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Surgery: PESTANA Shelf > Pestana Trauma > Flashcards

Pestana Trauma Flashcards

1
Q

2 causes of airway compromise

A

expanding hematoma

subcuntaenous emphysema

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2
Q

how are airways usually secured?

A

orotracheal intubation under direct vision with the use of a laryngoscope

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3
Q

when is the use of a fiberoptic bronchoscope indicated for securing an airway?

A

when there is sub-cu emphysema in the neck (occurs when there is injury to the tracheobronchial tree )

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4
Q

when is crichothyroidtomy indicated for securing an airway? 3

A

in times when intubation cannot be done with an orotracheal intubation, such as

  • laryngospasm
  • severe maxillofacial injuries
  • foreign body in the airway that cannot be dislodged
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5
Q

Clinical signs of shock

A

low BP (

tachycarida

low UO (

pale, cold, shivering, diaphoretic, thirsty and apprehnsive

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6
Q

in the trauma setting, what is shock usually caused by? 3

A

bleeding (hemorrhage)

pericardial tamponade

tension pneumothorax

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7
Q

How do these differ in terms of central venous pressure?

bleeding (hemorrhage)

pericardial tamponade

tension pneumothorax

A
  • bleeding (hemorrhage) = LOW CVP (flat veins)
  • pericardial tamponade = HIGH CVP (bulging veins)
  • tension pneumothorax = HIGH CVP
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8
Q

treatment of hemrorhagic shock at a trauma setting

A

surgical intervention to stop bleeding, followed by volume replacement (2L of LR w/o surgar, followed by PRBC) until UO reaches at ≥ 0.5 mL/kg/h while not exceeding CVP of 15mmHg

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9
Q

preferred route of fluid resuscitation

A

2 peripheral IV lines, 16 guage

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10
Q

what happens if you cannot establish a peripheral IV line in:

a little old lady

children

A

little old lady - percutaneous femoral vein catheter or saphenous vein cut-downs

children - intraossesus cannulation of the proximal tibia

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11
Q

how is pericaridal tamponade typically managed?

A

pericardiocentesis

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12
Q

how is tension pneumothorax diagnosed and managed?

A

by physical exam: presence of a skin flap that sucks air with inspiration and closes during expiration; do not wait for an x-ray or blood gases)

big needle/cathether into the pleural space followed by chest tube to water seal (both inserted high in the anterior chest wall)

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13
Q

3 causes of shock

A

hypovolemic

cardiogenic

vasomotor

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14
Q

causes of hypovolemic shock

management?

A

anything that causes massive fluid loss:

burns

peritonitis

pancreatitis

massive diarrhea

management: blood volume replacement (2L of LR w.o sugar + PRBC until UO reaches 0.5 - 2 ml/kg/h without exceeding CVP of 15 mmHg)

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15
Q

Ideal blood volume replacement

A

2L of LR solution (w/o sugar) + PRBC until UO reaches ≥ 0.5 - 2 mL/kg/h without exceeding CVP of 15 mmHg or less)

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16
Q

2 causes & management of cardiogenic shock?

A

MI or myocarditis

circulatory support - avoid giving blood + fluids since it will be lethal

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17
Q

3 main causes of vasomotor shock

A

anaphylactic reactions

high spinal cord transection

spinal anesthetic

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18
Q

how do pts with vasomotor shock present? 2

how should these patients be managed?

A

low CVP (flat veins), pink and warm patient

vasopressors + IVF

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19
Q

mgmt of patients with penetrating head trauma

A

surgical repair

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20
Q

mgmt of linear skull fractures

A

nothing if closed fracture

surgical closure if open fracture

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21
Q

pt with head trauma is neurologically intact

next best step in management?

A

can send them home only if they have family that will wake them up frequently during the next 24 hours to ensure that they’re not comatose

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22
Q

pt with head trauma suddenly becomes unconscious

next best step in management?

A

head CT (look for intracranial hematoma/bleed)

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23
Q

how do patients with fractures affecting the base of the skull present? 4

next best step in management of these patients? 2

what should you avoid in these patients? 1

A

raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind ear

Expectant management + CT H&N to assess the integrity of the cervical spine (since patients with these types of fractures typically have sustained a very severe head trauma)

avoid nasal endotracheal intubation

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24
Q

epidural hematoma

how to make the diagnosis?

management?

A

CT scan

emergency craniotomy

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25
Q

what happens if epidural hematomas are not treated?

A

fixed dilated pupil (usually ipsilateral to hematoma)

contralateral hemiparesis + decerebrate posture

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26
Q

subdural hematoma

how to make the diagnosis?

management?

A

CT scan: semi-lunar, crescent shaped hematoma

management depends if there is deviation of midline structures:

  • deviation -> craniotomy
  • no deviation -> decrease ICP by elevating head, hyperventilation, avoid fluid overload, give mannitol or furosemide
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27
Q

6 ways to decrease ICP

A

elevate head

hyperventilate until PCO2 = 35

(hypocapnia causes constriction/ hypercapnia causes dilation of cerebral arteries/arterioles)

avoid fluid overload

Rx: mannitol or furosemide

sedation (decrease oxygen demand of the brain)

hypothermia ( “” )

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28
Q

CT of head shows evidence of diffuse blurring of the GW matter interface and multiple small punctate hemorrhages.

Diagnosis?

Management? 2

A

Diffuse axonal injury - usually occurs when there is severe head trauma

therapy - reduce ICP (there is a flashcard about this) or surgery if there is a hematoma

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29
Q

in which patients do chronic subdural hematomas occur? 2

how do they usually present?

how are they diagnosed and treated?

A

in very old or severe alcoholics

mental status deteriorates over the course of several days or weeks as the hematoma forms

CT scan

surgical evacuation

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30
Q

patient shows up with a penetrating trauma to the neck

when would surgery be indicated? 3

A

expanding hematoma

deteriorating vitals

esophageal/tracheal injury (blood)

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31
Q

patient presents to the ED after falling and hitting his head in a snowboard accident.

next best step in management?

A

CT of H&N (cervical spine)

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32
Q

how do patients with complete transection of the spinal cord present?

A

lack of sensory + motor function below the lesion

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33
Q

how do patients with hemisection/Brown-sequard of the spinal cord present?

A

ipsilateral loss of pain + proprioception

contralateral loss of temperature and pain sensation
“control temp/pain”

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34
Q

how do patients with anterior cord syndrome?

how does this usually develop?

A

loss of motor, pain, and temperature (injury to spinothalamic tracts) bilaterally and distal to the injury with preservation of vibratory and positional sense (DCML columns are intact)

typically seen in burst fractures of vertebral bodies

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35
Q

how do patients with central cord syndrome present?

how does this usually develop? 3

A

paralysis and burning pain in the upper extremities with preservation of most functions in the lower extremities (according to wiki, patients may have some evidence of bladder dysfunction/retention)

forced hyperextension of the neck (usually secondary to rear end collision), which may cause either

  1. bleeding into the central part of the cord
  2. selective axonal disruption in the lateral columns at the level of the injury to the spinal cord with relative preservation of the grey matter
  3. fracture dislocation -> anteroposterior compressive forces also distribute the greatest damaging effect on the central mass of the cord substance
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36
Q

patient presents with suspected spinal cord injury

next best steps in management? 3

A

get stat CT and MRI

high dose steroids (avoids swelling)

surgical reduction (if there is a vertebral subluxation)

37
Q

rib fracture in elderly - what should you be concerned about?

how would you manage these patients? 2

A

rib fractures can be deadly because of this sequence:

rib pain -> hypoventilation -> atelectasis -> pneumonia

trmt: local nerve block + epidural cathether

38
Q

pneumothorax management

A

CXR

chest tube placed upper + anterior lung field and connect to water seal

39
Q

hemothorax causes

how is it diagnosed?

management

why is this important?

A

causes: lung bleed or intercostal artery

diagnosed via CXR

management depends on cause of bleed:

  • lung - chest tube placed in lower lung fields and connect to water seal (usually will stop itself since the lung is a low pressure system)
  • intercostal artery - thoracotomy (incision into the pleural space of the chest)

blood needs to be evacuated to prevent development of empyema

40
Q

when is thoracotomy indicated for a hemothorax? 2

A

if > 1.5 L of blood is recovered when chest tube is recovered

or if > 600 cc in tube drainage occurs over the course of 6 hours

41
Q

what is a flail chest and when does it occur?

management? 4

A

occurs in the setting of multiple rib fractures that allow a segment of teh chest wall to cave in during inspiration and bulge out during expiration (paradoxical breathing)

management

  1. fluid restriction + diuretics (contused lungs are very sensitive to fluid overload)
  2. ABG
  3. bilateral chest tubes to prevent tension pneumothorax since broken ribs can puncture the lung
  4. r/o transection of the aorta (since a flail chest usually occurs under the setting of a traumatic injury)
42
Q

patient has deteriorating blood gases and CXR that shows “white out of the lungs”

what is your diagnosis and what is the next best step in management?

A

Pulmonary contusion

  1. fluid restriction + diuretics (contused lungs are very sensitive to fluid overload)
  2. ABG
  3. bilateral chest tubes to prevent tension pneumothorax since broken ribs can puncture the lung
  4. r/o transection of the aorta (since a flail chest usually occurs under the setting of a traumatic injury)
43
Q

patient presents with a sternal fracture, as evidenced on a CXR

next best step in management? 2

A

suspect that there is cardiac injury as well, so get EKG and troponins

44
Q

patient presents to ED after a head-on car crash with a truck. He was fine for the first hour, but suddenly decompensates and dies. What is your suspicion?

how can you prevent from happening the next time?

A

traumatic rupture of the aorta

usually occurs in the setting of a big decleration injury, where the aorta is injured resulting in a hematoma that is initially contained by the adventitia until it blows up and kills the patient

prevent by using non-invasive diagnostic tests: TEE or CT angio; and if positive, immediate surgical correction either with a prosthetic or stent graft

45
Q

crepitus is palpated along the upper chest and lower neck.

diagnosis and next best steps in management 3?

A

subcu emphysema secondary to traumatic rupture of the trachea or major bronchus

CXR + fiberoptic bronchoscopy for intubation (secures airway), followed by surgical repair

46
Q

patient with chest trauma is intubuated and placed on a respirator. Minutes later, he flatlines.

what just happened?

next steps in management?

A

air embolism - leads to sudden cardiac arrest

cardiac massage ASAP to try to resuscitate the patient

47
Q

2 main causes of causes of air embolism

A

when patient with chest trauma is intubated and placed on a respirator

when subclavian vein is opened to the air, which results in sudden collapse and cardiac arrest; examples include supraclaviuclar LN biopsies, central venous line placement, CVP lines that become disconnected

48
Q

Fat embolism

how do these patients usually present?

A

long bone fractures

petechial rash in axilla + neck

fever

tachycardia

low platelet count

respiratory distress

CXR - bilateraly patchy infiltrates

49
Q

fat embolism

how is it diagnosed?

Mainstay of therapy?mu

A

CXR - bilateraly patchy infiltrates

respiratory support

50
Q

management of gunshot wound to abdomen

A

exploratory laparotomy for repair of intraabdominal injuries

51
Q

when is exploratory laparatomy of stab/gunshot wound to abdomen indicated? 3

A
  1. penetration (viscera protrudes from abdomen)
  2. hemodynamic instability (shock, low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic)
  3. signs of peritoneal irritation

if any of these signs are absent, digital exploration of the wound (gentle insertion of gloved finger), CT scan, and observation is indicated

52
Q

3 main places where 1.5 L of blood can “hide”

A

abdomen

pelvis

thigh

53
Q

when do signs of shock secondary to bleeding generally occur?

what are these signs?

A

when there is > 25 - 30% of blood loss

shock, low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic

54
Q

patient with multiple traumas has a normal CXR and no evidence of pelvic or femur fracture suddenly undergoes hypovolemic shock for no reason.

What should you suspect? Next best step in management?

A

internal bleeding

get a CT (shows presence of blood)

indication of hypovolemic shock - low CVP with fast thready pulse, no obvious external source of blood loss, low UO, cold/pale patient who is shivering and diaphoretic

55
Q

patient has CT scan that shows the presence of blood around the spleen (or liver) and has low CVP with a fast, thready pulse. How would you determine if this person needs surgery?

A

fluid bolus/resuscitation

if patient responds -> no surgery

if patient does not respond -> surgery

56
Q

how do you determine if patients have intra-abdominal bleeding?

A

FAST - screens for blood in the in the perihepatic space, perisplenic space, pericardium, and pelvis

57
Q

4 components of FAST

A

screens for blood in the in the

  1. perihepatic space (Morrison’s pouch aka hepatorenal recess)
  2. perisplenic space
  3. pericardium
  4. pelvis
58
Q

if FAST is (+), what happens next?

A

exploratory laparotomy

59
Q

patient presents wiht multiple lower rib fractures on the L side is hemodynamically stable

diagnosis? management?

A

ruptured spleen

splenectomy + post-op immunization against encapsulated bacteria (pneumococcus, H. influenza, meningococcus)

60
Q

patient undergoes a prolonged abdominal laparotomy after sustaining multiple stab wounds. Intraoperatively, he receives multiple transfusions due to significant blood loss and the surgery lasts 12 hours. Post-op, his surgical sites continue to bleed and his INR is measured to be 2.

What’s going on and what is the next best step in management?

A

Perioperative coagulopathy

10 U of platelet packs + FFP

61
Q

what is the abdominal compartment syndrome in the context of surgery?

how do these patients usually present and how are they managed?

A

occurs when lots of flood and blood was given during the course of prolonged laparatomy, such that by the time of closure, all of the tissues are swollen and the abdominal wound cannot be closed without significant tension

ACS develops usually during POD#2, when the patient develops

  • abdominal distension with sutures cutting through the tissues
  • hypoxia develops secondary to inability to breathe
  • renal failure from pressure on the renal vessels

prevent by placing a temporary mesh to be removed at a later date when closure might be possible

62
Q

management of a non-expanding pelvic hematoma

A

nothing

63
Q

management of a expanding pelvic hematoma (2)

A

blood replacement

arteriographic embolization of the arterial bleed (does not work for venous bleeds)

64
Q

how is a pelvic hematoma diagnosed?

A

when patient with a pelvic fracture has evidence of hypovolemic shock without any evidence of bleeding elsewhere

65
Q

how do urethral injuries usually present?

A

blood at meatus (urethral opening of penis)

scrotal hematoma

sensation of wanting to void, but cannot

high-riding prostate on DRE

66
Q

patient comes in with a suspected urethral injury

what is the next best step in management?

what should be avoided?

A

retrograde urethrogram

avoid inserting a foley catheter - may compound an existing injury

67
Q

man presents to the ED complaining of significant penile pain. Physical exam shows large penile shaft hematoma with normal appearing glans

Diagnosis? Management?

A

Penile fracture - usually occurs to an erect penis during a vigorous intercourse session

emergency surgical repair is indicated, otherwise impotence will ensue as AV shuts develop

68
Q

management of a penetrating injury to the extremity without evidence of significant bleed

A

can safely assume that it does not involve major vessel, so tetanus prophylaxis + wound cleaning is indicated

69
Q

management of a penetrating injury to the extremity wit evidence of significant bleed/expanding hematoma, and decreased pedal pulses

A

assume that it involves a major vessel, surgical exploration + repair

70
Q

patient sustains a major fracture to his arm after trying to protect himself from an oncoming baseball bat. You suspect damage to his arteries and nerves in addition to his bone fracture.

How would you manage this?

A

stabilize bone first, then focus on vascular repair, and then leave the nerve for last

fasciotomy is done afterwards since the prolonged ischemia can result in a compartment syndrome

71
Q

4 major concerns of crush injuries

A

Concerns:

  1. hyperkalemia
  2. myoglobinemia
  3. myoglobinuria
  4. renal failure

Management:

  1. vigorous fluid administration
  2. osmotic diuretics
  3. alkalinization
72
Q

management of chemical burns

A

massive irrigation

73
Q

management of high voltage electrical burns 4

A

massive debridgements +/- amputation

also concern of myoglobinemia/uria and renal failure with excess muscle injury, so give:

vigorous fluid administration

osmotic diuretics (mannitol)

alkalinzation of the urine

74
Q

diagnosis 3 and management 2 of respiratory burns/inhalation injuries

A

diagnosis: fiberoptic bronchoscopy + ABG + carboxyhemoglobin levels
management: intubation if evidence of airway compromise, 100% oxygen (shortens carboxyhemoglobin half-life)

75
Q

What is the rule of 9s in adults? How is it different than infants?

A

used to assess extent of burns; used to estimate fluid needs via

kg * extent of burns * 4 = mL of LR for the first 8 hours

76
Q

how do you estimate fluid needs in burn patients? 2

A
  1. use the rule of 9s (see image), which is used to assess extent of burns; which is then used to estimate fluid needs via kg * extent of burns * 4 = mL of LR for the first 8 hours
  2. as soon as UO data was available, fluids can be fine-tuned such that an hourly UO of 1-2 cc/kg/hr while avoiding CVP > 15 mmHg can be targeted
77
Q

why are fluids usually stopped on the third day for burn patients?

A

because plasma trapped in the burn edema would be reabsorbed and a large diuresis would ensue

78
Q

appropriate pre-determined rate of fluid infusion in an adult whose burns exceed >20% of body surface

A

1 L/h of LR (w.o sugar), then adjust to produce the desired UO (1 - 2 cc/kg/hr while avoiding CVP >15mmHg)

79
Q

why is LR fluid without glucose indicated for burn patients or patients who require fluid resuscitation?

A

to avoid an osmotic diuresis secondary to glycosuria, which would cause an increase an hourly UO (remember the targeted UO is 1 - 2 cc/kg/hr, so if this is reached faster with the osmotic diuresis, then one may turn down the IVF, which is bad!)

80
Q

baby with burns that cover > 20% of his body should receive IVF at an initial rate of…

A

20 mL/kg/hr and subsequently fine-tuned in response to urinary output

81
Q

topical agents to use on burn patients and the idications for each one 3

A

silver sulfadiazine

mafenide acetate (for burns that are deep)

triple antibiotics (for burns near the eyes)

82
Q

management of provoked dog bites (petting a dog)

A

no rabies prophylaxis indicated

83
Q

management of wild animals

A

rabies prophylaxis (Ig + vaccine)

84
Q

patient comes in after snake bit him; PE: signficant tenderness around bite site, swelling, discoloration

next step in management? treatment?

A

draw blood for:

  • typing + crossmatch
  • coagulation studies
  • LFT/Renal function

treatment: ​anti-venin such as CROFAB

85
Q

anaphylactic reaction develops after a bee sting. treatment?

A

epinephrine

removal of stingers without squeezing them

86
Q

patient comes in after being bit by a black widow spider with N, V, and severe generalized muscle cramps

management?

A

IV gluconate + muscle relaxants

(venom acts on nerves and cause massive release of ACh, NE, and GABA)

87
Q

patient presents with this lesion after being bit by a spider

what type of spider bite is this? management?

A

suspect bite from brown recluse spider because there is a skin ulcer with necrotic center and surrounding halo of erythema

Dapsone (abx) + surgical excision of the skin ulcer +/- skin grafting

88
Q

dirtiest bite ever

A

human bites

89
Q

management of human bites? 2

A

extensive irrigation + surgical debridement

Surgery: PESTANA Shelf (14 decks)

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