Shelf Flashcards
How could you distinguish pericardial tamponade from tension pneumothorax?
CVP is high in both conditions.
In pericardial tamponade, there is NO respiratory distress.
What is the definition of shock
Systolic BP less than 90.
UOP less than 0.5mL/kg/hr
Fast feeble pulse
Trauma: shock is due to bleeding (most common), pericardial tamponade or tension pneumothorax. If shock is due to bleeding, CVP is low. If shock is due to pericardial tamponade or tension pneumothorax, CVP is high.
Circulatory collapse in flushed, “pink and warm” patient with signs of shock is concerning for
Vasomotor shock - seen in anaphylaxis and high spinal cord transaction.
A linear skull fracture that is closed with no overlying wound is….
Left alone
Rhinnorhea, otorrhea, raccoon eyes, ecchymosis behind ear concerning for
Base of skull fracture
Spinal cord injury
Primary - initial insult
Secondary - occurs in minutes to hours following the insult and involves spinal cord edema that leads to central hemorrhagic necrosis.
Management: ensure secure airway and Hemodynamic stability, next bladder catherization to ensure no acute urine retention.
Rule out vascular injury in clavicle fracture with:
Angiogram - examine subclavian artery
Brachial plexus is also at risk.
Clavicle injuries:
Middle third of clavicle:
Distal third:
Middle third: Brace, rest, ice
Distal third of clavicle: open reduction and internal fixation
Valgus stress test for MCL
Repeat. Only perform arthroscopy if MRI is inconclusive.
If PCWP increases in response to infusion but there is no sig change in BP in the setting of an accident, consider:
Myocardial contusion – meaning compromises LV function. Next step is urgent echocardiogram.
What rules against hypovolemic shock in this case is that hypovolemic shock has low starting PWCP.
Uncomplicated diverticulitis:
Bowel rest, oral antibiotics, observation. Hospitalize if elderly, immunosuppressed or have elevated Leukocytosis.
Complicated diverticulitis:
Drainage percutaneously if collection is greater than 3cm. Less than 3cm, treat with IV antibiotics and observation.
If after 5 days from drainage there is no symptom resolution, surgery for drainage and debridement.
Doppler pressure of ______ is threshold for escharotomy
25-40.
If escharotomy provides no relief, consider fasciotomy.
A patient with focal neurological signs and acute head trauma should get:
Emergency craniotomy
Tracheobronchial separation is treated with;
Surgery
No risk of adenal insufficiency in pt on prednisone of 5mg or less.
Repeat.
Children with blunt trauma to the abdomen who present with Epigastric pain and repetitive vomiting are concerning for…
Management:
Duodenal hematoma
Management: NG suction and parenteral nutrition. Most duodenal hematomas resolve in 1-2 weeks. The hematoma is between the sub mucosal and muscular layers. If conservative management fails, then laparotomy or laparoscopy.
A man over the age of 60 with back pain, hypotension, syncope is concerning for…
Abdominal aortic aneurysm rupture. If a RUPTURED AAA is suspected, he should be taken to the operating room right away.
Needle shaped crystals on urinalysis indicate
Uric acid stones. These stones must be evaluated by CT scan or IV pyelography because they are radiolucent.
Stones less than 0.6cm can pass with IV hydration and analgesia.
Colonoscopy should not be performed in setting of acute pathology because of increased risk of
Bowel perforation
If an esophageal rupture is suspected, management is:
Confirm diagnosis with water-soluble esophagogram. Then attempt primary closure and drainage of mediastinum (mutually left-sided pleural effusion) within 6 hours to avoid mediastinitis.
CXR in esophageal rupture demonstrates pleural effusion, pneumomediastinum, and/or pneumothorax.
Patients with a positive psoas sign concerning for appendiceal abscess (these patients usually have symptoms of appendicitis for over 5 days) should be manages with
IV antibiotics, bowel rest, and (if appropriate) Percutaneous drainage. They should have an INTERVAL appendectomy in 6-8 weeks because complication rate of immediate surgery is high.
Indications for surgical intervention in chest trauma
1500mL of blood loss when chest tube inserted or greater than 600mL over 6 hours.
Dyspnea, tachypnea, chest pain, hypoxemia especially worsened by intravascular volume expansion with patchy, irregular alveolar infiltrates on CXR in the setting of Motor vehicle accident is concerning for
Pulmonary contusion
Petechiae, respiratory distress, and mental status changes 12-72 hours after long bone fracture is concerning for…
Fat emboli
Sudden hypotension, tachycardia, back pain following cardiac catherization is concerning for…
Retroperitoneal hematoma. Diagnose with CT of the abdomen and pelvis without contrast. Treatment is conservative. No surgery usually required.
The final sequel of compartment syndrome in the upper extremity after a fracture for example, is ___
Volkmann’s ischemic contracture where dead muscle is replaced by fibrous tissue.
Genu varus (bow legs) are normal until age 3. Beyond that age, they are concerning for ________ and can be managed by _____
Blount disease (disturbance of medial proximal tibial growth plate). Managed with surgery.
Osgood-Schlatter’s disease (_________) is treated with
Osteochondrosis of the tibial tubercle. Usually teenagers with persistent pain over tibial tubercle. Treat with immobilization of knee or cast for 4-6 weeks.
If a growth plate is bisected by a fracture, then appropriate management is
Open reduction and internal fixation to realign it perfectly. However, if the growth plate were intact and only lateral displacement occured, then closed reduction is acceptable.
Bone tumors in adults are usually metastatic
Investigate with bone scan first. Then follow up with x-rays. The exception to this is multiple myeloma where x-rays are preferred.
A shoulder dislocation that is held close to the body and internally rotated is the less common ______ dislocation of the shoulder
Posterior
Colles fracture, which occurs in fall on an outstretched arm in older woman (usually osteporotic) and results in a dorsally displaced radius is managed with ….
Referred to as “dinner fork” appearance.
Closed reduction and long arm cast
If scaphoid fracture x-Ray shows angulation and displacement, them open reduction and internal fixation is required. If only the history is positive and x-rays are non-concerning, then thumb spica cast.
Tenderness over anatomic snuff box is usually the clue.
Repeat
For trigger finger, first line therapy is …
Steroid injection
A mom who has been holding her baby often with wrist flexion and thumb extension is at risk for…
De Quervain’s tenosynovitis. The pain is on the radial side of the wrist. Can be reproduced with thumb in closed fist and ulnar deviation of wrist. Treatment: steroid injection.
For contracture where palmar facial nodules can be felt, the treatment is:
Surgery when it is causing disruption in normal activity.
The above condition is known as Dupuytren’s contracture.
An amputated digit should be cleaned with sterile saline and ww tapped in saline-moistening gauze, placed in sealed bag and transported on a bed of ice
Repeat.
An EF under 35% is a risk for peri-operative MI
Repeat
Do not use thrombolytics to treat MIs in the post-operative setting. CPK-MB is the most sensitive isozyme to pick up myocardial damage.
Repeat
Palpable or audible snap occurring while slowly extending the knee from full flexion while simultaneously applying tibial torsion with tenderness on medial side is concerning for…
Medial meniscus injury
A patient with a first time DVT should be started on heparin and transitioned to 3 months of Warfarin therapy with an INR goal of 2-3
Repeat
A joint replacement that becomes symptomatic 3 months afterward is likely to be? 6 months afterwards is likely to be?
3 months - Staph aureus
6 months - Staph epidermis (coagulase negative Staph)
In this disease marked by dysphagia, solids are swallowed more easly than liquids.
Achalasia.
Diagnosis: manometry
Treatment: repeated dilations or surgical myotomy (Heller myotomy)
Succussion splash is associated with _____
Pyloric stricture
Normal CXR findings do not rule out acute cardiac tamponade. In acute cardiac tamponade, the CXR is often normal because only a small amount of fluid is required in the pericardial sac to cause tamponade.
Repeat.
What therapy is available for persistent Primary Raynaud’s?
Calcium Chanel blocker
Digoxin,Verapamil, adenosine should NOT be used in WPW. They increase AV node refractory period thus favoring accessory pathway and placing at risk of V-Fib. Instead use anti-arrhythmic like procainamide.
Repeat
In hypothermia, ________ (EKG changes) seen
J Osborne Waves
All mechanical obstructions caused by incarcerated hernias undergo surgical repair
Repeat
A small bowel carcinoid tumor with liver metastases that causes diarrhea, flushing of the face, wheezing, R sided heart valvular damage (jugular venous pulse)
Carcinoid syndrome
24 hour 5-hydroxyindolacetic acid
For rectal cancers, management may include:
Pre-op chemotherapy and radiation
Treat primary peritonitis with a single bacterial agent with
Antibiotics. No surgery.
Acute hemorrhagic pancreatitis is more severe and is marked by lower hematocrit, at presentation: elevated WBC count, elevated blood glucose, low serum calcium
Repeat
After ____ weeks of observation, pancreatic pseudocysts must be drained percutaneously.
6 weeks. Chance of rupture, bleeding, or secondary infection increases precipitously at this point.
Treatment of acalculous cholecystitis
Antibiotics and Percutaneous cholecystostomy. Definitive therapy is cholecystectomy.
In acute cholecystitis, perform cholecystectomy within 72 hours
Repeat
