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Surgery > Pestana- 1. Trauma > Flashcards

Pestana- 1. Trauma Flashcards

1
Q

How is an airway most commonly inserted?

A

Orotracheal intubation

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2
Q

How do you visualize the airway during an orotracheal intubation?

A

laryngoscope

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3
Q

If a patient has a c-spine injury and you cannot keep the head stable for orotracheal intubation, what is your other option?

A

Nasotracheal intubation over a fiber optic bronchoscope

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4
Q

What is a sign of major traumatic disruption of the tracheobronchial tree?

A

subcutaneous emphysema in the neck

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5
Q

What is required when securing an airway in a patient with subcutaneous emphysema in the neck?

A

fiberoptic bronchoscope

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6
Q

What is required if intubation cannot be done in the usual manner and time is limited?

A

cricothyroidotomy

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7
Q

At what age do you start feeling comfortable with doing a cricothyroidotomy?

A

12 (due to potential need for future laryngeal reconstruction)

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8
Q

List the clinical signs of shock.

A

-Low BP (

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9
Q

What are the typical causes of shock in trauma?

A
  • Bleeding (hypovolemic/hemorrhagic)
  • Pericardial tamponade
  • Tension pneumothorax
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10
Q

In what type of shock is CVP (central venous pressure) low?

A

hypovolemic shock (bleeding)

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11
Q

How may you differentiate tension pneumothorax with pericardial tamponade?

A

Pericardial tamponade has NO respiratory distress where tension pneumothorax has severe respiratory distress

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12
Q

What are some other hints that your patient has tension pneumothorax?

A
  • Unilateral absence of breath sounds
  • Unilateral hyperresonance to percussion
  • Mediastinum is shifted to opposite side
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13
Q

What is the routine volume replacement in the treatment of hemorrhagic shock?

A
  • 2L of Ringer lactate (without sugar)

- Blood (Packed RBCs)

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14
Q

When do you know to stop volume replacement in hemorrhagic shock?

A
  • Urine output reaches 0.5-2 mL/kg/h

- CVP does NOT exceed 15mmHg

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15
Q

What is the preferred route of fluid resuscitation in the trauma setting?

A

2 peripheral IV lines, 16-gauge

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16
Q

What are the alternatives to the 2 peripheral IV lines in fluid resuscitation in the trauma setting?

A
  • Percutaneous femoral vein catheter

- Saphenous vein cut-downs

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17
Q

What might you use to fluid resuscitate a child

A

Intraosseus cannulation of the proximal tibia

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18
Q

If the diagnosis of pericardial tamponade is not clear from clinical exam, what do you use to diagnose?

A

sonogram

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19
Q

How do you treat pericardial tamponade?

A
  • Pericardiocentesis
  • Tube
  • Pericardial window
  • Open thoracotomy
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20
Q

How do you manage tension pneumothorax?

A

Immediate big needle/IV catheter into affected pleural space

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21
Q

After inserting big needle or IV catheter into affected pleural space in a tension pneumothorax, what is the next step?

A

chest tube connected to underwater seal (inserted high in the anterior chest wall)

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22
Q

What is the CVP in cardiogenic shock?

A

high (see big, distended veins)

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23
Q

How do you treat cardiogenic shock?

A

circulatory support (DO NOT GIVE FLUIDS AND BLOOD)

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24
Q

In what 3 situations do you see vasomotor shock?

A
  • Anaphylactic reactions
  • High spinal cord transections
  • High spinal anesthesia
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25
Q

What is the CVP in vasomotor shock?

A

low

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26
Q

What is the main therapy for vasomotor shock?

A

vasopressors

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27
Q

What do you do with a closed (no overlying wound) linear skull fracture?

A

leave it alone

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28
Q

What do you do with an open linear skull fracture?

A

wound closure

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29
Q

When do you go to the OR with a linear skull fracture?

A

if it is comminuted or depressed

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30
Q

What do you always get in a patient who had head trauma and goes unconscious?

A

CT scan

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31
Q

What are the signs of fracture to the base of the skull?

A
  • Raccoon eyes
  • Rhinorrhea
  • Otorrhea or ecchymosis behind the ear
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32
Q

What should you always do if a patient has a fracture at the base of their skull?

A

assess integrity of c-spine iwth CT scan

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33
Q

What should you always avoid if a patient has a fracture at the base of their skull?

A

nasal endotracheal intubation

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34
Q

How do you typically manage patient’s with fractures at the base of their skulls?

A

expectant management

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35
Q

What are the 3 components of neurologic damage from trauma?

A
  • Initial blow
  • Subsequent hematoma development (displacing midline structures)
  • Development of increased ICP
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36
Q

What shape is an epidural hematoma?

A

biconvex, lens-shaped

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37
Q

How do you treat an epidural hematoma?

A

emergency craniotomy

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38
Q

What is the typical presentation of someone with epidural hematoma?

A

Trauma, unconscious, lucid interval, coma (fixed dilated pupil, contralateral hemiparesis, decerebrate posture)

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39
Q

What shape is a subdural hematoma?

A

semilunar, crescent-shaped

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40
Q

When do you do craniotomy on a subdural hematoma?

A

if midline structures are deviated

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41
Q

How do you manage subdural hematoma?

A

Prevent further damage by reducing ICP:

  • Monitor ICP
  • Elevate head
  • Hyperventilate
  • Avoid fluid overload
  • Mannitol or furosemide
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42
Q

What is the PCO2 goal when you are hyperventilating to reduce ICP?

A

35

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43
Q

What is the suggested option to decrease oxygen demand (rather than sedation) in patients wtih increased ICP?

A

hypothermia

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44
Q

What are the CT findings in diffuse axonal injury?

A

Diffuse blurring of the gray-white matter interface and multiple small punctate hemorrhages

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45
Q

True or false: hypovolemic shock cannot happen from intracranial bleeds

A

TRUE (not enough space in head for amount of blood needed to produce shock)

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46
Q

What do you do for a gunshot wound to the upper zone of the neck?

A

Arteriographic diagnosis and management

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47
Q

What do you do for gunshot wounds to the base of the neck?

A

arteriography, (water-soluble) esophagogram, esoghagoscopy and bronchoscopy

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48
Q

When can you observe a stab wound to the neck?

A

if it is located in the upper and middle zone and the patient is asymptomatic

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49
Q

What must you do in all patients with blunt trauma to the neck (who have neuro deficits or who have TTP over c-spine)?

A

ascertain the integrity of the cervical spine (CT)

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50
Q

What are the findings in a Brown-Sequard lesion?

A

Unilateral paralysis and loss of proprioception distal to injury; Contralateral loss of pain perception

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51
Q

What causes Brown-Sequard lesion?

A

clean knife blade, etc.

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52
Q

What causes anterior cord syndrome?

A

burst fractures of vertebral bodies

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53
Q

What are the findings in an anterior cord syndrome?

A

loss of motor function and pain/temperature bilaterally below lesion with preservation of vibration and positional sense

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54
Q

What causes central cord syndrome?

A

forced hyperextension of the neck (ex. rear end collisions)

*more common in elderly

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55
Q

What are the findins in central cord syndrome?

A

paralysis and burning pain in the upper extremities (preservation of most functions in lower extremities)

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56
Q

What do you do to precisely diagnose a spinal cord injury?

A

MRI

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57
Q

What do some people think may help in the management of spinal cord injury?

A

immediate high-dose corticosteroids

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58
Q

How can a rib fracture cause PNA in the elderly?

A

Pain –> hypoventilation –> atelectasis –> pneumonia

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59
Q

How do you treat rib fracture in the elderly?

A

local nerve block and epidural catheter

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60
Q

What can cause pain pneumothorax?

A

-Penetrating trauma (ex. jagged edge of broken rib to knife)

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61
Q

What are the findings in pain pneumothorax?

A
  • Moderate SOB
  • Unilateral loss of breath sounds
  • Unilateral hyperresonance to percussion
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62
Q

How do you treat pain pneumothorax?

A
  • CXR
  • Chest tube (upper, anterior)
  • Connect to underwater seal
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63
Q

How do you differentiate hemothorax from pain pneumothorax?

A

very similar to pain pneumothorax (causes/symptoms) but you will have dullness to percussion in affected side)

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64
Q

How do you dx a hemothorax?

A

CXR

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65
Q

Why must you evacuate the blood from a hemothorax?

A

to prevent the development of empyema

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66
Q

How do you evacuate the blood from a hemothorax?

A

low placed chest tube

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67
Q

Is surgery typically needed for hemothorax?

A

NO- lung is low pressure system and usually stops bleeding by itself

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68
Q

What are the indications for surgery with a hemothorax?

A
  • Recovery of >/= 1500 mL of blood when chest tube is inserted
  • Collecting >600 mL of tube drainage over 6 hours
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69
Q

What is a sucking chest wound?

A

Injury where there is a flap that sucks air in with inspiration and closes during expiration

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70
Q

What is the risk if you do not treat a sucking chest wound?

A

tension pneumothorax

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71
Q

What is the treatment for a sucking chest wound?

A

occlusive dressing that allows air out (taped on 3 sides) but not in

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72
Q

What is the name for when multiple rib fractures allow a segment of chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing)?

A

flail chest

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73
Q

What is the real problem with flail chest?

A

underlying pulmonary contusion

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74
Q

How do you treat flail chest?

A

fluid restriction and diuretics

75
Q

What do you use if your flail chest patient needs a respiratory due to pulmonary dysfunction?

A

bilateral chest tubes

76
Q

What is a common injury that occurs with flail chest?

A

traumatic transection of the aorta

77
Q

When will a pulmonary contusion show up after chest trauma?

A

immediately to up to 48 hours later

78
Q

How does a pulmonary contusion present?

A

deteriorating blood gases and “white out” of lungs on CXR

79
Q

What should be ordered with a sternal fracture?

A

EKG

Troponins

80
Q

What is a possible complication of sternal fracture?

A

myocardial contusion

81
Q

How does a traumatic rupture of the diaphragm present?

A

bowel in chest (physical exam and CXR)

82
Q

On what side will you see/hear bowel in a traumatic rupture of the diaphragm?

A

ALWAYS on left

83
Q

How do you evaluate possible traumatic rupture of the diaphragm?

A

laparoscopy

84
Q

Where does traumatic rupture of the aorta occur

A

junction of the arch and descending aorta

85
Q

How do traumatic ruptures of the aorta occur?

A

big deceleration injuries

86
Q

What type of fractures may give you a hint that the patient could have a traumatic rupture of the aorta?

A

first rib, scapula, sternum

“very hard to break bones”

87
Q

What is the most appropriate diagnostic tool for traumatic rupture of the aorta in a trauma setting?

A

spiral CT (CT angio)

88
Q

If a patient develops subcutaneous emphysema in upper chest and lower neck, what happened?

A

1) traumatic rupture of trachea or major bronchus

2) large “air leak” from a chest tube

89
Q

What is the diagnostic tool for a potential traumatic rupture of the trachea/major bronchus?

A

fiberoptic bronchoscopy (allows for intubation to secure airway beyond the lesion)

90
Q

What are the two major causes of subcutaneous emphysema?

A
  • Rupture of the esophagus

- Tension pneumothorax

91
Q

When does rupture of the esophagus generally occur?

A

after endoscopy

92
Q

What should be suspected when sudden death occurs in a chest trauma patient who is intubated and on a respirator?

A

air embolism

93
Q

In what situations is the subclavian vein exposed that may allow an air embolism to occur?

A
  • Supraclavicular node biopsies
  • Central venous line placement
  • CVP lines that become disconnected
94
Q

How do you treat air embolism?

A

cardiac massage (with patient placed left side down)

95
Q

How do you prevent air embolism?

A

use Trendelenburg position when the great veins at the base of the neck are to be entered

96
Q

What do you expect in a patient who has undergone multiple trauma, long bone fractures, and develops petechial rashes in the axillae/neck, fever, tachycardia and low platelets + respiratory distress?

A

fat embolism

97
Q

What is the proper diagnostic method for diagnosing fat embolism?

A

fat droplets in urine

98
Q

What is the treatment for gunshot wounds to the abdomen (below level of nipple line)?

A

exploratory laparotomy

99
Q

In what cases must a stab wound be managed with exploratory laparotomy?

A
  • Penetration (protruding viscera)
  • Hemodynamic instabiity
  • Peritoneal irritation
100
Q

How do you treat blunt trauma to the abdomen?

A
  • Exploratory laparotomy (if peritoneal irritation)

- Determine if there are internal injuries/bleeds

101
Q

What are some signs of internal bleeding in a patient with blunt abdominal trauma?

A
  • Drop in BP
  • Fast, thready pulse
  • Low CVP
  • Low UOP
  • Cold, pale, anxious patient who is shivering, thirsty and perspiring
102
Q

How much blood is lost before signs of shock occur?

A

25-30% (around 1500mL in average adult)

103
Q

List the only 3 places where internal bleeds leading to shock can occur in the human body?

A
  • Abdomen
  • Thighs (femur fracture)
  • Pelvis
104
Q

Intraabdominal bleeding diagnosis can be made most accurately with what tool?

A

CT scan

105
Q

From where does blood usually originate in intraabdominal bleeds?

A

liver or spleen

106
Q

What is the problem with doing CT scans on patients with intraabdominal bleeds?

A

patients must be hemodynamically stable

107
Q

What are 2 ways to quickly diagnose intraabdominal bleeding in a patient who is hemodynamically unstable?

A
  • Diagnostic peritoneal lavage (DPL)

- Focused Abdominal Sonogram for Trauma (FAST)

108
Q

What is the most common source of significant intraabdominal bleeding in blunt abdominal trauma?

A

ruptured spleen

109
Q

What is required if the spleen must be removed rather than repaired?

A

Postoperative Immunization against encapsulated bacteria (Pneumococcus, H flu, meningococcus)

110
Q

What is the empiric treatment for intraoperative coagulopathy (in multiple trauma with multiple transfusions)?

A

10 units each of platelets and FFP

111
Q

What do you do if patient develops coagulopathy, hypothermia and acidosis in the intraoperative setting?

A

terminate laparotomy, pack bleeding surfaces, temporary closure, resume surgery when patient is warm/ coagulopathy is treated

112
Q

What is it called when prolonged surgery with many fluids/blood products are given lead to tissue swelling so that the abdominal wound cannot be closed without undue tension?

A

abdominal compartment syndrome

113
Q

How do you manage abdominal compartment syndrome?

A

Place temporary cover over abdominal contents

  • Absorbable mesh (later grafted over)
  • Nonabsorbable plastic (removed later when closure is possible)
114
Q

What should you expect in a patient on POD#2 who gets distention, hypoxia 2/2 inability to breathe, renal failure from pressure on vena cava and retention sutures cutting through tissues?

A

abdominal compartment syndrome (can have a later onset)

115
Q

What is a damage control laparotomy?

A

quick laparotomy where bleeders are clamped, damaged viscera is temporarily occluded, contamination is cleaned, and patient is closed until a later date after they can be properly resuscitated (helps prevent complications like consumption coagulopathy and abdominal compartment syndrome)

116
Q

How do you manage a non-expanding pelvic hematoma?

A

leave it alone

117
Q

What organs must be evaluated in pelvic fractures?

A
  • Rectum
  • Bladder
  • Vagina (women get pelvic exams)
  • Urethra (men get retrograde urethrogram)
118
Q

Why is surgery not an ideal option in pelvic fractures with ongoing significant bleeding?

A

bleeding sites are often inaccessible and opening pelvic hematoma removes tamponade effect

119
Q

What is the ideal treatment for pelvic fractures with associated ongoing hematoma?

A

Pelvic fixators + b/l internal iliac artery angiographic embolization (by IR)

120
Q

What should be suspected in a patient with hematuria after a penetrating or blunt abdominal trauma?

A

urologic injuries

121
Q

What injury is associated with pelvic fracture and blood at the meatus (in males)?

A

urethral injury

122
Q

What are some associated symptoms of urethral injury in a male?

A
  • Scrotal hematoma
  • Sensation of wanting to void but cannot (posterior injury)
  • “High riding” prostate on rectal exam
123
Q

What should be avoided/done in a patient with a suspected urethral injury?

A

NO FOLEY!

Do a retrograde urethrogram

124
Q

How is a bladder injury diagnosed?

A

retrograde cystogram

125
Q

How do you treat extraperitoneal leaks at the base of the bladder?

A

placing a Foley catheter

126
Q

How do you treat intraperitoneal bladder leaks?

A

Surgical repair + protection with suprapubic cystostomy

127
Q

What is the typical associated finding in renal injury?

A

lower rib fractures

128
Q

What is a rare potential sequela of injuries to the renal pedicle?

A

development of AV fistula leading to CHF

129
Q

If renovascular HTN develops after a trauma, what most likely happened?

A

renal artery stenosis

130
Q

What should be done in the setting of a scrotal hematoma?

A

sonogram to be sure the testicle is not ruptured

131
Q

What is “fractured” in a penis fracture?

A

corpora cavernosa

tunica albuginea

132
Q

What must be done for a fractured penis?

A

emergent surgical repair

133
Q

What happens if you do not fix a fractured penis?

A

impotence will ensure (AV shunts develop)

134
Q

How do you manage a penetrating injury to the extremity that has no major vessels in the injury tract?

A
  • Tetanus prophylaxis

- Cleaning of wound

135
Q

How do you manage a penetrating injury to the extremity that has major vessels near the injury tract?

A
  • Doppler studies or CT angiogram (if patient is asymptomatic)
  • Surgical exploration and repair (if absent distal pulses, etc)
136
Q

In what order should combined artery, nerve, bone injuries be repaired?

A
  • Stabilize bone
  • Vascular repair
  • Nerve
  • Fasciotomy (prolonged ischemia could lead to compartment syndrome)
137
Q

What are potential hazards posed by crush injuries to the extremities?

A
  • Hyperkalemia
  • Myoglobinemia
  • Myoglobinuria
  • Renal failure
138
Q

How might you prevent most of the metabolic complications of crush injuries?

A
  • Vigorous fluid administration
  • Osmotic diuretics (mannitol)
  • Alkalinization of the urine
139
Q

What is the very first step in managing chemical burns?

A

massive irrigation (ex. tap water/shower)

140
Q

Which are worse, acid burns or alkaline burns?

A

alkaline burns

141
Q

What should you always be aware of with high-voltage electrical burns?

A

they are always deeper and worse than they appear to be

142
Q

What are some orthopedic injuries that occur secondary to massive muscle contractions in high-voltage electrical burns?

A
  • Posterior dislocation of the shoulder

- Compression fracture of vertebral bodies

143
Q

What are some later complications associated with high-voltage electrical burns?

A

Cataracts

Demyelinization syndromes

144
Q

What is a respiratory burn?

A

chemical injury caused by smoke inhalation

145
Q

How do you confirm the diagnosis of a respiratory burn?

A

fiberoptic bronchoscopy

146
Q

What is the best tool to determine if respiratory support is needed with respiratory burns?

A

blood gases

147
Q

What levels need to be monitored in someone with a respiratory burn?

A

carboxyhemoglobin

148
Q

How do you treat elevated carboxyhemoglobin?

A

100% oxygen

149
Q

What can be performed if a circumferential burn leads to the cutoff of blood supply (collection of edema)?

A

escharotomy (bedside, no anesthesia necessary)

150
Q

What should be suspected if a child has scald marks on its buttocks?

A

child abuse

151
Q

What is the most critical and life-saving component of the management of extensive thermal burns?

A

fluid replacement

152
Q

What is the fluid that accumulates beneath a burn?

A

plasma lost from circulating space that is trapped at the burn site

153
Q

What can occur due to the internal shift of fluids with extensive burns?

A

hypovolemic shock and death

154
Q

What is the rule of 9s?

A

Head= 9% of body surface (in babies 18%)
Upper extremities= 9% X2 of body surface
Lower extremities= 18% X2 of body surface (9X1.5 in babies)
Trunk= 36% of body surface

155
Q

What do you use to assess how much fluid to give a burn patient?

A
  • Aim for hourly UOP of 1-2 mL/kg/hr

- Avoid CVP over 15 mmHg

156
Q

What is the appropriate predetermined rate of fluid infusion in an adult with burns >20% of body surface area?

A

1000 mL/hr of RInger lactate (no sugar) then adjust

157
Q

Why do you avoid sugar in Ringer lactate in burn patient?

A

avoid osmotic diuresis from glycosuria (invalidation of meaning of the hourly UOP)

158
Q

What is the appropriate predetermined rate of fluid infusion in a baby with burns >20% of body surface area?

A

20 mL/kg/hr

159
Q

How do baby burns differ than adult burns?

A

third degree burns in babies will look deep bright red instead of leathery, dry and gray

160
Q

What is the standard topical agent for adult burns?

A

silver sulfadiazine

161
Q

What is the topical agent to use if deep penetration is desired for thick eschar or cartilage?

A

mafenide acetate

162
Q

What are the issues with using mafenide acetate over a broad surface area?

A

it hurts and can cause acidosis

163
Q

What topical treatment is used for burns near the eyes?

A

triple antibiotic ointment

164
Q

How long do burn patients need NG suction?

A

1-2 days

165
Q

What type of intensive nutritional support do burn patients need?

A

high-calorie/high-nitrogen diets (preferably via the gut)

166
Q

When do you start thinking about grafting non-regenerated burn sites?

A

after 2-3 weeks of wound care and general support

167
Q

What are the conditions for early excision and grafting (starting on day one/in the OR)?

A

-Burns

168
Q

What is required for all bites?

A

tetanus prophylaxis and wound care

169
Q

When might you give rabies prophylaxis with a provoked dog bite in an animal with no obvious signs of rabies?

A

if the bite is to the face

170
Q

What is rabies prophylaxis?

A

immunoglobulin + rabies vaccine

171
Q

Who should get rabies prophylaxis?

A

those who receive unprovoked dog bites or bites from wild animals

172
Q

What percent of bites from poisonous snakes are envenomated?

A

around 70%

173
Q

What are the most reliable signs of envenomation after a snake bite?

A

severe local pain
swelling
discoloration
(within 30 minutes of the bite)

174
Q

What labs should be taken on someone with an envenomated snake bite?

A

Type and cross
Coag studies
LFTs
Renal function

175
Q

What is the treatment for an envenomated snake bite?

A

antivenin (CROFAB)

176
Q

What snake has yellow and red rings touching and why is this important?

A

coral snakes (have neurotoxin that needs to be promptly neutralized with specific antivenin)

177
Q

What is the dosage of epinephrine used to treat anaphylaxis from bee stings?

A

0.3-0.5 mL of 1:1000 solution

178
Q

What are symptoms of black widow spider bite?

A

nausea
vomiting
severe generalized muscle cramps

179
Q

What is the antidote for black widow spider bites?

A

IV calcium gluconate

180
Q

What does a brown recluse spider bite look like?

A

skin ulcer with necrotic center and surrounding halo of erythema (often noticed the day after bite occurs)

181
Q

What is the treatment for brown recluse spider bites?

A

Dapsone (may need surgical excision/skin grafts)

182
Q

What is the classic presentation of someone with human bites?

A

someone with sharp cut over knuckles (after fight)

183
Q

What is the antibiotic of choice for treating human bites?

A

Amoxicillin-clavulanate

Surgery (13 decks)

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