Pestana pearls Flashcards
Securing an airway in someone with subcutaneous emphysema in the neck?
Fiberoptic bronchoscope required
How is an airway actually inserted in an awake patient?
Orotracheal. Rapid induction with monitoring of pulse ox w/ laryngoscope
Topical anesthesia less common
Securing airway in C-spine injury?
Orotracheal too! As long as HEAD IS SECURED and not moved.
Running out of time but need airway?
Cricothyrotomy NOT UNDER 12 YO.
How do you verify that breathing is ok?
Bilateral breath sounds on chest
Good pulse ox
Way to figure out if shock is hemorrhagic?
Check CVP…it’s LOW (empty veins)
3-8 is normal
When is CVP high?
In both pericardial tamponade and tension pneumo
you see big distended neck veins
Tension pneumo physical exam findings?
No breath sounds / hyperresonant to percussion/ tracheal deviation
When you’re giving fluids when should you stop?
Don’t exceed CVP of 15 mmHg
Tamponade management?
Pericardial window, give fluids and blood while doing it
Anyone with head trauma who becomes unconscious…
…gets a CT scan
Acute subdural hematoma on CT with a midline shift
Craniotomy
Prognosis still bad
Acute subdural hematoma on CT WITHOUT midline shift
ICP monitoring, elevate HOB, hyperventilate, avoid fluid overload, mannitol or furosemide
Hypothermia to decrease oxygen demand
When do you see anterior cord syndrome?
Burst fractures of the vertebral bodies
What do you do for suspected cord fracture?
MRI and give some high dose steroids
How do you stop the source of bleeding for a hemothorax?
You don’t; it’s usually a source from the LUNG which will stop by itself as it’s a low pressure system
Rarely it’ll be a systemic vessel (usually intercostal artery)–> thoracotomy
Factors that dictate whether surgery is needed after chest tube inserted to hemothorax?
> 1500 mL out on insertion
200mL/hr
600mL over 6 hours
Someone comes in with flail chest. What do you do?
Fluid restriction + diuretics (contused lung is sensitive to fluid overload)
AND LOOK FOR traumatic transection of the aorta!
What makes you worry about traumatic rupture of the aorta?
It’s a “hidden injury” until it blows up and kills patient.
Be suspicious with broken hard-to-break bones or wide mediastinum.
TEE, spiral CT (CT angio), or MRA
Who gets an air embolism?
Chest trauma patient who is intubated and on a respirator
Also happens when subclavian vein is open to the air (CVP line disconnected, supraclavicular node biopsies)
What do you see in someone with a fat embolism?
Petechial rashes in the axillae and neck, fever, tachycardia, low platelet count
Hypoxemia and bilateral patchy inflitrates on CXR.
RX: RESPIRATORY SUPPORT
Stab wound to the abdomen that has clearly penetrated (viscera are protruding)?
Ex lap MANDATORY
Stab would to abdomen with peritoneal irritation?
Ex lap MANDATORY
Stab wound to the abdomen without penetration or peritoneal irritation?
Digital exploration and observation
If you’re highly suspicious of intraabdominal bleeding in hemodynamically stable patient?
CT SCAN
Suspicious of intraabdominal bleeding in hemodynamically UNSTABLE patient?
FAST exam
Pt develops coagulopathy intraoperatively?
Platelet packs + FFP (~10 units each)
Pt gets intraoperative coagulopathy with ACIDOSIS and HYPOTHERMIA?
Stop right away, pack the bleeding surfaces before closing
How do you treat a pelvic hematoma?
Leave it alone ! as long as it’s not expanding
Pelvic fracture. Next step?
Rule out associated injuries by checking all holes (rectum, bladder, vagina F, urethra M)
Pelvic fractures with ongoing significant bleeding?
Controversial!
Pelvic fixators.
External fixation
Angiographic embolization for ARTERIAL bleeding
Penetrating urologic injury (“Shot right above the pubis”)
SURGICALLY EXPLORED/REPAIRED
Scrotal hematoma/high riding prostate/urge to void but unable
Urethral injury
Do retrograde urethrogram
Suspected bladder leak w/ pelvic fracture?
Retrograde cystogram w/ postvoid films to see extraperitoneal leaks.
Extraperitoneal leak= treat with Foley
Intraperitoneal leak= SURGICAL REPAIR/ suprapubic cystostomy
Suspected renal injury
CT scan
Scrotal hematoma
Check for testicle rupture w/ u/s
Penis fracture?
Risk of AV shunts; repair asap
1 worry about penetrating injuries of the extremities
Vascular injury
Extremity injury near no major vessels?
Tetanus ppx & wound cleaning only
Extremity injury near major vessels but asx patient?
Doppler or CTA
Extremity injury with obvious vascular one?
Surgery & repair obvi
Bone stabilization then vascular repair then nerve
Add fasciotomy bc prolonged ischemia can lead to compartment syndrome
Crush injury
IVF, osmotic diuretics, alkalinization of urine to prevent renal issues/hyperkalemia
Kid swallowed draino
Scope them to r/o perf
Electrocution? Late sequelae?
Same as crush injury plus massive debridement
Ortho injuries
Cataracts, demyelinization syndromes
Respiratory burns
Fiberoptic bronch to confirm
DECIDE respirator or not w/ ABGs
Treatment of burns
Tetanus ppx, topical silver sulfadiazine (mafenide acetate for deep…can produce acidosis) (triple abx ointment for eyes)
NG suction 1-2d then high calorie/high nitrogen diets
2-3wks of wound care then GRAFTING for areas that didn’t regenerate
Who gets EARLY excision and grafting?
Minimal burn (
How do you dose snake antivenin?
By size of bite not size of patient!
Splint during transportation, otherwise no messing with it
Black widow bite?
Red hourglass
N/V/muscle cramps
IV calcium gluconate + Muscle relaxants
Brown recluse bites?
Necrotic center with surrounding halo of erythema skin ulcer
Dapsone
May need surgery or skin grafting
Developmental dysplasia of hip rx?
Abduction splinting w/ Pavlik harness for ~6 mo
Legg Calve Perthes dz?
Avascular necrosis of capital femoral epiphysis
~6 yo
Dec hip ROM, hip or knee pain
Walk with limp, guarding of passive hip motion
“Atrophy of prox thigh muscle”
AP & lateral hip x-ray
Rx by keeping the femoral head within the acetabulum w/ casting & crutches
Slipped capital femoral epiphysis?
Sole of foot turned inward when legs dangle
Hip flexed-> thigh into external rotation and CAN’T GO INWARD
Dx: x-ray
Rx: Tack it back with pins
Septic hip?
Have had febrile illness then refuse to move hip
ORTHO EMERGENCY
Hold hip flexed
Dx: Aspiration under GENERAL anesthesia; if pus comes out more open drainage happens
Little kid has febrile illness then gets severe LOCALIZED bone pain (no hx of trauma there)
MRI then ABX (acute hematogenous osteomyelitis)
X-ray is useless it’s negative for a few wks.
Genu varum
Bowlegs normal up to 3 yo.
After 3 its probably Blount dz–> SURGERY.
Genu valgus?
Knock-knee. Normal 4-8yo. No rx.
Osgood-Schlatter dz
Osteochondrosis of tibial tubercle
Teens w/ localized pain over tibial tubercle, NO knee swelling
RICE
If still no relief–> extension or cylinder cast 4-6 wks
Club foot
Serial plaster casts in neonatal pd
If no response, surgery betw 9-12 mo
Bone fracture areas that are problematic in kids?
Supracondylar fractures of humerus
Anywhere involving growth plate
Kid falls on hand w/ arm extended. What is it?
Supracondylar fracture of humerus
Casting/traction…AND MONITOR FOR VASCULAR OR NERVE INJURY
Fracture in kid involving growth plate?
Closed reduction if laterally displaced
If growth plate in transected need OPEN REDUCTION & INTERNAL FIXATION to prevent uneven growth
Osteogenic sarcoma
10-25 yo growing near knee, “sunburst” on x-ray
Ewing sarcoma
5-15yo, diaphysis of long bones, “onion skinning” on x-ray
Multiple myeloma rx?
CHEMO
Thalidomide if that fails
Badly broken bones that are misaligned…
…need open reduction and internal fixation
Sx of anterior shoulder dislocation?
May have numbness over deltoid from stretching of the axillary nerve
Dx: AP and lateral x-ray
Who gets posterior shoulder dislocation?
Epileptic and electrical burn
X-ray view needs to be axillary or scapular lateral view
Hit by a nightstick?
Diaphyseal fracture of proximal ulna with anterior dislocation of radial head
OPEN REDUCTION AND INTERNAL FIXATION for broken bone
CLOSED REDUCTION for dislocated bone
Workup for FOOSH?
H&P alone then thumb spica cast for udisplaced fractures…x-ray usu neg
Displaced/angulated fracture needs open reduction-internal fixation
Metacarpal neck fracture
X-ray
Mild- closed reduction/ulnar gutter splint
Bad- Kirschner wire or plate fixation
Femoral neck fracture?
Replace the femoral head with a prosthesis for faster healing! (Bc you’re worried about avascular necrosis)
Intertrochanteric fracture?
ORIF
Watch out for DVT/PE bc they’re immobile…heparin
Femoral shaft fracture?
Intramedullary rod fixation
Bilateral and comminuted can lead to blood loss
Open is an ortho emergency- OR cleaning & closure within 6 hrs
Collateral ligament tears rx?
Hinged cast
Meniscal tear rx?
Open repair
Who gets tibial stress fractures?
Men forced to march. TTP over very specific part of bone but NORMAL x-ray
Rx: Cast, repeat x-ray in 2 wks
Tibia/fibula fractures that can’t be aligned?
Intramedullary nailing
Otherwise casting
Achilles rupture?
Loud pop, gap when palpating tendon
Cast in equinus position (months of healing) or surgery faster
Ankle fracture?
BOTH malleoli break
AP, lateral, mortise x-ray
ORIF if displaced
Knees hit steering wheel?
Posterior dislocation of hip
Emergent reduction…risk of avascular necrosis
Gangrene rx?
IV penicillin, extensive debridement, HBO
Fracture in middle to distal third of humerus?
Radial nerve involvement–>wrist drop
You waited too long to restore flow to popliteal artery so…
…do a prophylactic fasciotomy
Facial fracture/closed head injury?
CHECK C-SPINE
What do you do if surgery is needed for median nerve injury?
EMG before
Trigger finger?
Wake up in middle of night w/ finger acutely flexed, painful “snap” with extension
STEROID INJECTION
De quervain tenosynovitis?
Mom holding baby. Give steroids
Felon?
Pressure can build up and lead to tissue necrosis; SURGICAL DRAINAGE
Mallet or Jersey finger?
Splint
Lumbar disc herniation?
Peak age 45-46.
Several months of vague aching back pain THEN sudden onset of neurogenic pain precipitated by A FORCED MOVEMENT
Exacerbated by coughing, sneezing, defecating
Bed rest for 3 weeks
Cauda equina syndrome?
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia
IMMEDIATE SURGICAL DECOMPRESSION
Where are venous stasis ulcers?
Edematous, indurated, hyperpigmented skin above medial malleolus
Painless w/ granulating bed
Pt has varicose veins and frequent cellulitis
Dx: Duplex scan
Rx: Support stockings, unna boot
Who gets plantar fasciitis?
Older overweight ppl
Disabling sharp HEEL pain each time foot touches ground. Worse in morning
X-ray: Bony spur at pain location (though this is not a problem in and of itself)
Rx: Self limiting in 12-18 months
Rx for an acute attack of gout?
Indomethacin and colchicine
Rx for chronic gout?
Allopurinol and probenicid
