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SURGERY > Pretest_4_TraumaandShock > Flashcards

Pretest_4_TraumaandShock Flashcards

1
Q

The finding of an air-fluid level in the left lower chest with an NG tube entering it after blunt trauma to the abdomen is diagnostic of

A

diaphragmatic rupture with gastric herniation into the chest

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2
Q

How is diaphragmatic rupture repaired?

A

immediate laparotomy: examination of intra=abdominal viscera for injuries and exposure of the diaphragm to allow secure repair

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3
Q

What are diagnostic peritoneal lavage findings?

A

1) >10 cc gross RBC
2) RBC > 100,000/mL
3) WBC > 500/mL
4) elevated amylase
5) detectable bile, bacteria, or food fibers

All should undergo exploratory lap to rule out bowel injury

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4
Q

What organ is most likely to be damaged in blunt abdominal trauma?

A

the spleen

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5
Q

What is the test of choice for evaluation of abdominal injury after blunt trauma?

A

Abdominal ultrasound (or “FAST” = focused assessment with sonography for trauma)

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6
Q

What is the treatment of choice for hemodynamically unstable patients with arterial/venous extremity injuries?

A

ligation! Venous repair if hemodynamically stable

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7
Q

Fasciotomy may be required for arterial injury, but should be done in conjunction with and after:

A

reestablishment of arterial flow

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8
Q

How do you accomplish rapid decompression of the pleural space to treat a tension pneumothorax?

A

large gauge (14) needle into intrapleural cavit through the second intercostal space at the midclavicular line just above the third rib. Subsequent placement of chest tube around 4th rib mid-axillary oce urgency has been relieved

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9
Q

Which rib fracture patients should be hospitalized?

A

elderly, multiple rib fractures, demonstrate ventilatory compromise, or have underlying respiratory problems (COPD, smoking)

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10
Q

A patient who receives penetrating injury below the nipples (T4) should get what study to assess for diaphragmatic or abdominal injuries?

A

diagnostic laparoscopy (not CT, which has low sensitivity)

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11
Q

Insulin levels (fall/rise) after injury.

A

Though initially they fall with release of catecholamines, then they RISE

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12
Q

Treatment for traumatic injury to common bile duct:

  • complete transection WITH loss of tissue:
  • complete transection WITHOUT loss of tissue
  • laceration or partial transection:
A
  • complete transection WITH loss of tissue:
    unstable: T tube placement; staged repair
    stable: biliary enteric bypass with Roux-en-Y choledochojejunostomy or cholecystojejunostomy
  • complete transection WITHOUT loss of tissue: primary end-to-end repair
  • laceration or partial transection: primary repair
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13
Q

Which patients with neck injuries should undergo initial angiography?

A

Stable patients with zone III (between the angle of the mandible and the skull), zone I (between sternal notch and lower border of cricoid cartilage), or multiple neck wounds.

Note: zone II is between the lower border of the cricoid cartilage to the angle of the mandible

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14
Q

T/F: All hemodynamically unstable patients with a penetrating neck wound should be explored.

A

True!

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15
Q

An upper GI series showing a coiled spring appearance of the second and third portions of the duodenum is diagnostic for:

How is it treated?

A

duodenal hematoma! Since most resolve spontaneously, observation is the initial mangement strategy. Patients whose obstructive symptoms do not resolve after 2 weeks shoud undergo exploratio nand evacuation of the hematoma.

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16
Q

Management of closed radial nerve palsies:

A

fracture reduction and observation; recovery close to 90%. Operate after several months if function not returning.

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17
Q

If regenerating axons make contact with the distal neurilemma sheath that remains where the original nerve had retracted after injury, what is the rate of nerve regrowth?

A

1 mm/day

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18
Q

Uncal herniation causes (miosis/mydriasis) of the (ipsilateral/contralateral) eye.

A

Uncal herniation causes MYDRIASIS of the IPSILATERAL eye because of compression of the oculomotor nerve (that carries parasympathetic fibers on the outside of its sheath)

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19
Q

What is “flail chest” and how is it managed?

A

Paradoxical respiratory movement in a portion of the chest wall requiring at least two fractures in each of three adjacent rib or costal cartilages.

Managed with analgesia, chest physiotherapy, and mechanical ventilation of respiratory compromise occurs. No chest stabilization.

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20
Q

Oxygen therapy after carbon monoxide poisoning should continue until the COHb levels reach ___%

A

10%

Oxygen therapy should be 100% oxygen mask unless seizures/coma, in which case hyperbaric oxygen

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21
Q

What is the therapy for cardiogenic shock? If that fails?

A

Inotropes (dobutamine and dopamine). Patients refractory to inotropes may require mechanical circulatory support with an intra-aortic balloon pump.

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22
Q

WHy is the tissue deep within the center of an extremity likely to be injured while the superficial tissues are spared in an electrical burn (vs thermal burn)?

A

Bone, fat, and tendons offer greatest resistance to electricity. Deeper injuries than thermal burns

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23
Q

Why is fasciotomy more frequently required than escharotomy with electrical injury?

A

Deep myonecrosis can occur and increase intracompartmental pressures, compromising limb perfusion

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24
Q

Why do electrical burn patients require opthamlologic follow-up?

A

Electrical burn patients can develop cataracts even months after the injury

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25
Q

The highest rate of vascular injury occurs with which fracture/dislocation?

A

dislocation of knee

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26
Q

In general, major joint dislocations are more associated with vascular injury than fractures, except which type of fracture?

A

Type III supracondylar humerus fracture, where displacement of bone may injure or entrap the tethered brachial artery

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27
Q

What are indications for thoracic exploration following injury?

A

1) 1500 mL of blood on inital chest tube placement
2) persistent bleeding at a rate of 200 mL/h for 4h
3) “ of 100 mL/h for 8h

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28
Q

While most necrotizing fasciitis infections are polymicrobrial, monomicrobial necrotizing soft tissue infections can be caused by:

A

1) Group A beta-hemolytic streptococcus

2) Clostridium (treated with high-dose penicillin G)

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29
Q

Which is a better predictor of significant cardiac complications following cardiac contusion: EKG or echo?

A

EKG! Less than 10% of patients have an abnormal initial EKG, but virtually all who eventually develop complications do

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30
Q

Trauma is associated with (positive/negative) nitrogen balance.

A

Negative! Protein breakdown increased to be incorporated into acute phase proteins and glucose; synthesis diminished.

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31
Q

List some acute phase proteins:

A

fibrinogen, haptoglobin, compelment, ferritin

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32
Q

What happens to serum glutamine levels following injury and sepsis?

A

They fall as glutamine is replicating fibroblasts, lymphocytes, and intestinal endothelial cells consume it; prevents atrophy of GI tract

33
Q

What are the catabolic proteins in the traumatized patient?

A

TNF (primary), IL-1, glucagon, epinephrine, cortisol

34
Q

Why is the use of barium contraindicated in suspected rectal perforation? What imaging study should be used?

A

Its spillage into the peritoneal cavity mixed with feces could increase the likelihood of an intra-abdominal abscess

A CTAP should be used; if ambiguous, rigid sigmoidoscopy in the OR can be follow-up

35
Q

T/F: The presence of pulses reliably excludes significant arterial injury.

A

False!

36
Q

T/F; Venous injury, in the absence of an expanding hematoma, does not mandate exploration.

A

True! This is because there are numerous collateral venous channels in the extremities.

37
Q

When is prophylactic fasciotomy performed?

A

Indicated in the presence of

  • an ischemic period exceeding 4-6h
  • combined arterial and major venous injury
  • prolonged periods of hypotension
  • massive associated soft tissue trauma
  • massive edema
38
Q

During shock, if the kidneys are not adequately perfused, the body becomes hypokalemic because of which 3 reasons:

A

1) increased tissue release (protein catabolism)
2) anaerobic metabolism
3) decreased renal perfusion (aldosterone causes distal K secretion)

39
Q

When is surgery indicated in blowout orbital fractures?

A

1) enopthalmos >2mm
2) diplopia on primary or inferior gaze
3) entrapment of extraocular muscles (eg can’t move eye upwards)
4) fracture >50% of orbital floor

40
Q

The lactate in lactated Ringer undergoes waht in the liver?

A

Metabolism to bicarbonate!

41
Q

What are indications for renal exploration following injury?

A

1) hemodynamic instability
2) ongoing hemorrhage requiring significant transfusion
3) avulsion of the pedicle

42
Q

If there is a urethral disruption, what type of catheter can be placed?

A

suprapubic!

43
Q

A free-floating prostate on rectal examination or a scrotal hematoma should raise suspicion of…

A

urethral injury! Along with blood at the urethral meatus

44
Q

T/F: Only small pancreatic hematomas should be explored to search for pancreatic injury.

A

FALSE! All pancreatic hematomas

45
Q

Injury of the major pancreatic duct at the distal end (left of the mesenteric vessels) is treated with:

A

distal pancreatectomy

46
Q

Injury ofthe major pancreatic duct in the region of the head of the pancreas (to the right of the mesenteric vessels) is treated with:

A

Roux-en_Y limb of jejujum brought to drain transected duct

47
Q

When is a pancreaticoduodenectomy used to treat traumatic pancreatic injury?

A

ONLY when there is extensive blunt injuries to both the pancreatic head and duodenum

48
Q

According to the Poiseuille law, fluid is administered faster when a catheter is (shorter/longer) with a (smaller/larger) diameter.

A

Shorter catheter with larger diameter. Flow is proportional to the fourth power of the radius of the catheter and inversely proportional to its length!

49
Q

What is the benefit of “piggybacking” blood into transfusion lines that are delivering crystalloid?

A

It will dilute and warm the blood, thus decreasing the blood’s viscosity, enhancing flow, and minimizing hypothermia

50
Q

Name one benefit and one drawback to the PASG (pneumatic antishock garment).

A

Benefit: increases peripheral resistance; controls bleeding from pelvic fractures and immobilizes to prevent fracture movement

Drawback: to take off the suit, one must ensure satisfactory intravenous volume (otherwise risk irreversible hypotension!). This can delay evaluation of concealed injuries to the lower body

51
Q

In the absence of sepsis, patients with enterocutaneous fistulas should be treated initially with

A

bowel rest, TPN, and correction of electrolyte abnormalities. Should conservative management fail, surgical closure is performed

52
Q

Which fistulas are less likely to close with conservative management: proximal small-bowel (stomach to mid-ileum) or distal (distal ileum or colon)?

A

proximal small-bowel

53
Q

Who benefits from an ER thoracotomy? Who should not receive one?

A

Indicated: 1)cardiac tamponade with rapid deterioration,

2) intra-abdominal bleeding requiring cross-clamping of the descending aorta,
3) faint or absent pulses and distant heart sounds requiring internal cardiac massage (other efforts unsuccessful)

Contraindicated: 1) no vital signs in the field; 2) blunt trauma to multiple organ systems with no vital signs in the ER

54
Q

What is the treatment for a traumatic femoral artery injury?

A

End to end anastamosis if tension-free; otherwise reversed saphenous vein graft

55
Q

Defects in teh diaphragm should be repaired via (abdominal/thorax) approach

A

abdominal (explore for coexisting injuries)

56
Q

T/F: The grade of splenic injury correlates to the need for operative intervention.

A

False!! Even a grade V injury (shattered spleen or hilar vascular injury) does not preclude a trial of nonoperative therapy

57
Q

1) loss of the aortic knob
2) deviation of hte NG tube in the esophagus
3) depression of hte left mainstrem bronchus
4) an apical cap (apical pleural hematoma)
5) massive left hemothorax
6) multiple left-sided rib fractures
are all findings associated with

A

thoracic aortic injury

58
Q

Most traumatic aortic injuries are located near

A

the ligamentum arteriosus

59
Q

Positive DPL findings:

A

1) >10 cc gross blood
2) >100K RBC
3) >500 WBC
4) elevated amylase, bili, or alk phos

60
Q

In patients with injuries to the spine in these regions, loss of sympathetic regulation results in loss of vasomotor tone and hypotension = neurogenic shock.

A

cervical and high thoracic

61
Q

What is the amount of isotonic crystalloid resuscitation for an unresponsive hypotensive patient?

A

20mL/kg body weight

62
Q

When do you start transfusing blood in hypotensive patient? What is the relationship to crystalloid?

A

Blood is started if a REPEAT crystalloid does not cause patient to respond

63
Q

Pericardiocentesis is performed under local or general anesthesia?

A

local

64
Q

A finding of free fluid in the pelvis mandates what?

A

an exploratory lap

65
Q

If bleeding is encountered on opening the pericardial window to resolve tamponade, what is the next stpe?

A

sternotomy

66
Q

Immediate treatment of an open pneumothorax is

A

placement of occlusive dressing over the defect; subsequent intervention = placement of thoracostomy tube

67
Q

Despite the increase in insulin levels in injured humans, there is hyperglycemia because

A

there is increased peripheral resistance to insulin

68
Q

T/F: There is no need to perform exploration of an unstable patient with a zone II neck injury.

A

False. All UNSTABLE patients should have exploration of penetrating neck wound

69
Q

What are absolute indications for neck exploration following injury?

A

airway distress (stridor/hoarsenss/dysphonia); signs of visceral injury (subcutaneous air/hemoptysis, dysphagia); hemorrhage (expanding hematoma, unchecked external bleeding), and neurologic symptoms referable to carotid injury (stroke or altered mental status) or lower cranial nerve or brachial plexus injury

70
Q

When should a duodenal hematoma be explored/evacuated?

A

If the patient is already undergoing laparotomy for other injuries
If obstructive symptoms do not resolve after 2 weeks (to r/o perforation/injury to head of pancreas)

71
Q

In the face of inadequate volume resuscitation, what is the best way to reduce ICP?

A

hyperventilation (mannitol and reverse Trendelenburg may exacerbate hypotension)

72
Q

What is the next step for suspected rectal perforation?

A

CT scan

73
Q

For ductal injury to the head of the pancreas (right of the mesenteric vessels), what is the treatment?

A

Roux-en-Y jejunopancreostomy

74
Q

Why should an interposition prosthetic graft be avoided in a traumatic destruction of 5cm of the SFA?

A

infection at the suture line can lead to delayed hemorrhage

75
Q

T/F: A positive DPL in a hemodynamically stable patient does not require ex lap.

A

TRUE

76
Q

What is normal CVP?

A

2-6 mm Hg / 5-10 cm H2O

77
Q

In abdominal compartment syndrome, because the venous return decreases, the ICP (increases/decreases) and CPP (increases/decreases).

A

ICP increases, so CPP decreases

78
Q

Abdominal compartment syndrome results in (increased/decreased) peak airway pressures and (increased/decreased) plasma renin and aldosterone.

A

increased

increased plasma renin and aldosterone because renal perfusion is less

SURGERY (21 decks)

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