Surgery Flashcards
The PROPPR trial showed that _____________.
in MTP, a 1:1:1 ratio of blood/plasma/platelets was non-inferior to 1:1:2; in fact, there were decreased deaths from exsanguination in the 1:1:1 group
Describe the idea of permissive hypotension.
In hemorrhagic shock, patients should be allowed to have SBP 80-90 to reduce the risk that hypertension can exacerbate bleeding.
True or false: TXA has been shown to be unhelpful in hemorrhagic shock and should not be given.
False
TXA should be given as soon as possible in hemorrhagic shock.
How to run a good resuscitation: ___________.
- prepare (know where things are, know protocols)
- identify roles
- tell all non-role people to leave the bay
- talk through thinking
- calm down
How is a trauma resuscitation different from a non-trauma resuscitation?
- Access is extremely important
- Activate MTP
- Keep patient warm (hypothermia can cause DIC)
- The person leading the resuscitation cannot do procedures, so delegate leadership if you need to do a procedure
How many units of blood are in the UNC ED cooler?
6
What is acute coagulopathy of trauma-shock (ACoTS)?
One-fourth of red traumas develop fibrin-consuming bleeding that is identifiable on TEG.
Why should you only give 1 L of crystalloid to a trauma patient?
Studies show that overuse of crystalloid (like 2 L) increases risk of hypothermia, coagulopathy, and death
Studies show that just having MTP available decreases _____________.
mortality
What is the evidence for permissive hypotension in trauma patients?
There’s not a lot, but some small studies suggest patient improvements with SBPs 90-100 mm Hg.
What are the “hard signs” of vascular injury?
Observed pulsatile bleeding
Arterial thrill (ie, vibration) by manual palpation
Bruit over or near the artery by auscultation
Signs of distal ischemia
Visible expanding hematoma
These warrant immediate OR.
If you see a midline bullet, get a ___________ film.
crosstable
Know if it’s in the spine.
Bags of platelets at UNC contain _________ units.
6
How does TEG work?
The test uses kaolin to activate clotting then a monofilament spins and pulls a clot out. You then get a graph that tells you how long it took to generate the clot.
The R-value is the time to the initial clot and represents the clotting pathway.
The alpha angle is the speed of clot development and represents the level of fibrinogen in the blood.
The mean amplitude is the height of the waves and represents the size of the clot that develops. This is dependant on the amount of platelets.
How do you interpret TEG?
- Prolonged R: failure of intrinsic and extrinsic pathway -> give FFP
- Prolonged R w/ a reduced alpha angle: give FFP and cryoprecipitate
- Low mean amplitude (low amplitude wave): give platelets
What percent of people who sustain cardiac arrest from a trauma survive?
7%
Which type of trauma has a better prognosis, blunt or penetrating?
Penetrating
Review the West guidelines for thoracotomy.
Blunt trauma: less than 10 min of prehospital CPR
Penetrating trauma: less than 15 min of prehospital CPR (less than 5 min if penetrating to neck or extremity)
- Both with witnessed arrest.
Review the three eponymous exam findings associated with retroperitoneal hematoma.
Cullen’s sign: periumbilical hematoma
Grey-Turners sign: flank hematoma (“you’ve gotta TURN them over to see it”)
Bryant’s sign: scrotal hematoma
Left shoulder pain from splenic injury is called __________ sign.
Kehr
True or false: CT is the gold standard for traumatic hollow viscus injury.
True but it is insensitive
If you have a suspicion for traumatic hollow viscus injury – say from blunt trauma with shearing force in a patient who has persistent abdominal pain – then consider admitting for observation.
True or false: It’s fine to use a smaller chest tube for traumatic PTX without signs of hemothorax.
False
Pigtail tubes should not be used in traumatic PTX.
If a patient has a penetrating chest wound but is stable and has a normal CXR, why would you repeat another CXR?
Pneumothoraces can take up to 6 hours to develop after a penetrating wound, so it can develop even if the initial CXR is negative.
Don’t forget that ________________ is also a method of decompressing tamponade.
thoracotomy
X-rays to evaluate for pneumoperitoneum need to be done __________.
upright (so that subdiaphragmatic air is visible above the liver)
What is the management of partial small bowel obstruction?
A partial SBO – characterized by air-fluid levels with the ability to pass some stool/gas or air seen distal to the obstruction on imaging – should be managed with 12-24 hours of observation. If the patient doesn’t improve on their own they should have surgical correction.
What landmark delineates direct and indirect inguinal hernias?
The inferior epigastric artery
Medial to the artery is a direct hernia. Lateral is indirect. (“MDs don’t LiE” = medial direct, lateral indirect)
Review the treatment of thrombosed hemorrhoids.
Thrombosis of hemorrhoids causes exquisite pain the peaks at 48-72 hours. After that window the clot organizes and the engorgement usually stabilizes, both of which help relieve the pain.
If a person presents within 72 hours after an increase in the pain of their hemorrhoids, then removal of the clot can help to treat their pain. Administer local anesthetic and then do an elliptical incision to remove the clot.
____________ inguinal hernias pass through the inguinal canal.
Indirect
These also pass lateral to the inferior epigastric vasculature.
What is the 3/6/9 rule for bowel dilation?
It is the ULN for luminal diameters:
- Small bowel: 3 cm
- Colon: 6 cm
- Cecum: 9 cm
Air fluid levels w/ a ______________ sign on upright KUB is virtually diagnostic of SBO.
string of pearls
What is complicated SBO?
Complicated SBO is SBO w/ any feature that suggests bowel compromise (i.e., perforation, ischemia, or necrosis). Look for the following:
- Peritonitis on exam
- Imaging findings of pneumoperitoneum, positive FAST, or pneumatosis
- Fever
- Leukocytosis
- Lactic acidosis
- Tachypnea
Compared to older children, kids 5 and under are more likely to present with what signs of appendicitis on exam?
Diffuse abdominal pain and rebound tenderness
It’s thought that because the diagnosis is more often missed or delayed in this age group that kids are more likely to develop peritonitis.
Review the psoas sign.
RLQ pain on extension of the right hip
What is the Rovsing sign?
RLQ pain on palpation of the LLQ
What study has the highest sensitivity for ruling out acute cholecystitis?
HIDA
When should you not attempt reduction of a hernia?
When there are signs of strangulation – overlying redness, tenderness at rest, and fever.
Hernias at the lateral edge of the rectus abdominis muscles are called what?
Spigelian
What ribs are at the manubrium and sterno-manubrial junction?
Manubrium: 1st
Sterno-manubrial junction: 2nd
Which kind of perforated ulcer usually does not show free air on upright CXR?
Posterior duodenal
Review the five grades of liver laceration.
I: Subcapsular hematoma
II: Intraparenchymal hematoma
III: Contained active bleed or vascular injury (e.g., fistula formation)
IV: Parenchymal disruption, uncontained active bleeding
V: Juxtahepatic venous injury
Note, there are many more criteria.
True or false: all grade V liver lacerations require operative intervention.
False
Liver bleeds are extremely difficult to operatively manage, so IR and resuscitation are the mainstays of treatment.
What is the most commonly injured abdominal organ from GSWs?
Small intestines
What is more common in young patients, sigmoid or cecal volvulus?
Cecal
Think “Sigmoid in Seniors”.
