Ortho / Trauma Flashcards
ORTHO – Intramedullary reaming/nailing of pathological fracture
[20A06] A patient is due to have intramedullary reaming and nailing of a pathological fracture of the femur secondary to metastatic renal cell carcinoma.
a) Outline the key issues this case presents. (50%)
b) Describe how you would manage these issues. (50%)
High Risk due to
1. Metastatic disease
- pt selection
- Optimise
– Renal - HTN, DM
– Ca - malnutrition, superimp infection, chem ind lung injury,
- local effect of Ca and distal mets
** mass/mets/meds/metabolic
- Major blood loss
- optimise Fe txf
- G+H with threshold - Emboli - tumor/fat during reaming
- vigilance
- up FiO2 prior reaming - Post op pain
- Simple analgesics
- PCA
- PCRA*
ORTHO – Visual loss a/w spinal surgery in prone position
[18B01]
a) Outline the mechanisms that may contribute to visual loss associated with spinal surgery in the prone position. (50%)
b) Describe strategies that may reduce the risk of visual loss in this situation. (50%) (also 04B02)
Surgery:
1. Cardiac
2. Spinal
3. H&N
Most - PION non-arteritic
Prone + BL > 1L + >6h = 96% cases
Mech:
1. ION
2. retinal ischaemia
- AION - progressive, oedmatous dis
- PION - acute, normal disc
3. Cortical blindness
4. External ocular inj = corneal abrasion
5. Acute glaucoma
BCIS
SS_OR1.4
OHA p447 / AAGBI 2020 / AoA/BoA 2015
BCIS
bone cement implantation syndrome
Methylmethacrylate bone cement
Complications
20% periop cardio resp in CEMENTED pros
Severe compl 2%
CP arrest in 0.5%
Features
1. HYPOXIA
2. HYPOTENSION
3. CVS Collapse
*Grade
I: SpO2 < 94%, sbp fall > 20%
II: <88% / 40% / unexpected LOC
III: CVS collapse = CPR
Prev/Mx
1. Suction bone cavity
2. Measure BP frequent
3. Euvolaemic prior cement
4. Inc FiO2
6. Stop N2O
Risk factors (MCQ)
1. Male
2. ASA 3-4
3. >85 year
4. CCF/CVD
5. COPID/lung
6. diuretics/warfarin
7. osteoporosis
8. Cancer
ORTHO – Spinal surgery in prone position with rheumatoid arthritis
[17B03] A 55-year-old male with severe steroid dependent rheumatoid arthritis requires spinal surgery in the prone position. Discuss your considerations for patient positioning for the procedure.
(also 13A12, 11B07, 10A02, 05A10)
(72.4%) This was answered well with a discussion of how to keep the cervical spine safe as well as mention of other issues related to the prevention of musculoskeletal, nerve and eye injuries. Candidates did poorly if they didn’t make mention of the issues particularly relevant to rheumatoid arthritis
Prone
1. ETT
- secure at good depth
2. CVS
- free abdo
3. Resp
- 100% FiO2 prior flip
4. PNS
- Brachial plexus
- ulnar
5. Pressure area
- AION - direct pressure
- PION - dec perfusion
+
- abdo compression - mesenteric ischaemia
RA
1. C-spine
- unstable
- TMJ involvment
- cricoarytenoid arthritis
2. Multisystemic
3. Meds SE
* Steroids
* DMARDS
- MTX - ILD/folate
- SSZ (neutropaenia, thrombocytopaenia, Pulm fibrosis)
- Azathioprine (hep, BM supp)
4. Chronic pain
5. Tech diff
- Lines
- skin fragile
ORTHO – Post-op ulnar neuropathy
[17A09] Outline the risk factors for, possible mechanisms of, and methods to prevent, postoperative ulnar neuropathy (also 05B12)
(90.3%) This question was answered well. Candidates needed to demonstrates a clear understanding and sensible approach mentioning risk factors such as extremes of body habitus, mechanisms including direct pressure and perfusion problems and preventative measures such as attention to positioning and padding.
Pt/Surg/Anaes
Pt
1. Male
2. Extreme of habitus
Anaes
* Positioning
Mechanisms
1. Direct trauma
2. Compression/stretch
3. Ischaemia
4. Tox
5. Pre-existing nerve injury
6. Idiopathic
Prevention
- ID high risk
- care with position
- pad risky areas
- correct phys abnorm
- min tourinquet pressure /dur
ORTHO – Beach-chair shoulder surgery
[14A12] A patient is scheduled on your list for arthroscopic shoulder surgery. The surgery is to be performed in the beach chair position. List the problems associated with this position and describe how you could minimise them. (also 12A02, 07B05, 04B03)
(44.3%) This required
issues related to
placing the patient in the position including
- eye protection,
- head positioning to avoid traction on the nerve plexi as well as
- pressure care.
Some detail:
- risks of orthostatic hypotension and subsequent cerebral, myocardial hypoperfusion, and measures to monitor for and minimize such effects.
A: ETT secured/checked limited access
B: Ventilation improves
*C:
- Hypotension - IVF/pressors
- BP monitoring -
**- Cerebral ischaemia
D: Nerves - positiion carefully
E: Eyes/heels/elbows/arms/legs
- free of compression
- pad/support
CRITICAL CARE & TRAUMA– Rib fractures
[19A09] List the factors associated with increased mortality following rib fractures. (30%) Describe a comprehensive rib fracture management plan. (70%)
inc mortality
Pt
1. Age > 65
2. Comorbid - CVS/REsp
3. Pneumonia
Injury
1. # of ribs
* 6+ rib # = 3x die with 24hr vs 1 rib
- Assoc injuries
- HTX, limbs #, pelvic #, head/liver/spleen/heart/diaphragm inj
B) Rib # mx
***Gold standard = CT
1) # 2) sites 3) flail 4) thoracic/pulm contusion
*** Ventilation
1. Supp O2 - for hypoxia and use of sed analgesics
2. Esc to HFNP or NIV
3. PPV - limit atelectasis and red WOB
4. PT - inc spiro + assisted coughing
*** Analgesia
1. Multimodal
2. Rib # pathway
3. Stratify severity and guide analgesia
STUMBL score = calc risk of complications
Options
- simples - started unless CI
- opioids - tramadol/oxy
- PCA
Regional
1. Ant/lat - SAP
2. post/lat - ESP/ SAP / PVB
*epi (if poor from ESP/SAP)
3. Bilat - thoracic epi OR bil at PVB or bilat ESP/SAP
CRITICAL CARE & TRAUMA– Haematemesis / gastroscopy / liver disease
[19A05] A 61-year-old man presents with a large haematemesis. He has known alcoholic liver disease and sedation is requested for an urgent gastroscopy. Outline your peri-procedural concerns
(69.2%) Consideration of the following issues was required to pass this question * Chronic liver disease
* Adequate pre-operative resuscitation
* Clear understanding of airway risks and airway protection
* Plan for post-procedural care
CRITICAL CARE & TRAUMA– Cell salvage
[18B08] a. Describe the process of intraoperative cell salvage. (50%)
b. Discuss the indications and contraindications for intraoperative cell salvage. (50%)
[11B13] What are the benefits and limitations of red blood cell salvage? (50%) How would you justify its introduction into your institution? (50%)
[05A15] Discuss the advantages and disadvantages of intra-operative blood salvage.
61%
Collection/processing/reinfusion
Anticoags
Red cell vs whole blood
CRITICAL CARE & TRAUMA– Minimising peri-op blood loss.
[15B03] An adult patient is scheduled for a major operation during which significant blood loss is expected. Describe strategies you would consider peri-operatively when planning to minimise blood loss and transfusion requirement.
(79.5%) The borderline standard should have included preoperative strategies but this was not crucial to pass depending on the strength of the rest of the answer. Candidates needed to demonstrate a clear understanding of at least 2 major strategies to minimise blood loss and transfusion requirement.
Strategies
- Anaemia - mx - pre/inra/post
- Blood loss - min - p/i/p
- Tolerance to anaemia - p/i/p
CRITICAL CARE & TRAUMA– Acute Traumatic Coagulopathy (ATC)
[17B13] Discuss your strategy for the management of coagulopathy in the multitrauma patient.
[12B10] A trauma patient presents thirty minutes after a significant crush injury, with an estimated 40% blood loss. He was previously well. 1. Explain the coagulation abnormalities you would expect in this patient at this stage. (60%) 2. Discuss the current evidence for treatment of these abnormalities. (40%)
63.8% / 62.6%
Trauma induced coagulopathy & resus initiated changes
1. Coag abn: int/ext pathway, factor involvement, PLT fx impairment, thrombin/fibrin generation
2. Evidence for Rx ~ targets/monitoring aimed at correcting deficits, restoring CO, prevent further loss, deliver O2 red cells
[14B13] a. Describe the function of a three-chamber underwater seal chest drainage system. (a diagram may be useful) (50%)
b. Evaluate the use of this system in the management of haemopneumothorax secondary to blunt chest trauma? (50%)
(9%) As a minimum candidates were expected to demonstrate the three principles / function of the system [draw or explain] i.e. - Drainage / collection
- Underwater seal
- Application of controlled negative pressure
A diagram such as this represents the basic amount of information to pass part a of the question.
In evaluating its use in trauma related haemopnuemothorax recognition of its utility in dealing with persistent air leak and drainage of fluid and air was important as was some comment on potential problems.
Pt –> 1. trap –> 2. UWSC –> 3. manometer –> suction
- trap - measure drainage
- UWSC - prev AIR re-enter
- Manometer - suction attached, continuous bubble
Swinging = patency
Bubbling = air leak ~ BPF
Stop bubbling = PTX reexpanded; tube blocked; suction disconn
CRITICAL CARE & TRAUMA– Acute Traumatic Coagulopathy (ATC)àupdated answer
[12B10] A trauma patient presents thirty minutes after a significant crush injury, with an estimated 40% blood loss. He was previously well. 1. Explain the coagulation abnormalities you would expect in this patient at this stage. (60%)
- Discuss the current evidence for treatment of these abnormalities. (40%)
Coag abn
1. Acute caog
- low fib
- high fib deg products
- APTT/PT - high/N
- Plt - low/N
-TEG/ROTEM
Newest GL
European Guideline on MNG of Major Bleeding & Coagulopathy following Trauma 2023
Trials
PAMPer -
PROMMTT - survivor bias
PROPPR - underpowered
Early use blood product - unclear
– RePHILL - PRBC/lyoplas vs NS = no diff in mortality or lactate clearance
What guidelines do you know for NOF #?
QCH viva night 2024 - Ben Cahill
Do not delay due to pending echo, aim corPP and CPP + ST higher level care
Surgery <36h
- analgesia
- fluid resus
- MDT
- daily list prioritise
- std preop ax
Risk ax ***
- Nottingham Hip Fracture Score (NFHS) = most acc pred of mortality among hip # pop
- Frailty score - pred d/c destination
- 4AT - postop del
- NH-RISK - AKI
Nerve block to suppl GA and spinal
SSB repeat every 6h
FIB > FNB
Careful anaes > type of anaes
BCIS - 20% compl, 2% severe compl, 0.5% CPA
Transfusion: Hb >90-100 if IHD or unable to mobilise
AAGBI 2020
Trauma Trials
Transfusion
PROPPR - 2015 -
Blood product ratio of 1:1:1 vs 1:1:2 (FFP:platelets:RBCs); n=680 in the US. No difference in mortality (22.4 vs 26%).
PAMPer - 2018 - what if we give the FFP pre-hospital? n=501 in the US. Mortality was much better (23% vs. 33.0%)COMBAT
