in pt with fat emboli 2) PE a- where do most arise from b- sx, Po2, Pco2, HR and RR, pH abnormality c- rx 3) Air emboli rx ```

Answer 153

1)a-petechia, hypoxia, confusion b-LE (hip, femur) fx/ortho procedures c-sudan red stain 2) a-ileofemoral resion b- CP and dyspnea, dec Po2 and Pco2, respiratory alkalosis, inc HR and RR, hypotension and shock if massive c- heparin, coumadin. open or percutaneous suction catheter embolectomy if pt is in shock despite massive pressors and ionotropes 3) place pt head down and roll to left (keeps air in RV and RA), then aspirate air out with central line of PA catheter to RA/RV.

Question 154

Intra-aortic balloon pump (IABP) 1) when does it inflate? 2) deflate? 3) what is a contraindication 4) where to place 5) effect on afterload, BP and coronary perfusion

Answer 154

1) diastole (T wave) 2) P wave (systole) 3) aortic regurg 4) tip of catheter just distal to left subclavian (1-2 cm above the top of the arch) 5) decreases afterload (deflation during ventricular systole), improves diastolic BP (inflation during ventricular diastole), improves diastolic coronary perfusion

Question 155

Cardiovascular receptors- actions of each 1) alpha-1 2) alpha-2 3) beta-1 4) beta-2 5) dopamine receptors

Answer 155

1) vascular smooth muscle constriction, gluconeogenesis and glycogenolysis 2) venous smooth muscle constriction 3) myocardial contraction and rate 4) relaxes bronchial smooth muscle, relaxes vascular smooth muscle, increases insulin, glucagon and renin 5) relax renal and splanchnic smooth muscle

Question 156

CV drugs- what receptors do they act on, dose and effects | 1) Dopamine (include actions at each dose)

Answer 156

1) start at 2-5ug/kg/min initially= renal dose (dopamine receptors) 6-10ug/kg/min= beta adrenergic= heart contractility >10ug/kg/min=alpha-adrenergic (vasoconstriction and inc BP)

Question 157

CV drugs- what receptors do they act on, dose and effects | 2) Dobutamine

Answer 157

3ug/kg/min initially. Beta-1=inc contractility, tachycardia with higher doses

Question 158

CV drugs- what receptors do they act on, dose and effects | 3) Milrinone (and secondary effects)

Answer 158

Phosphodiesteras inhibitor-> inc cAMP--> inc Ca flux and myocardial contractility - also causes vascular smooth muscle relaxation and pulmonary vasodilation

Question 159

CV drugs- what receptors do they act on, dose and effects 4) Phenylephrine 5) Norepinephrine 6) Epinephrine

Answer 159

4) 10ug/min. alpha-1-> vasoconstriction 5) 5ug/min. low dose- beta-1-> inc contractility. -high dose- alpha-1 and alpha-2->vasoconstriction (potent slanchnic vasoconstrictor 6) 1-2ug/min to start. low dose- beta 1 and 2 (inc contractility and vasodilation)-> can lower BP at low doses high dose- alpha-1 and alpha-2 (vasoconstriction)-> inc cardiac ectopic pacer activity and myocardial O2 demand

Question 160

CV drugs- what receptors do they act on, dose and effects | 7) Isoproterenol (and s/e)

Answer 160

1-2ug/min initially. Beta 1 and 2-> inc HR and contractility, vasodilates S/E- arrhythmogenic, inc heart metabolic demand (rarely used), may actually dec BP

Question 161

CV drugs- what receptors do they act on, dose and effects | 8) Vasopressin

Answer 161

V1 receptor-> vasoconstriction V2 (intrarenal)-> water reabsorption at collecting ducts V2 (extrarenal)-> release for factor VIII and vWF

Question 162

CV drugs- what receptors do they act on, dose and effects 9) Nipride ( and s/e- what should you check for)

Answer 162

arterial vasodilator | s/e- cyanide toxicity at doses >3ug/kg/min for 72 hours. check thiocyanate levels and signs of metabolic acidosis

Question 163

Cyanide toxicity treatment

Answer 163

amyl nitrite, then sodium nitrite

Question 164

CV drugs- what receptors do they act on, dose and effects | 10) Nitroglycerin

Answer 164

venodilation with dec myocardial wall tension from decreased preload. *moderate coronary vasodilator

Question 165

CV drugs- what receptors do they act on, dose and effects | 11) hydralazine

Answer 165

alpha-blocker- lowers BP but can cause rebound hypertension

Question 166

Pulmonary system: 1) equation for compliance 2) what does a high compliance equate to 3) in pts with ARDS, fibrotic lung diseases, reperfusion injury, pulmonary edema, atelectasis is compliance increased or decreased

Answer 166

1) change in volume/ change in pressure 2) easy to ventilate 3) decreased

Question 167

Aging 1) how does aging effect FEV1 2) vital capacity 3) functional residual capacity

Answer 167

1) decreased FEV1 2) decreased vital capacity 3) increased functional residual capacity

Question 168

V/Q ratio 1) where is it highest 2) where is it lowest

Answer 168

ventilation/perfusion ratio 1) highest in upper lobes 2) lowest in lower lobes

Question 169

Ventilator 1) how to improve oxygenation 2) how to decreased CO2 3) purpose of pressure support 4) what FiO2 should you keep it to prevent O2 radical toxicity 5) at what plateau and peak is barotrauma of concern and what should you do to prevent 6) how does PEEP work 7) complications from excessive PEEP 8) when to use high-frequency ventilation

Answer 169

1) inc FiO2 or inc PEEP (alveoli recruitment->improves FRC) 2) inc rate or volume 3) decreases the work of breathing (inspiratory pressure is held constant untill minimum volume is reached 4) 30 and peak >50--> need to decrease TV and consider pressure control ventilation 6) improves FRC and compliance by keeping alveoli open-> best way to improve oxygenation 7) dec RA filling, dec CO, dec renal blood flow, dec UOP, inc pulm vascular resistance 8) used a lot in kids, tracheoesophageal fistula, bronchopleural fistula

Question 170

Pulmonary function measurements 1) total lung capacity 2) Forced vital capacity 3) Residual volume 4) Tidal Volume 5) functional residual capacity 6) effect of surgery, sepsis and trauma on FRC and why 7) expiratory reserve volume

Answer 170

1) lung volume after maximal inspiration (TLC=FVC +RV) 2) maximal exhalation after inhalation 3) lung volume after maximal expiration (20% TLC) 4) volume of air with normal inspiration and expir 5) lung volume after nl expiration (FRC=ERV+RV) 6) all decrease FRC. Surgery (atelectasis), sepsis (ARDS), trauma (contusion, atelectasis, ARDS) 7) volume of air that can be forcefully expired

Question 171

Pulmonary function measurements 8) Inspiratory capacity 9) FEV1 10) minute ventilation (how to calculate) Describe changes in TLC, RV, FVC, and FEV1 in 11) Restrictive lung disease 12) Obstructive lung disease

Answer 171

8) maximum air breathed in from FRC 9) volume of air that can be forcefully expired in 1 second after max inhalation 10) TV x RR= minute ventilation 11) dec TLC, RV and FVC. nl or inc FEV1 12) inc TLC and RV. dec FEV1. FVC can be nl or dec

Question 172

1) dead space- what is it and where is it 2) do the following increase or decrease dead space: drop in C.O., PE, pulm HTN, ARDS, excessive PEEP 3) why is work of breathing increased in COPD

Answer 172

1) area of lung that is ventilated but not perfused 2) increases with all. can lead to high CO2 buildup (hypercapnia) 3) prolonged expiratory phase

Question 173

ARDS 1) primary mediating cell type 2) MC cause and other causes 3) effect on lungs 4) Criteria for diagnosing ARDS

Answer 173

1) PMNs 2) MC- pneumonia. Other- sepsis, multi-trauma, severe burns, pancreatitis, aspiration, DIC 3) inc proteinaceous material, inc A-a gradient, inc pulmonary shunt 4) acute onset, bilateral pulmonary infiltrates, PaO2/FiO2 <18)

Question 174

Aspiration 1) what pH and volume is associated with inc degree of damage 2) What is Mendelson's syndrome 3) MC site of aspiration pneumo

Answer 174

1) pH0.4cc/kg 2) chemical pneumonitis from aspiration of gastric secretions 3) Right Lower Lobe

Question 175

Atelectasis 1) what is it 2) MC cause 3) symptoms 4) what comorbidities increase risk 5) rx

Answer 175

1) collapse of alveoli resulting in reduced oxygenation 2) poor inspiration post-op (MC cause of fever in 1st 48hr) 3) fever, tachycardia, hypoxia 4) COPD, upper abd surgery, obesity 5) IS, pain control, ambulation

Question 176

what can throw off a pulse ox

Answer 176

nail polish, dark skin, low-flow states, ambient light, anemia, vital dyes

Question 177

effect on lung vasculature of 1) PGE1, prostacyclin (PGI2), Nitric oxide and bradykinin 2) hypoxia, histamine, serotonin, TXA2 3) Alkalosis 4) Acidosis 5) Nitroprusside, nitroglycerin and nifedipine

Answer 177

1) pulm vasodilation 2) pulm vasoconstrict 3) pulm vasodilator 4) pulm vasoconstrictor 5) pulmonary shunting

Question 178

Renal system 1) MC of postop renal failure 2) how many nephrons need to be damaged for renal dysfnc to occur 3) what is best test for azotemia 4) how to calculate and what the results mean

Answer 178

1) hypotension 2) 70% 3) FeNa 4) FeNa= (urine Na/Cr)/(plasma Na/Cr). 3%=parenchymal

Question 179

Prerenal/parenchymal (renal) 1) Urine osmolarity (mOsm) 2) U/P osmolality 3) U/P creatinine 4) Urine Na 5) FeNa

Answer 179

1) >500/ 250-350 2) >1.5/ 20/ 40 5) 3%

Question 180

Management steps for Oliguria

Answer 180

1st- make sure pt is volume loaded (CVP 11-15) 2nd- do diuretic (lasix) trial 3rd- dialysis if needed

Question 181

Indications for dialysis

Answer 181

fluid overload, hyperkalemia, metabolic acidosis, uremic encephalopathy, uremic coagulopathy, poisoning

Question 182

1) Difference bw hemodialysis and CVVHD | 2) how much does hct increase for each liter taken off with dialysis

Answer 182

1. HD- rapid, can cause large volume shifts CVVH- sloer, good for ill pts who cannot tolerate the volume shifts (ie- septic shock). 2) 5-8

Question 183

``` Renin 1) what causes release and by what cells 2) action Angiotensin Converting enzyme 3) where is it 4) effect Aldosterone 5) what causes release and where from 6) effect 7) effect of angiotensin II ```

Answer 183

1) decreased pressure sensed by juxtaglomerular apparatus or increased Na concentration sensed by macula densa - beta-adrenergic stimulation and hyperkalemia also cause release 2) converts angiotensinogen (synth in liver) to angiotensin I 3) lung 4) converts angiotensin I to angiotensin II 5) adrenal cortex releases in response to angiotensin II 6) acts at distal convoluted tubule to reabsorb water by up-regulating the Na/K ATPase on the membrane (Na reabsorbed, K secreted) 7) vasoconstricts and inc HR, Contractility, glycogenolysis and gluconeogenesis. Inhibits renin release

Question 184

Atrial natriuretic peptide (or factor) 1) where is it released from 2) actions

Answer 184

1) atrial wall 2/2 atrial distension | 2) inhibits Na and water resorption in the collecting ducts and vasodilates

Question 185

which limb of kidney controls GFR

Answer 185

efferent limb

Question 186

renal toxic drugs, how they cause injury 1) NSAIDS 2) Aminoglycosides 3) Myoglobin and rx 4) contrast dyes and prevention/rx

Answer 186

1) inhibit prostaglandin synthesis-> renal arteriole vasoconstriction 2) direct tubular injury 3) direct tubular injury (rx- alkalinize urine) 4) direct tubular injury. rx- pre-hydrate before contrast exposure is best. otherwise- HCO3- or N-acetylcysteine

Question 187

SIRS 1) causes 2) what is most potent stimulus and what is released as a consequence 3) mechanism behind it 4) diff bw sepsis and SIRS

Answer 187

1) shock, infection, burns, multi-trauma, pancreatitis, severe inflammatory responses 2) endotoxin (lipopolycaccharide-lipid A) is the most potent stimulus for SIRS-> TNF release 3) TNF-alpha and IL-1-> inflam response-> shock and multiorgan dysfnc 2/2 capillary leakage, microvascular thrombi and hypotension 4) sepsis= SIRS + infectious source

Question 188

Definition of 1) SIRS 2) Shock 3) Multisystem Organ Dysfunction

Answer 188

1) T>38 or 90bpm, RR>20 or PaCO212,000 or <4,000 2) above + arterial hypotension despite adequate volume resuscitation (inadequate tissue oxygenation) 3) above + progressive but reversible dysfnc of 2+ organs 2/2 acute disruption in hemostasis

Question 189

Diagnositic criteria for sig organ dysfnc 1) pulmonary 2) CV 3) Renal 4) Liver 5) Nutrition 6) CNS 7) Coagulation 8) Host defenses

Answer 189

1) need for mech. ventilation, PaO2:FiO2 ration < 2.5 L/min/m^2 3) Cr>2xbaseline on 2 consecutive days or need for dialysis 4) bili >3mg/dl on 2 consec days or PT>1.5 5) >10% reduction in lean body mass; albumin<1000 or invasive infection including bacteremia

Question 190

Brain death 1) what Temperature, BP, drugs and metabolic derangements preclude diagnosis 2) what physical exam findings must the pt exhibit and for how long 3) EEG findings 4) MRA findings 5) T/F: you cannot have deep tendon reflexes with brain death

Answer 190

1) T

Question 191

Apnea test for brain death 1) what is it 2) what is a positive test result 3) what are negative results

Answer 191

1) pt pre-oxygenated via catheter delivering O2 at 8L/min at carina and CO2 nl before start of test - then disconnect from ventilator for 10 min to determine if brain death 2) CO2>60 or increase in CO2 by 20mmHg at end of test is positive (meets criteria for brain death) 3) BP drops ( put back on vent

Question 192

Carbon Monoxide poisoning 1) effect on O2 sat 2) how it works and sx 3) how to diagnose 4) rx

Answer 192

1) can falsely elevate O2 sat on pulse ox 2) binds Hgb directly-> carboxyhemoglobin-> can't bind O2-> sx- Nausea, HA, confusion, coma, death 3) carboxyhemoglobin level >10% or >20% in smokers 4) 100% O2 on ventilator. Displaces carbon monoxide. rarely need hyperbaric O2

Question 193

Methemoglobinemia 1) Cause 2) mechanism 3) effect on O2 sat 4) rx

Answer 193

1) from nitrites such as Hurricaine spray 2) nitrites bind Hgb 3) O2 sat reads 85% 4) rx- methylene blue

Question 194

What is critical illness polyneuropathy and effect on ventilation

Answer 194

motor>sensory neuropathy with sepsis. Can lead to failure to wean from vent

Question 195

Reperfusion injury 1) Cause 2) other role for the cause 3) Most important cell mediator

Answer 195

1) Xanthine Oxidase in endothelial cells forms toxic oxygen radicals 2) Xanthine oxidase also involved in metabolism of proteins to uric acid 3) PMNs

Question 196

DKA 1) sx and labs 2) rx

Answer 196

1) N/V, thirst, polyuria, inc glucose and ketones, dec Na, inc K 2) NS and insulin

Question 197

ETOH withdrawal 1) sx 2) rx

Answer 197

1) HTN, tachycardia, delirium, seizures after 48hrs | 2) thiamine, folate, B12, Mg, K, prn lorazepam (Ativan)

Question 198

ICU psychosis 1) when do you see it 2) what other causes must you r/o

Answer 198

1) after POD3 | 2) r/o metabolic (hypoglycemia, DKA, hypoxia, hypercarbia, electrolyte imbalances) and organic (MI, CVA) causes

Question 199

Burn classification- symptoms/depth 1) 1st degree 2) 2nd degree 3) 3rd degree 4) 4th degree

Answer 199

1) Sunburn (epidermis only) superficial 2) superficial dermis (papillary)- painful to touch, blebs and blisters, hair follicles intact, blanches (don't need skin graft deep dermis (reticular)- decreased sensation, loss of hair follicules (need skin graft) 3) down to subcutaneous fat- leathery (charred parchment) 4) Down to bone, into adjacent adipose or muscle tissue

Question 200

1) which burns heal by epithelialization (and where does epithelialization begin) 2) which burns can cause rhabdomyolysis with myoglobinuria 3) what is rx of rhabdo

Answer 200

1) 1st and superficial 2nd degree burns. epithelialization is primarily from the hair follicles 2) extremely deep burns, electrical burns or compartment syndrome 3) IVF, alkalinize urine (diuretics)

Question 201

Admission criteria for burns- what burns should you admit

Answer 201

1) 2nd or 3rd degree burns if * >20% for all ages or >10% if age 50 * to significant portions of hands, face, feet, genitalia, perineum, or skin overlying major joints 2) 3rd degree burns >5% any age 3) electrical and chemical burns 4) inhalation injury, mechanical trauma, preexisting medical conditions 5) suspect of child abuse or neglect 6) injuries in pts with special social, emotional or long-term rehabilitation needs

Question 202

Burns 1) what age groups is death highest in 2) MC type of burn 3) most likely type to come to hospital and be admitted

Answer 202

1) children and elderly (hardest to get away) 2) scald 3) flame burns

Question 203

Assessing percentage of body surface burned (rule of 9's. How many percent for each in adults and kids: 1) head 2) arms 3) chest 4) back 5) legs 6) perineum 7) palm

Answer 203

1) 9% in adult, 18% in kids 2) 9% each arm (18% total) 3) 18% anterior, 4) 18% posterior 5) 18% each leg in adult, 14% each leg in kids 6) 1% 7) 1% each * can also use pt palm to estimate injury (palm=1%)

Question 204

Parkland formula 1) what % burn can it be used for 2) calculation 3) what type of fluid to use 4) best measure of resucitation 5) in what pts canparkland grossly underestimate volume requirements 6) at what point can you use colloid

Answer 204

1) >/=20% 2) 4cc/kg x %burn in first 24 hours (give 1/2 of volume in first 8hr) 3) LR in first 24 hr 4) UOP (0.5-1.0 cc/kg in adults, 2-4cc/kg in children

Question 205

Indications for Escharotomy 1) how soon do you need to perform 2) when should you perform it 3) when to do fasciotomy

Answer 205

1) within 4-6hr 2) circumferential deep burns, low temp, weak pulse, dec capillary refill, dec pain sensation or dec neuro fnc in extremity, prbms ventilating pt with significant chest/torso burns 3) if compartment syndrome suspected after escharotomy

Question 206

risk factors for burn

Answer 206

v. old or young, ETOH or drug use, smoking, low socioeconomic status, violence, epilepsy

Question 207

Child abuse 1) accounts for what % of burns 2) what history elements should make you suspect 3) physical exam elements

Answer 207

1) 15% 2) delayed presentation for care, conflicting hx's, previous injury 3) sharply demarcated margins, uniform depth, absence of splash marks, dorsal location on hands, very deep localized contact injury

Question 208

lung injury in Burn 1) cause 2) risk factors for airway injury 3) signs/sx on physical exam 4) indications for intubation 5) MC infection and cause of death in pts with >30%BSA burns

Answer 208

1) carbonaceous materials and smoke (NOT heat) 2) ETOH, trauma, closed space, rapid combustion, extremes of age, delayed extrication 3) facial burns, wheezing, carbonaceous sputum 4) upper airway stridor or obstruction, worsening hypoxemia (massive volume resuscitation can worsen sx) 5) pneumonia

Question 209

``` Unusual Burns 1) Acid and alkali burns a- rx b- which causes deeper burns and type of necrosis associated with each 2) rx for hydrofluoric acid burns 3) rx for powder burns 4) tar burn rx 5) electical burn complications 6) lightening complications ```

Answer 209

1) a- copious water irrigation b- alkalis produce deeper burns 2/2 liquefaction necrosis. Acid burns produce coagulation necrosis 2) spread Calcium over wound 3) wipe away before irrigation 4) cool, then wipe away with a lipophilic solvent (adhesive remover) 5) rhabdomyolysis, compartment syndrome, polyneuritis, quadriplegia, transverse myelitis, cataracts, liver necrosis, intestinal or gallbladder pref, pancreatic necrosis 6) Cardiopulmonary arrest 2/2 electrical paralysis of brainstem

Question 210

1st week of burn care 1) when to excise burn wounds and for what burns 2) how much blood loss, skin excision and OR time is maximum for each burn wound excision 3) caloric need in 1st week 4) protein need 5) best non-protein source of calories in burn pts

Answer 210

1)

Question 211

Grafts 1) when are skin grafts C/I in burn 2) what type of skin graft is best 3) Split thickness or full thickness skin grafts- - a) advantages - b) where is donor skin site regenerated from on STSG - c) what is blood supply to skin graft for days 0-3 - d) when does neovascularization occur - e) what areas are unlikely to support the graft 4) thickness of STSG and parts of skin that comprise it

Answer 211

1) cx + for beta-hemolytic strep or bacteria >10^5 2) Autograft (STSG or FTSG) 3) a-dec infection, dessication, protein loss, pain, water loss, heat loss and RBC loss compared to dermal substitutes - b) from hair follicles and skin edges - c) imbibition (osmotic) - d)around day 3 - e) poorly vascularized beds including tendon, bone without periosteum and XRT areas 4) 12-15 mm (includes epidermis and part of dermis)

Question 212

``` 1) Homografts a-give examples b- when to use and how long they last 2)Xenografts a- when to use -why aren't they as good as homografts 3) what is last resort ```

Answer 212

``` 1) a-allografts, cadaveric skin b- vascularize but are eventually rejected, last 2-4 wks. good temporizing material 2) ie- Porcine a- last 2 weeks -don't vascularize 3) Dermal substitutes ```

Question 213

Grafts 1) when to use meshed grafts 2) reasons to delay autografting 3) MC reason for skin graft loss 4) when to use STSG and advantages and disadvantages 5) when to use FTSG and advantages and disadvantages

Answer 213

1) use for back, flank, trunk, arms, legs 2) infection, not enoug skin donor sites, pt septic or unstable, don't want any more donor sites with concomitant blood loss 3) hematoma or seroma under graft - apply pressure dressing (cotton balls) to the graft to prevent fluid build up underneath 4) more likely to survive bc easier for imbibition and subsequent revascularization 5) less wound contraction- good for areas such as palms and back of hands

Question 214

what type of graft can improve burn scar hypopigmentation and irregularities

Answer 214

dermabrasion thin split thickness grafts

Question 215

Specialized Burn Care 1) Rx of face burns 2) Hand burn rx (superficial and deep) 3) Palms 4) Genitals

Answer 215

1)topical abx for 1st week, FTSG for unhealed areas (nonmeshed) 2)superficial- ROM exercises, splint in extension if too much edema deep- immobilize in extension for 7 days after skin graft (need FTSG), then PT. may need wire fixation of joints if unstable or open 3)try to preserve specialized palmar attachments. splint hand in extension for 7days after FTSG 4) can use meshed STSG

Question 216

Burn wound infection rx 1) role of ppx abx 2) what to apply immediately after burn 3) MC infecting organisms (top 4) 4) what burns are more likely to become infected 5) T/F: Topical agents have decreased incidence of burn wound bacterial infections 6) what has increased in incidence 2/2 topical abx

Answer 216

1) none 2) bacitracin or neosporin 3) Pseudomonas> Staph> E. Coli and Enterobacter 4) >30%BSA 5) True 6) candida

Question 217

1) How is immunity impaired in burn pts

Answer 217

granulocyte chemotaxis and cell-mediated immunity are impaired

Question 218

Slivadene (Silver Sulfadiazine) 1) side effects 2) what allergy in pts in C/I to use 3) what is it ineffective for 4) what is it effective for 5) penetration and effect on epithelialization

Answer 218

1) neutropenia and thrombocytopenia 2) sulfa 3) some Pseudomonas 4) Candida 5) limited eschar penetration, can inhibit epithelialization

Question 219

SIlver Nitrate 1) S/E and what pts is it C/I in 2) penetration 3) what is it ineffective for

Answer 219

1) -electrolyte imbalances (hyponatremia, hypochoremia, hypocalcemia, hypokalemia) - discoloration - methemoglobinemia (C/I in pts with G6PD def) 2) limited eschar penetration 3) some pseudomonal species and GPC

Question 220

Sulfamylon (mafenide sodium) 1) S/E 2) penetration 3) coverage compared to other burn abx

Answer 220

1) metabolic acidosis 2/2 carbonic anhydrase inhibition (-> dec renal conversion of H2CO3 to H2O and CO2) 2) good eschar penetration-> good for burns overlying cartilage 3) broadest spectrum against pseudomonas and GNRs

Question 221

which of the burn abx have painful application

Answer 221

sulfamylon

Question 222

Mupirocin 1) good for what type of infection 2) drawback of use

Answer 222

1) MRSA | 2) expensive

Question 223

WHAT are the following a sign of in burn: peripheral edema, 2nd to 3rd degree burn conversion, hemorrhage into scar, erythema gangrenosum, green fat, black skin around wound, rapid eschar separation, focal discoloration

Answer 223

burn wound infection

Question 224

1) MCC of burn wound sepsis 2) MC viral infection in burns 3) amount of bacteria that is cutoff for burn wound infection 4) best way to detect burn wound infection/differentiate from colonization

Answer 224

1) pseudomonas 2) HSV 3)

Question 225

Complications after burns- why do the following occur 1) Seizures 2) peripheral neuropathy 3) ectopia and rx 4) eye injury- how to dx and rx 5) symblepharon- what is it and rx 6) heterotopic ossification of tendons rx 7) fractures- rx 8) curling's ucler- what is it 9) Marjolin's ulcer- what is it 10) rx of corneal abrasion

Answer 225

1) usually iatrogenic 2/2 [Na] 2) 2/2 small vessel injury and demyelination 3) from contraction of burned adnexa (rx- eyelid release) 4) dx- fluorescein staining to find injury, rx- topical flouroquinolone or gentamicin 5) eyelid stuck to conjuctiva. rx-release with glass rod 6) PT, may need OR 7) often need external fixation while burn treatment 8) gastric ulcer 2/2 burn 9) highly malignant sqamous cell CA that arises in chronic non-healing burn wounds or unstable scars 10) topical abx

Question 226

Hypertrophic scar 1) when does it occur 2) what burn injuries is it more common in 3) rx

Answer 226

1) 3-4 mo after injury 2/2 inc neovascularization 2) more likely to be deep thermal injuries that take >3wk to heal, heal by contraction and epithelial spread, or heal across flexor surfaces 3) steroid injection into lesion (best), silicone, compression, wait 1-2 yr before scar modification surgery

Question 227

Erythema multiforme and variants 1) list the variants in order from least severe to most severe and how to dx 2) underlying disease in all 3) causes 4) rx 5) T/F- give steroids to these pts

Answer 227

1) Erythema Multiforme- least severe (self-limited, target lesions) Stevens-Johnson syndrome- more serious (

Question 228

Skin- composition of each layer 1) Epidermis 2) Dermis

Answer 228

1) primarily cellular (keratinocytes and melanocytes) | 2) primarily structural proteins (collagen) for the epidermis

Question 229

``` 1) keratinocytes a-skin layer b-where it originates from c- purpose 2) melanocytes a-origin b) skin layer c) how is melanin transferred bw melanocytes d) differences in melanocytes bw races ```

Answer 229

1) a) epidermis b) basal layer c) provides mechanical barrier 2) a) neuroectodermal (neural crest) cells in basal layer of epidermis b) basal layer of epidermis c) have dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes d) same density of melanocytes. Difference is in melanin production

Question 230

1) Langerhans cells a- function b- where they originate from c- what type of hypersensitivity reaction do they have a role in

Answer 230

``` 1)a-dendritic cells (Antigen-presenting cells MHC class II) of skin and mucosa b- bone marrow c- contact hypersensitivity reactions (type IV) ```

Question 231

Sensory nerves of the Skin- what do they sense: 1) pacinian corpuscles 2) Ruffini's endings 3) Krause's end-bulbs 4) Meissner's corpuscles

Answer 231

1) pressure 2) warmth 3) cold 4) tactile sense

Question 232

1) role of eccrine sweat glands and type of sweat | 2) role of apocrine sweat glands, type of sweat and where the highest concentration is

Answer 232

1) aqueous sweat (thermal regulation, usually hypotonic) | 2) milky sweat (highest [] in palms and soles), most sweat is the result of sympathetic nervous system via acetylcholine

Question 233

1) t/F: lipid-soluble drugs have decreased skin absorption 2) what is predominant type of collagen in skin and role 3) what is tension and what creates it in skin 4) what is elasticity in skin and what is responsible for creating elasticity 5) what are cushing's striae

Answer 233

1) false, increased absorption 2) Type I, gives tensile strength (70% of dermis) 3) resistance to stretching (Collagen) 4) ability to regain shape- created by branching proteins that can stretch to 2 x nl length 5) red stretch marks in cushing's: caused by loss of tensile strength and elasticity

Question 234

``` FLAPS 1) MCC of pedicled or anastomosed free flap necrosis 2) how does tissue expansion occur 1) TRAM flabs: a- what is it b- what vessels does it rely on c-what is most imp determinant of TRAM flap viability d- potential complications ```

Answer 234

1) venous thrombosis 2) by local recruitment, thinning of the dermis and epidermis mitosis 3)a- Transverse rectus abdominis myocutaneous flap reconstruction b-superior epigastric vessels c- periumbilical perforators d- flap necrosis, ventral hernia, bleeding, infection, abdominal wall weakness

Question 235

Pressure sores- describe the 4 stages and treatment for each

Answer 235

Stage I- erythema and pain, no skin loss- keep pressure off Stage II- partial skin loss with yellow debris- local rx, keep pressure off Stage III- full-thickness skin loss, subcutaneous fat exposure. rx- sharp debridement, likely need myocutaneous flap Stage IV- involves boney cortex, muscle. rx- myocutaneous flap

Question 236

UV radiation 1) effect on skin 2) best factor for protecting skin from UV radiation 3) which type is responsible for chronic sun damage

Answer 236

1) damages DNA and repair mechanisms. Both a promoter and initiator. 2) melanin 3) UV-B

Question 237

Melanoma 1) % of skin cancers 2) % of skin cancer deaths 3) risk factors for melanoma 4) MC melanoma site in Men 5) in women

Answer 237

1) 5% 2) 65% 3) -displastic, atypical or large CONGENITAL nevi- 10% lifetime risk for melanoma - familial BK mole syndrome- 100% lifetime risk - Xeroderma pigmentosum - fair complexion, easy sunburn, intermittent sunburns, previous skin CA, previous XRT - 10% are familial 4) back 5) legs

Question 238

Melanoma 1) factors that worsen prognosis 2) signs of melanoma and what is most ominous sign 3) MC location for distant met 4) what cells does it originate from 5) how to dx and rx for a-2cm lesion or cosmetically sensitive area

Answer 238

1) men, ulcerated lesions, ocular and mucosal lesions 2) ABCDE- asymmetry (angulation, indentation, notching, ulceration, bleeding), Borders irregular, Color change (darkening), diameter increase, evolving over time. Blue color is most ominous sign 3) lung 4) neural crest cells (melanocytes) in basal layer of epidermis 5)a- dx- excisional bx, rx- resection with margins b-incisional bx/punch bx. rx- resect with margins

Question 239

What staging should you get for melanoma

Answer 239

CT chest/abd/pelvis, LFTs, LDH for all melanoma >/=1mm, examine all possible draining LNs

Question 240

Types of melanoma 1) which is most superficial and what kind of margins do you need for it 2) least aggressive type 3) most common type and where it originates from 4) most aggressive type 5) type MC in african americans 6) type MC on palms/soles

Answer 240

1) Melanoma in situ or thin lentigo maligna (hutchinson's freckle)- just in spuerfical papillary dermis so 0.5-cm margins are ok 2) lentigo meligna melanoma- minimal invasion, radial growth first, elevated nodules 3) superficial spreading melanoma- intermediate malignancy, originates from nevus/sun-exposed areas 4) Nodular- most likely to have mets at time of dx with deepest growth. Verticle growth 1st, bluish-black with smooth borders. can occur anywhere on body 5) Acral lentiginous- v. aggressive 6) Acral lentiginous

Question 241

``` Management of melanoma 1) recommended surgical margins for tumor a- in situ b-2mm 2) management of nodes a- if clinically positive nodes b- if clinically negative nodes 3) management of mets 4) vaccines for systemic disease ```

Answer 241

1) a) 0.5-1cm b) 1cm c) 1-2cm d) 2cm margins 2) involved nodes are usually NT, round, hard, 1-2cm a) resect clinically positive nodes b) sentinel LN bx if tumor >/=1mm deep * if anterior head/neck melanoma >/=1mm deep need to include superficial parotidectomy (20% met rate to parotid) 3) resection if isolated and can be resected with low risk procedure 4) IL-2 and tumor vaccines

Question 242

Basal cell carcinoma 1) where does it originate from 2) pathology findings 3) what is the most aggressive type and what does it produce 4) treatment 5) MC location

Answer 242

1) epidermis- basal epithelial cells and hair follicles 2) peripheral palisading of nuclei and stromal retraction 3) Morpheaform type- has collagenase production 4) 0.3-0.5cm margins. XRT and chemo of limited benefit for inoperable disease, metastases or neuro/lymphatic/vessel invasion 5) 80% on head and neck

Question 243

Name the type of skin/soft tissue cancer 1) MC malignancy in the U.S. 2) overylying erythema, papulonodular with crust and ulceration, usually red-brown 3) pearly appearance, rolled borders, slow and indolent growth 4) MC soft tissue sarcoma 5) can develop in post-XRT areas or in old burn scars 6) actinic keratoses is a risk factor for 7) may have surrounding induration and satellite nodules

Answer 243

1) Basal cell CA (4x more common than squamous skin CA) 2) Squamous cell CA 3) basal cell CA 4) #1 malignant fibrous histiosarcoma, #2liposarcoma 5) squamous cell CA 6) squamous cell CA 7) squamous cell CA

Question 244

Squamous cell carcinoma 1) how common are mets compared to basal cell CA and melanoma 2) risk factors 3) risk factors for mets 4) rx

Answer 244

1)mets more frequent than basal cell but less frequent than melanoma 2) actinic keratoses, xeroderma pigmentosum, Bowen's disease (SCC in situ), atrophic epidermis, arsenics, hydrocarbons (coal tar), chlorophenols, HPV, immunosuppresion, sun exposure, fair skin, previous XRT, previous skin CA 3) poorly differentiated, greater depth, recurrent lesions, immunosuppression 4) 0.5-1cm margins for low risk high risk- can do Mohs (margin mapping using conservative slices, not for melanoma) when trying to minimize area of resection (ie-if on face) *regional adenectomy for clinically positive nodes

Question 245

Soft Tissue Sarcoma 1) MC location and age group 2) tumor characteristics 3) what initial imaging do you need 4) dx 5) how does it spread 6) MC site for mets 7) how is it staged

Answer 245

1) 50% from extremities, 50% in children (arise from embryonic mesoderm) 2) large, rapid growth, painless 3) CXR to r/o lung mets; MRI before bx to r/o vascular, neuro or bone invasion 4) excisional bx if mass 4cm (need to eventually resect bx skin site if shows sarcoma) 5) hematogenous spread (LN mets rare) 6) lung 7) based on GRADE (not size)

Question 246

Sarcoma treatment 1) margins 2) adjuvant therapy (when to do XRT, type of chemo used and when to use) 3) rx of isolated mets 4) are drains used routinely?

Answer 246

1) at least 3-cm margins with at least 1 uninvolved fascial plane. try to perform limb-sparing op. Place clips to mark site of likely recurrence (will XRT these later 2) postop XRT for high-grade tumors, close margins or tumors >5cm - chemo with doxorubicin-based. For tumors >10cm, may benefit from preop chemo-XRT to allow limb sparing resection 3) if no other evidence of systemic disease resect. Otherwise palliate with XRT 4) no

Question 247

``` Sarcoma 1) prognosis and why 2) Head and neck sarcomas a- population they occur in b- why is rx more difficult c- MC type 3) visceral and retroperitoneal sarcomas a-MC type b-most imp prognostic factor ```

Answer 247

1) poor overall prog 2/2 delay in dx, difficulty with total resection, difficulty getting XRT to pelvic tumors, 40% 5-year survival rate with complete resection 2) a-peds pts b-proximity to vital structures-> postop XRT for positive or close margins as neg margins may be impossible to obtain c- rhabdomyosarcoma 3) leiomyosarcomas and liposarcomas

Question 248

Risk factors and associated CA 1) asbestos 2) PVC and arsenic 3) chronic lymphedema

Answer 248

1) mesothelioma 2) angiosarcoma 3) lymphangiosarcoma

Question 249

Kaposi's sarcoma 1) type of sarcoma 2) MC sites and sx 3) MC malignancy in what pts 4) Rx

Answer 249

1) vascular sarcoma 2) oral and pharyngeal mucosa-> bleeding and dysphagia 3) AIDS pts 4) rarely a cause of death in AIDS pts. primary goal is palliation. - AIDS tx (HAART) is best (shrinks tumor) - consider XRT or intra-lesional vinblastine for local disease - interferon-alpha for disseminated disease - surgery for severe intestinal hemorrhage

Question 250

1) #1 soft tissue sarcoma in kids a-where it occurs and which site has poorest prognosis b- 2 subtypes (which is MC, which is worst Prog) c-rx

Answer 250

1) Childhood rhabdomyosarcoma a-head/neck, GU, extremities and trunk (poorest prog) b- embryonal subtype is most common, Alveolar subtype-worst prognosis c-surgery, doxorubicin-based chemo

Question 251

``` Bone sarcomas 1) T/F- rarely metastasize 2) Osteosarcoma a-MC location b- cell type it originates from c-MC age group ```

Answer 251

1) False, most are metastatic at time of dx 2)a- increased incidence around knee b-metaphyseal cells c- children

Question 252

Genetic syndromes for soft tissue tumors: what tumors are seen in the following: 1) Neurofibromatosis 2) Li-fraumeni syndrome 3) hereditary retinoblastoma 4) Tuberous sclerosis 5) Gardners syndrome

Answer 252

1) CNS tumor, peripheral sheath tumor, pheo 2) childhood rhabdomyosarcoma and many others 3) other sarcomas 4) angiomyolipomas 5) familial adenomatous polyposis, and intra-abdominal desmoid tumors

Question 253

other skin conditions and rx 1) lip lacerations 2) Xanthoma- (and what cell type dose it contain) 3) Warts (verruca vulgaris) 4) growth associated with cafe-au-lait spots, axillary freckling, peripheral nerve and CNS tumors

Answer 253

1) align vermillion border 2) yellow, contains histiocytes. rx- excise 3) viral origin. initial rx- liquid nitrogen 4) Neuromas (neurofibromatosis and von Reckinghausen's syndrome)

Question 254

Name the skin condition 1) keratoses- premalignant in sun-damaged areas, need excisional bx if suspicious 2) keratoses-not premalignant skin lesion on trunk on elderly, can be dark 3) keratoses-associated with squamous cell ca 4) neuroendocrine skin ca, very aggressive and malignant with early regional and systemic spread. has red to purple papulonodule or indurated plaque. Also name the components of the tumor 5) painful benign tumor composed of blood vessels and nerves, MC in terminal aspect of digit. What is rx?

Answer 254

1) Actinic Keratosis 2) Seborrheic keratosis 3) arsenical keratosis 4) Merkel cell CA- components are neuron specific enolase (NSE), cytokeratin, neurofilament protein 5) Glomus cell tumor. rx- tumor excision

Question 255

Desmoid tumors 1) where do they occur 2) when do they occur 3) prognosis 4) rx

Answer 255

1 and 2) occur in fascial planes - anterior abdominal wall (MC)- seen after pregnancy, trauma or surgery - intra-abdominal- associated with Gardner's syndrome and retroperitoneal fibrosis (oten encases bowel making it hard to get en block resection) 3) high risk of local recurrence, benign but v locally invasive, no distant spread 4) surgery if possible, chemo (sulindac, tamoxifen) if vital structure involved or too much bowel would be taken

Question 256

Bowens Disease 1) associated CA 2) associated virus 3) rx 4) T/F- wide local excision is an good treatment

Answer 256

1) SCC in situ, 10% turn into invasive SCC 2) HPV 3) *imiquimod*, cautery ablation, topical 5-FU, regular bx to r/o CA 4) F- void wide local excision if possible (high recurrence rate with HPV)

Question 257

Keratoacanthoma 1) characteristics 2) benign or malignant 3) dx 4) rx

Answer 257

1) rapid growth, rolled edges, crater filled with keratin, involutes spontaneously over months. can be confused with SCC 2) benign 3) biopsy to be sure not SCC 4) excise if small; if large bx and observe

Question 258

Hyperhydrosis 1) what is it 2) rx

Answer 258

1) inc sweating, esp noticible in palms | 2) thoracic sympathectomy if refractory to varient of antiperspirants

Question 259

Hydradenitis 1) what is it 2) MC organisms involved 3) rx

Answer 259

1) infection of the apocrine sweat glands, usually in axilla and groin regions 2) staph/strep are MC organisms 3) 1st- abx and improved hygeine. May need surgery to remove skin and associated sweat glands

Question 260

Benign cysts- name them 1) MC, completely mature epidermis with creamy keratin material 2) in scalp, no epidermis 3) over tendons, usually over wrist, filled with collagen material 4) midline, intra-abdominal and sacral lesions usual, need resection due to malignancy risk 5) congenital coccygeal sinus with ingrown hair, gets infected and needs to be excised

Answer 260

1) epidermal inclusion cyst 2) Trichilemmal cyst 3) Ganglion cyst 4) dermoid cyst 5) pilonidal cyst