PESTANA 1 Flashcards
Why does the tx of flail chest involve fluid restriction and diuresis?
The real problem in flail chest is the underlying contusion; contused lung is highly susceptible to fluid overload
How is intraoperative development of coagulopathy treated (i.e. from increased intraop time)? How is the lethal triad in operations for trauma of coagulopathy, metabolic acidosis, and hypothermia treated?
Platelet packs and FFP (10 packs each, empiric tx); if the triad occurs then terminate the laparotomy, pack bleeding surfaces and temporarily close
What other injuries are renal injuries often associated with in trauma?
Lower rib fractures
Why isnt there any sugar in lactated ringers?
To avoid glycosuria and loss of fluids
What is the antidote for black widow spider bites?
Calcium gluconate
What is the most reliable diagnostic test of MI in the post op period?
Troponins (x3)
How do you diagnose or suspect an “early mechanical bowel obstruction” post-operativley?
A “paralytic ileus” that does not resolve may be an early mechanical obstruction from adhesions
On what POD will a DVT cause fever? Dx? Tx?
POD 5; Doppler US, heparin bridge to warfarin
What is the main dx to consider when a post op pt becomes disoriented and confused?
Hypoxia
When is surgical exploration of penetrating neck trauma done?
In cases of expanding hematoma, deteriorrating vitals, and clear signs of esophageal/tracheal injury such as coughing up or spitting up blood
If splenic salvage is not possible and splenectomy is required in trauma, what must be done post-op?
Vaccination against meningococcus, pneumococcus, and HiB)
What is a good way to correct a metabolic alkalosis?
Abundant KCL administration (5-10 mEq/hr) allows the kidneys to correct it (i.e. you are fixing a hypochloremic hypokalemic metabolic alkalosis!)
What surgical intervention is often needed to treat the sequelae of circumferential burns?
Escharotomy (i.e. the circumferential burn forms an eschar that cuts of blood supply)
How can you tell clinically, (by looking at a pt), that the CVP is low?
Neck veins are flat (or just veins in general i.e. difficulty getting IV access)
What is the mgmt of GSW to abdomen? Is it necessary to remove bullet?
Ex lap with repair of intraabdominal injuries; not required to remove bullet
What is the standard topical tx in burns? What if deep access is needed? How are burns near the eyes treated?
Silver sulfadiazine; Mafenide acetate but do not use everywhere since it hurts and can cause acidosis; triple antiobiotic ointment - silver sulfadiazine near the eyes burns
What 2 drugs classically cause malignant hypothermia? What is the Tx? What other sequela must you watch out for?
Halothane, Succinylcholine; IV dantrolene, correction of acidosis, 100% O2, and cooling blankets; myoglobinuria
When is ex lap required for blunt abdominal injury?
Signs of peritoneal inflammation (acute abdomen) or signs of internal bleeding i.e. hemodynamic instability without a source
Which burn victims are candidates for early excision and grafting?
Those with very limited burns i.e. less than 20%
What should you think if there are very high fevers and severe wound pain within hours of surgery?
Possible gas gangrene
Loss of motor fxn and loss of pain/temp on both sides distal to injury with preservation of vibratory and positional sense
Anterior cord syndrome (often in burst fx of vertebral bodies)
What are some alternatives if peripheral IV lines cannot be inserted for resuscitation?
Femoral catheter or saphenous vein cut-downs; kids < 6 can get IO
What if in a trauma pt you attempt to pass a Foley catheter but cannot?
Should cue you into urethral injury
How do you treat Ogilvie syndrome?
First rule out mechanical obstruction you can then give IV neostigmine and a long rectal tube
On what POD will a UTI cause a fever?
POD 3 (UA UC and appropriate Abx)
How do you treat intraoperative tension ptx?
If abdomen open, decompress through the diaphragm? If not you can do the same needle decompression as in ED (2nd IC space); either way place formal chest tube later
What if a pt with a potential C spine injury needs an airway?
The airway must be dealt with before assessing the C spine
how do you manage a pt with head trauma who went unconscious at any point? What about someone who did not lose consciousness?
They need a CT of the head to r/o intracranial hematomas; they can go home if neurologically intact and family will wake them up frequently during next 24 hrs
An entrance or exit below this landmark is said to involve the abdomen?
Nipple (so Tx is ex lap)
What test is a good “yes-no” for intraabdominal bleeding?
FAST or the time-honored (DPL but that?s rarely ever done)
How is precise diagnosis of spinal cord injury best obtained?
MRI
What is the clinical significance of a basilar skull fx?
The pt has sustained severe head trauma and also needs evaluation of C spine; will require CT and cannot have nasotracheal intubation
How are penetrating urologic injuries dealt with as a rule?
Surgically explored
How much water has been lost for every 3 mEq/L the sodium is above 140?
1 L i.e. a sodium of 149 = 3 L lost
On what post-op day will a pneumonia cause a fever?
POD 3 but there probably was already a fever from atelectasis this would present as a persistence of atelectasis
What is the hallmark of urologic injuries in trauma?
Hematuria
If a pt is therapeutically anticoagulated and throws a PE what should you do?
Add an IVC filter (Greenfield filter); this is also done if the pt has one and anticoagulation is contraindicated
If you have hypovolemic shock, what is the one place you should not consider the person to be exsanguinating from?
intracranial bleeds cannot cause hypovolemic shock
What is the recommendation for a smoker before any surgery?
Cessation of smoking for 8 weeks with incentive spirometry and deep breathing exercises
How do you Tx fracture of the penis?
Emergency surgical repair as impotence will ensue as arteriovenous shunts develop
How do you Dx renal injuries? How are they Tx’d? What are the sequelae?
CT; usually leave them alone unless vessel disrupted; AVM formation leading to CHF or renal artery stenosis leading to HTN
How do you tx extraperitoneal leaks of bladder injury? Intraperitoneal?
Insert foley catheter; surgical repair with protection with suprapubic cystostomy
How are bladder injuries diagnosed?
Retrograde cystogram that must include post-void films to r/o extraperitoneal leadks at the bladder that may have been obscured by a bladder full of dye
What is the role of surgery in diffuse axonal injury? How do you know based on CT findings that is the Dx? Tx?
None unless there is also a hematoma; blurring of gray-white jxn with small punctate hemorrhages; aim Tx at preventing further increase in ICP
What should be done in penetrating extremity trauma that is not near a major vascular territory?
Tetanus ppx and cleaning of the wound
What is the best diagnostic test for pericardial tamponade in trauma setting?
FAST, not CXR
Paralysis and loss of proprioception on side of spc injury and loss of pain on the other side
Hemisection of spc (Brown-Sequard)
What is a good way to prevent aspiration before intubating?
NPO and antacids before induction (since the acid is partially responsible for the chemical pneumonitis)
When should myocardial contusion be suspected? What will Dx it?
When there are sternal fx; EKG and troponins; Tx is aimed at complications like arrhythmias
What is the ultimate therapy for hyperkalemia? What are 3 other things that can be done?
Hemodialysis; IV dextrose and insulin; IV calcium (neutralizes K effect on plasma membrane); NGT suction to induce a hypokalemic hypochloremic metabolic alkalosis (also sodium kayelxate)
How long post-MI until you can do surgery? If it needs to be done before then, what should you do?
6 months; if needs to be done before then, you should admit to the ICU the night before
When can you avoid the OR in stab wounds to the abdomen?
If there are no signs of clear penetration (protruding viscera), no hemodynamic instability, no signs of peritoneal instability; if these are not present Tx can be digital insertion of a gloved finger (i.e. to r/o penetration)
What is the most common cause of intraoperative MI?
Hypotension
What hidden injury should be actively sought in a person with flail chest?
Traumatic disruption of the aorta because big chest trauma is required
When is hyperventilation recommened in head trauma? What is the goal?
When there are signs of herniation (radiographic/clinical); PCO2 of 35
What are the indications for surgery in hemothorax?
Recovering 1500 ml or more (massive hemothorax) when chest tube inserted or collecting over 600 ml over the next 6 hours; usually due to lung parenchyma bleeding which is low pressure but if intercostal vessel is nicked it can have massive bleeding
What would make you suspicious for a traumatic rupture of the trachea or major bronchus? What is the Tx?
Subcutaneous emphysema or large air leak from chest tube; fiberoptic bronchoscopy to secure intubation distal to the injury and surgical repair later
What is the tx of rib fracture? In whom is it deadly and why?
Intercostal nerve block; elderly because of progression of pain –> hypoventilation –> atelectasis –> pneumonia
What will you see on an ABG in acute PE?
Hypoxemia and hypocapnia (bc not perfusing and hyperventilating)
What are the 2 main things on the differential for low UOP in a normotensive pt? What should be done?
Fluid depletion vs. AKI; Bolus 500 mL IVF over 10-20 min if UOP increase they were volume depleted, if not there is AKI (a better way is to calculate FENA)
How do you Tx shock in a “pink and warm” pt?
Vasopressors bc this is vasomotor shock which can be anaphylactic or neurogenic
If a person is really starting to show s/s of shock about 1500 ml have probs been lost. What are the 3 places that could “hide”?
Abdomen (#1), pelvis, and femur as in femoral fx, but in primary survey the fx are ruled out so it almost always is intraabdominal
What are the causes in order of time of post-op fever?
APUDWA = Atelectasis (POD 1), Pneumonia (POD 3 if atelectasis not resolve), UTI, DVT, wound infection, deep abscesses
What electrolyte abnormality can cause paralytic ileus?
Hypokalemia
How do you treat a sucking chest wound? What will happen if not Tx’d?
3 sided occlusive dressing allowing air out but not in; tension ptx
What injury pattern is urethral injury usually associated?
Pelvic Fx, almost always in a man
Around what POD does a PE usually occur?
POD 7
In whom is an intraoperative tension ptx likely to occur?
In a pt with injury to the lung who is introduced to positive pressure ventilation; i.e. blunt chest trauma
What are some signs of basilar skull Fx?
Battles sign (ecchymosis behind ear), rhinorrhea, otorrhea, and Raccoon eyes
On what POD will a wound infxn cause fever? Dx? Tx?
POD 7; erythema and drainage; if cellulitis then abx if also abscess then drainage
What is the best diagnostic test to assess the C spine in trauma?
CT
If bone, vessel, and nerve are all injured what is the order in which they should be repaired?
Bone first then vessel (assuming the bone is in the way of the vascular repair), the the nerve; a fasciotomy should be added since compartment syndrome will likely develop
What tests can be ordered in a smoker before surgery to evaluate pulmonary risk?
Can start with FEV1 and then ABG
How does pulmonary contusion show up on CXR?
Either immediately or 48 hrs later as a white out; Tx involves fluid restrictions and diuresis to prevent third spacing
What is a good way to differentiate, clinically, (i.e. by looking at the pt) whether they have pericardial tamponade or tension pneumo?
In pericardial tamponade there is no resp. distress, in tension PTX there is
How will traumatic rupture of the diaphragm be diagnosed?
Bowel in the chest, always left side; Tx is surgery usually laparascopic unless hemodynamic unstable (a CI to laparascopy)
When do you do emergent craniotomies on ppl with subdural hematomas?
If there is midline shift noted but prognosis is bad, if no shift then ICP monitoring, raise head of bed 30 degrees, hyperventilate and give mannitol and furosemide
Why must you evacuate blood in a hemothorax? How does it present differently from plain ptx?
Prevent empyema; dullness to percussion vs. hyperresonance
What is a major physical exam differentiator between paralytic ileus and SBO?
Bowel sounds are absent in ileus and high-pitched in SBO
What is the most common source of significan intraabdominal bleeding in blunt abdominal trauma?
Splenic injury
In COPD what is compromised in surgery, oxygenation or ventilation?
Ventilation i.e. pCO2 is high
What is the tx of a human bite?
Require surgical debridement and irrigation with broad spec abx
How would you diagnose an early mechanical bowel obstruction after surgery?
A CT scan would show a transition point between dilated and normal/decompressed bowel whereas ileus would just show distended bowel, also ileus usually resolves in 4-5 days
Paralysis and burning pain in the upper extremities with preservation of most fxns in lower extremities
Central cord syndrome (often in elderly with hyperextension of neck i.e. rear end collision)
What is the first test to order when a post-operative pt becomes disoriented?
Blood gas (ABG) since hypoxia is the most likely cause– add resp. support
Why do pts with abdominal compartment syndrome have renal failure?
Compression on the IVC
What is an antibiotic that can be used for brown recluse bites?
Dapsone
On whom can SCD’s NOT be used on?
ppl with lower extremity fx
When is wound dehiscence classically seen after laparotomy?
POD 5 – cover the wound and make sure things like coughing are done with great care, reoperation should be planned to prevent evisceration now or ventral hernia later
What if a chest trauma pt who is on a respirator suddenly dies?
Probable air embolus
What treatment can shorten the halflife of carboxyhemoglobin?
Administration of 100% O2
What is the tx of chronic subdural hematoma? Who is it seen in?
Surgical evacuation produces dramatic cure (cf to acute subdural bleed); elderly, shaken baby, alcoholics.
What is the DDx of subQ emphysema in trauma?
Rupture of trachea, major bronchus, tension ptx, or rupture of esophagus (but usually that is after vomiting (Boerhaave) or pneumatic dilation of stricture)
What is the usual source of bleeding in a hemothorax?
The lung which is a low pressure system so stops bleeding on its own; if an intercostal artery is the cause a thoracotomy may be needed to stop
How should hyponatremia be treated if it was slow to develop i.e. SIADH? What about if rapid, i.e. overzealous fluid replacement etc.?
Fluid restriction; give isotonic fluids like NS or LR
Why should you replace K when correcting a long-standing acidosis?
Because the kidneys have been taking H for K and the person will be hypokalemic
What is the most common cause of zero urine output?
Mechanical issue, look for a kink or clot in the foley
What fractures should make you think of possible aortic trauma as welll?
First rib, sternum, and scapula, or flail chest (i.e. bones that are very hard to break)
What is the best test for detecting traumatic rupture of aorta in trauma?
CT angiography
Why would an electrical burn cause dislocation of the shoulder?
Due to massive high intensity muscle contraction
What2 things do you need to essentially deem that breathing is “ok”?
Breath sounds bilaterally and satisfactory pulse ox
What are some causes of air embolism?
Chest trauma, opening subclavian vein to air such as supraclavicular node biopsies, centra line placement
What is the usual precipitating event for ARDS?
Sepsis
How do you treat evisceration in a pt with a laparotomy
Keep pt in bed, cover with warm saline soaked sterile dressings and take to OR
Which patient is generally worse off clinically? An acute epidural hematoma or acute subdural?
Acute subdural, epidurals are often asx; However, epidurals always get emergent craniotomy whereas subdurals get it only if there is midline shift bc the prognosis is bad
What must you use to put in an airway if there is subcutaneous emphysema
A fiberoptic bronchoscope to assist since that usually indicates severe injury to the tracheobronchial tree
Can you use thrombolytic therapy for a perioperative MI?
No you’d have to use angioplasty and stenting
In whom is Ogilvie syndrome often seen?
It is colonic dilation in pts who have not had abdominal surgery; classically in debilitated ppl who have broken their hip or had prostatic or orthopedic surgery
What are 4 indicators of hepatic risk in surgery?
Bilirubin above 2; albumin below 3 (can also point towards malnutrition/nutrition risk); PT >16, or encephalopathy
Before what age is cricothyroidotomy a bad idea
12 because of the need for possible future laryngeal reconstruction
How do you tx aspiration? Who is the classic surgical pt in whom this occurs?
Bronchoscopy with removal of material; bronchodilators and resp support; a pt who is awake in a difficult intubation, combative, with a fulls stomach
How do you Tx linear skull fractures?
Leave them alone if they are closed (no overlying wound)? If comminuted or depressed need OR
What is the best tx for hypernatremia and why?
D5 1/2 NS; this rapidly repletes the volume but only nudges the tonicity
What is the rule for Tx of pelvic hematomas
Typically left alone if not expanding
Name 4 surgical risk factors for PE
Venous injury i.e. femoral venous catheter, pelvic Fx, age >40, anticipated long immobility period
How do you Tx a scrotal hematoma?
No specific intervention unless testicle is ruptured
What are 2 options for tx of DT’s? When will this develop post-op?
POD 2-3; IV bz’s or IV EtOH in D5
What are some signs of nutrition depletion pre-op (4)? What should be done?
Serum albumin
How is antivenin dosage based?
By the size of the envenomation not by the size of the person i.e. same dose for kid as adult
What should you do in penetrating extremity trauma if the injury occurs in a major vascular territory?
If no obvious signs of vascular injury like pulselessness, then you should get a doppler or angiography; if obvious signs of compromise then surgery
How do you deal with urinary retention post-op?
Straight cath (in and out catheterizations) q 6 hrs on POD 1; at POD 2-3 a Foley would be indicated
What physical sign is the worst for cardiac risk pre-operatively?
JVD; Tx with ACE-I, BB, diuretics should be done first
CT scan in trauma pt shows blurring of gray-white matter interface and multiple small punctate hemorrhages. Dx?
Diffuse axonal injury
What problems do circumferential burns pose on the extremities? The chest?
Formation of eschar that can cut of blood supply like a compartment syndrome but tx is an escharotomy not a fasciotomy; similar problem in chest can interfere with breathing
What is the initial Tx of hemorrhagic shock in urban settings (i.e. presence of trauma center)? What about elsewhere?
Surgical internvention to stop the bleeding with volume replacement after; Volume replacement first with 2 L LR followed by PRBCs until UOP > 0.5 mg/kg/hr
What is a common cause of the abdominal comparment syndrome?
Overaggressive volume replacement with IVF and blood in a laparotomy case in trauma
On what POD does a deep abscess cause a fever? What are some deep abscesses? Tx?
10-15; subhepatic, subphrenic, pelvic; percutaneous drainage
What is the mainstay of tx of ARDS?
PEEP without excessive volume (tidal volumes that are too large assoc. with barotrauma, pulm fibrosis etc); a source for sepsis should also be sought
What is the minimum ejection fraction allowed for noncardiac operations?
35%; risk of MI is 75-85%
How is orotracheal intubation done in an awake pt?
With rapid induction (i.e. etomidate)
In what type of injury is anterior cord syndrome often seen?
Burst fractures of the vertebral bodies
