Surgery Pestana vignettes Flashcards
1
Q
a pt in involved in a car accident is fully conscious, and his voice is normal does he need to be intubated?
A
(1) trauma, abcs NOPE! doesn’t need to be intubated now, if voice is normal his airway is NOT in immediate risk
2
Q
a patient with multiple stab wounds arrives in the ER fully conscious, and he has a normal voice, but he also has an expanding hematoma in the neck whats the next step in management?
A
(2) trauma - abcs intubate STAT by orotracheal intubation with rapid sequence anesthetic intubation & pulse oximetry the airway may be fine now, but its going to be compromised soon. intubation is indicated now before an emergency situation develops
3
Q
a patient with multiple stab wounds arrives in the ER fully conscious, and he has a normal voice, but he also has subcutaneous air (emphysema) in the tissues in the neck & upper chest whats the next step in management?
A
(3) trauma - abcs intubate STAT by fiberoptic bronchoscopy (best intubation option with subcutaneous emphysema) the airway may be fine now, but its going to be compromised soon. intubation is indicated now before an emergency situation develops
4
Q
a patient involved in a severe car accident has multiple injuries and is unconscious. He is breathing spontaneously, but his breathing sounds gurgled and noisy whats the next step in management?
A
(4) trauma - abcs orotracheal intubation - but special note that since pt is already unconscious, doesn’t need rapid anesthesia to intubate (duh)
5
Q
an unconscious pt is brought in by the paramedics with spontaneous but noisy & labored breathing. They relate that at the accident site the pt was conscious, but was complaining of neck pain and was able to move his lower extremities. He lost consciousness during the ambulance ride, and effort to secure a nasotacheal airway was unsuccessful whats the next step in management?
A
(5) trauma - abcs key: find an answer that provides AIRWAY w/o moving the neck key: DONT choose to do imaging before airway is secured! The perennial dilemma of airway management is what to do when there may be a cervical spine injury, but an airway is needed fast. The standard approach is that the airway cannot wait for neck x-rays or elaborate neck traction to be done. Orotracheal intubation can still be performed with manual in-line cervical immobilization (i.e., intubate without whipping the neck around), or better yet over a flexible bronchoscope. Some authors prefer nasotracheal intubation in this setting if facial injuries do not preclude it.
6
Q
A patient involved in a severe automobile crash is fully awake and alert, but he has extensive facial fractures and is bleeding briskly into the airway, and his voice is masked by gurgling sounds.
A
(7) trauma - abcs Securing an airway is mandatory, but the orotracheal route will not be suitable. **Cricothyroidotomy is probably the best choice under these circumstances. **Percutaneous transtracheal ventilation is another option (an intravenous catheter is placed into the trachea with high-pressure oxygen delivery). The old “emergency tracheostomy” can be a horror show and is no longer favored.
7
Q
an unconscious trauma pt has been rapidly intubated in the ER> he has spontaneous breathing and bilateral breath sounds, and his oxygen saturation by pulse oximetry is above 95 whats the next step in management?
A
(8) trauma - abcs As far as breathing is concerned, he is moving air (physical examination) and getting oxygen into his blood (oximetry). Deterioration could occur later, but right now we are ready to move to the “C” in the ABCs. The three conditions that might produce inadequate breathing are plain pneu- mothorax, tension pneumothorax, or flail chest with underlying pulmonary contusion. We will review those with other types of chest trauma.
8
Q
A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. Dx? Management? (3) Tx?
A
(9a) trauma - abCs - Circulation/Shock Dx: Hypovolemic shock Management: Big bore IV lines, Foley catheter and I.V. antibiotics. Tx: Ideally Exploratory Lap immediately for control of bleeding, and then fluid and blood administration.
9
Q
During a bank robbery an innocent bystander is shot repeatedly in the abdomen. When the emergency medical technicians (EMTs) arrive, they find him to be in shock. A fully staffed trauma center is 2 miles away from the site of the shooting. whats most imp for the paramedics to do onsite?
A
(10) trauma - abCs - Circulation/Shock scoop & run- dont waste time! An ambulance can travel 2 miles in 2 minutes- maybe 3. The point of the vignette is that elaborate attempts to start an IV at the site and begin to infuse Ringer lactate would waste precious time that would be best spent moving the patient to a place where the urgently needed laparotomy can be done (“scoop and run”).
10
Q
A 19-year-old male is shot in the right groin during a drug deal gone bad. He staggers to the hospital on his own, and arrives in the ER with a blood pressure of 90 over 70 and a pulse rate of 105. He is squirting bright red blood from the groin wound. whats the next steps?
A
(11) trauma - abC - circulation/ shock direct pressure to control bleeding first The point of this vignette is that control of the bleeding by direct local pressure is the first order of business before volume restoration is started. And a gloved finger or a sterile pressure dress- ing is the way to do it- not blind clamping or a tourniquet.
11
Q
A car accident victim has arrived in the ER, and the initial survey indicates that he is unconscious, with spontaneous but noisy breathing and a blood pressure of 80 over 60 with a pulse rate of 95. His head and neck veins are not obviously distended. While the anesthesia team is intubating him, another team is placing a central line for central venous pressure(CVP) measurement, and others are examining his chest and abdomen. Dx? Management?
A
(12) trauma - abC - circulation/ shock Hypovolemic shock - likely bleeding from unknown site + trouble breathing The emphasis on control of bleeding first and fluid replacement later cannot be implemented if we do not know yet where the bleeding is coming from, and whether it might stop sponta- neously or not. In a case like this, two large (16-gauge) peripheral lines should be started, and Ringer lactate should be poured in. At one time central venous lines were deemed essential for fluid resuscitation, but short, wide catheters in peripheral veins work better, and placing them does not interfere with other ongoing therapeutic and diagnostic maneuvers. Percutaneous femoral vein catheter is an acceptable alternative when peripheral IVs are hard to start. Saphenous vein cut-downs, which were very popular in the 1950s, have also made a comeback as a suitable route.
12
Q
A 4-year-old child has been shot in the arm in a drive-by shooting. The site of bleeding has been controlled by local pressure, but he is hypotensive and tachycardic. Two attempts at starting peripheral IVs have been unsuccessful. Dx? Management?
A
(13) trauma - abC - circulation/ shock In this age group, the access of last resort is intraosseous cannulation in the proximal tibia. The initial bolus of Ringer lactate would be 20 ml/kg of body weight.
13
Q
During a wilderness trek, a 22-year-old man is attacked by a bear and bitten repeatedly in the arms and legs. His trek companion manages to kill the bear and to stop the bleeding by applying direct pressure, but when paramedics arrive 1 hour later, they find the patient to be in a state of shock. Transportation to the nearest hospital will take at least 2 hours. Dx? Management?
A
(14) trauma - abC - circulation/ shock All the training that paramedics took to enable them to infuse IV fluids has not been wasted. In the urban setting we now prefer rapid transportation to the hospital (“scoop and run”), but in this case prompt and vigorous fluid resuscitation is in order. The preferred fluid is Ringer lactate (without sugar), infusing at least a couple of liters in the first 20 or 30 minutes.
14
Q
A 22-year-old gang member arrives in the ER with multiple gunshot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering, anxious, and asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. Dx? Management?
A
(15) trauma - abC - circulation/ shock What is it? Hypovolemic shock is still the best bet, but the inclusion of chest wounds raises the possibility of pericardial tamponade or tension pneumothorax. As a rule, if significant findings are not included in the vignette, they are not present. Thus, as given, this is still a vignette of hypovolemic shock, but you may be offered in the answers the option of looking for the missing clinical signs: distended neck veins (or a high measured CVP) would be common to both tam- ponade and tension pneumothorax; and respiratory distress, tracheal deviation, and absent breath sounds on a hemithorax that is hyperresonant to percussion would specifically identify tension pneumothorax.
15
Q
22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. Dx? Diagnostic test? Tx?
A
(16) trauma - abCs - Circulation/Shock Dx: Pericardial tamponade Diagnostic test: No X-Rays needed, this is a clinical diagnosis! Do Pericardial window. (****in the meantime, can give IVF) or pericardiocentesis, tap, tube to evacuate blood from pericardial space Tx: If positive, follow with Thoracotomy, and then Exploratory Lap.
16
Q
A 22-year-old gang member arrives in the E.R. with a single gunshot wound to the precordial area. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. Dx? Management?
A
(17) trauma - abCs - Circulation/Shock Dx: Pericardial Tamponade Management: Exploratory Lap (when the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might be done right away without prior pericardial window)
17
Q
A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He has labored breathing is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is tympantic, with no breath sounds. Dx? Management? (2 steps) Tx?
A
(18) trauma - abCs - Circulation/Shock Dx: Tension pneumothorax Management: 1. Immediate big bore IV catheter placed into the right pleural space (2nd intercostal midclavicular) 2. followed by Chest Tube to the right side, Immediately! (Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray.)
18
Q
A 22-year-old man is involved in a high-speed, head-on automobile collision. He arrives in the ER in coma, with fixed, dilated puprls. He has multiple obvious fractures in both upper extremities and in the right lower leg. His blood pressure is 70 over 50, with a barely perceptible pulse rate of 140. where is he bleeding?
A
(19) Trauma - abC- circulation/ shock NOT bleeding in the head! recognize he is in SHOCK & there isn’t enough room in the brain for a intracranial bleed to cause shock, therefore he much be bleeding somewhere else We have pointed out that shock in the trauma setting is caused by bleeding (the most common source), pericardial tamponade, or tension pneumothorax. This case fits right in, but the presence of obvious head injury might lead you into a trap: the question will offer you several kinds of intracranial bleeding (acute epidural hematoma, acute subdural hematoma, intracerebral bleed- ing, subarachnoid hemorrhage, etc.) as the answer. They are not. Intracranial bleeding can indeed kill you, but not by blood loss. There isn’t enough room in the head to accommodate the amount of blood needed to go into shock (roughly a liter and a half in the average size adult). Thus, you need to look for another source (we will elaborate in the section on abdominal trauma).
19
Q
A 72-year-old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMTs, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended, and he is short of breath. dx/ management?
A
(20) nonTrauma - abC- circulation/ shock What is it? old man, chest pain, straight- forward cardiogenic shock from massive myocardial infarction (MI). Management. Verify high CVP, electrocardiogram (ECG), enzymes, coronary care unit, etc. Do not drown him with enthusiastic fluid “resuscitation,” but use thrombolytic therapy if offered.
20
Q
A 17-year-old girl is stung many times by a swarm of bees. On arrival to the ER she has a blood pressure of 75 over 20 and her pulse rate is 150, but she looks warm and flushed rather than pale and cold. CVP is low. dx/ management?
A
(21) nonTrauma - abC- circulation/ shock Dx: Vasomotor shock (massive vasodilation, loss of vascular tone). Management. Vasoconstrictors. Volume replacement would not hurt.
21
Q
Twenty minutes after receiving a penicillin injection, a man breaks into hives and develops wheezing. On arrival at the ER his blood pressure is 75 over 20 and his pulse rate is 150, but he looks warm and flushed rather than pale and cold. CVP is low. dx/ management?
A
(22) nonTrauma - abC- circulation/ shock Dx: Vasomotor shock (massive vasodilation, loss of vascular tone). Management. Vasoconstrictors. Volume replacement would not hurt.
22
Q
In preparation for an inguinal hernia repair, a patient has a spinal anesthetic placed. His level of sensory block is much higher than anticipated, and shortly thereafter his blood pressure becomes 75 over 20, but he looks warm and flushed rather than pale and cold. CVP is low. dx/ management?
A
(23) nonTrauma - abC- circulation/ shock Dx: Vasomotor shock (massive vasodilation, loss of vascular tone). Management. Vasoconstrictors. Volume replacement would not hurt.
23
Q
A 17 year old girl is stung by a swarm of beesﾐor a man of whatever age breaks out with hives after a penicillin infectionﾐor a patient undergoing surgery under spinal anestheticﾐeventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flushed rather than pale and cold. CVP is low. Dx? Management? (2)
A
(21-23) nontrauma shock - ABCs - circulation Dx: Vasomotor shock (massive vasodilation, loss of vascular tone) Management: Vasoconstrictors and Volume replacement as needed
24
Q
An 18-year-old man arrives in the ER with an ax firmly implanted into his head. Although it is clear from the size of the ax blade and the penetration that he has sustained an intracranial wound, he is awake and alert and hemodynamically stable. management?
A
(1) Trauma - review from head to toe (head) The management of penetrating wounds is fairly straightforward. There will be exceptions, but as a rule the damage done to the internal organs (in this case the brain) will need to be repaired surgically. This man will go to the OR, and it will be there, under anesthesia and with full con- trol, that the ax will be removed. An important detail when the weapon is embedded in the patient and part of it is sticking out is not to remove it in the ER or at the scene of the accident.
25
In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and skull x-rays show an underlyinglinear skull fracture. He is neurologically intact and gives no history of having lost consciousness. management?
(2) Trauma - review from head to toe (head) The rule in skull fractures is that if they are closed (no overlying wound) and asymptomatic, they are left alone. If they are open (like this one), the laceration has to be cleaned and closed, but if not comminuted or depressed, it can be done in the ER.
26
In the course of a mugging, a man is hit over the head with a blunt instrument. He has a scalp laceration, and the skull x-rays show an underlying comminuted, depressed skull fracture. He is neurologically intact and gives no history of having lost consciousness. management?
(3) Trauma - review from head to toe (head) This one goes to the OR for cleaning and repair, and possible craniotomy.
27
A pedestrian Is hit by a car. When brought to the ER he has minor bruises and lacerations but is otherwise quite well, with a completely normal neurologic exam. However, the ambulance crew reports that he was unconscious at the slte, and although he woke up during the ambulance ride and is now completely lucld, he does not remember how the accident happened. management?
(4) Trauma - review from head to toe (head) Anyone who has been hit over the head and has become unconscious gets a computed tomography (CT) scan, looking for intracranial hematomas. If the CT scan and the neurologic exam are normall, he can go home - provided his family is willing to wake him up frequently over the next 24 hours to make sure he is not going into coma.
28
A car hits a pedestrian. He arrives in the ER in coma. He hasﾐ(raccoon eyesﾐ or clear fluid dripping from the noseﾐor clear fluid dripping from the earﾐor ecchymosis behind the ear)ﾐ Dx? Diagnostic Test? Tx?
(5-8) Trauma - review from head to toe (head) Dx: Base of the skull fracture. Diagnostic Test: CT scan and cervical spine X-Rays. Tx: needs neurosurgical consult and antibiotics
29
A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated. Dx? How is it diagnosed? Tx?
(9) Trauma - review from head to toe (head) Dx: Acute epidural hematoma (probably right side) Diagnostic Test: CT scan Treatment: Emergency surgical decompression (craniotomy) Good prognosis if treated, fatal within hours if it is not.
30
A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil. Dx? Diagnostic Test? Tx?
(10) Trauma - review from head to toe (head) Dx: Acute Subdural hematoma Diagnostic Test: CT scan (Also need to check cervical spine!) Treatment: Emergency craniotomy poor prognosis because of brain injury
31
A man involved in a high-speed, head-on automobile collision is in a coma.He has never had any lateralizing signs, and CT scan shows a small crescent- shaped hematoma, but there is no deviation of the midline structures. Dx? Diagnostic Test? Tx?
(11) Trauma - review from head to toe (head) Another subdural hematoma, but without lateralizing signs and evidence of displacement of the midline structures, surgery has little to offer. Management will probably be directed at con- trolling ICP, as detailed in the next vignette.
32
A patient involved in a head-on, high-speed automobile collision arrives in the ER in deep coma, with bilateral fixed dilated pupils. CT scan of the head shows diffuse blurring of the gray-white mass interface and multiple small punctate hemorrhages. There is no single large hematoma or displacement of the midline structures Dx? Diagnostic Test? Tx?
(12) Trauma - review from head to toe (head) The CT findings are classic for diffuse axonal injury. Prognosis is terrible, and surgery cannot help. Therapy will be directed at preventing further injury from increased ICP. Probably ICP monitoring will be in order. First-line measures to lower ICP include head elevation, hyper- ventilation, and avoidance of fluid overload. Mannitol and furosemide are next in line. Do not overdo the treatment. Lowering ICP is not the ultimate goal; preserving brain perfusion is. Thus, diuretics that lead to systemic hypotension, or measures that produce excessive cerebral vasoconstriction may be counterproductive. Lowering oxygen demand may also help. Sedation has been used for that purpose, and hypothermia is currently advocated for the same reason.
33
A 77-year-old man becomes �senile� over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Dx? Diagnostic Test? Tx?
(13) Trauma - review from head to toe (head) Dx: Chronic subdural hematoma. [DONT CONFUSE WITH ALZHEIMERS!!] Diagnostic Test: CT scan Treatment: Surgical decompression (craniotomy) Spectacular improvement expected
34
A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma with fixed, dilated pupils. He has multiple other injuries, including fractures of the extremities. His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What klnd of intracranial bleeding IS responsible for the low blood pressure (BP) and high pulse rate? dx/management/ tx?
(14) trauma - review from head to toe (head) I trust you remember this very same vignette from the review of shock. Shock does not result from intracranial bleeding (not enough room in the head for sufficient blood loss to cause shock). Look for answer of significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures).
35
A man has been shot in the neck and his blood pressure is rapidly deteriorating. next steps?
(15) trauma - review from head to toe (neck) RUSH TO THE OR
36
A 42-year-old man is shot once with a 22-caliber revolver. The entrance wound is in the anterior left side of the neck, at the level of the thyroid cartilage. X-rays show that the bullet is embedded in the right scalene muscle. He is spitting and coughing blood and has an expanding hematoma under the entrance wound. His blood pressure responded promptly to fluid administration, and he has remained stable. next steps?
(16) trauma - review from head to toe (neck) A clear-cut case of a penetrating wound in the middle of the neck (zone 2) that has alarming symptoms and therefore follows the rule (rather than the exception) for all penetrating injuries: immediate surgical exploration is required. This is true even though he is stable. The middle of the neck is packed with structures that should not have holes in them.
37
A young man is shot in the upper part of the neck. Evaluation of the entrance and exit wounds indicates that the trajectory is all above the level of the angle of the mandible. A steady trickle of blood flows from both wounds, and does not seem to respond to local pressure. The patient is drunk and combative but seems to be otherwise stable. next steps?
(17) trauma - review from head to toe (neck) Now we are getting into the exceptions. In this very high level of the neck there is no trachea or esophagus to worry about, but only pharynx- injuries of which are inconsequential. Vascular injuries are the only potential problem, but getting to them surgically is not easy. Thus angiog- raphy is a better choice, both for diagnosis and potentially for embolization.
38
A young man suffers a gunshot wound to the base of his neck. The entrance and exit wounds are above the clavicles but below the cricoid cartilage. He is hemodynamically stable. next steps?
(18) trauma - review from head to toe (neck) Zone 1 - also crammed with vital structures that should be promptly repaired if they are injured. But precise preoperative diagnosis would help plan the incision and surgical approach. If the patient is stable, the standard workup includes: angiography soluble contrast esophagogram (followed by barium if negative) esophagoscopy bronchoscopy This should be done even if the patient is asymptomatic.
39
In the course of a bar fight, a young man is stabbed once in the neck. The entrance wound is in front of the sternomastoid muscle on the right, at the level of the thyroid cartilage. The patient is completely asymptomatic, and his vital signs are completely normal. next steps?
(19) trauma - review from head to toe (neck) In stab wounds to the upper and middle zones of the neck, completely asymptomatic patients can be safely observed for 12 hours, without expensive workup or surgical exploration.
40
A patient who was the unbelted right front-seat passenger in a car flies through the windshield when the car crashes into a telephone pole at 30 miles an hour. He arrives in the ER strapped to a headboard and with sandbags on both sides of the neck. He has multiple facial lacerations but is otherwise stable. Examination of the neck reveals persistent pain and tenderness to palpation over the posterior midline of the neck. Neurologic examination is normal. next steps?
(20) trauma - review from head to toe (neck) Need to r/o C-spine injury: (1) check for neuro deficits (more about those later) (2) if pain over neck, get imaging! - AP & Lateral C-spine films (including T1), as well as odontoid views (3) If xrays negative & you are still suspicious - do a CT scan.
41
An 18-year-old street fighter gets stabbed in the back, just to the right side of the midline. He has paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side. dx?
(21) trauma - review from head to toe (spinal cord) this is a classic spinal cord hemisection, better known as Brown Sequard syndrome.
42
A patient involved in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense and position. dx?
(22) trauma - review from head to toe (spinal cord) Anterior cord syndrome.
43
An elderly man is involved in a rear-end automobile collrsron in which he hyperextends his neck. He develops paralysis and burning pain on both upper extremities while maintaining good motor function in his legs. dx? management?
(23) trauma - review from head to toe (spinal cord) What is it? Central cord syndrome. Management for cases 21- 23: Start with the precise diagnosis. X-rays and CT scans are good to look at the cervical bones. To look at the cord, magnetic resonance imaging (MRI) is better. Beyond that, I doubt that the long and complicated tnanagement of spinal cord injuries will be tested on the examination, but one item might show up: there is some suggestion that high-dose corticosteroids soon after a spinal cord injury may help minimize the permanent damage. Pick that answer, if it's offered, for the acute management.
44
A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterror axillary line. Chest x-ray confirms the presence of a rib fracture, with no other abnormal findings. dx/ management?
(1) trauma review head to toe (chest) A plain rib fracture is the most common chest injury. It is bothersome but trivial in most peo- ple, but it can be hazardous in the elderly (splinting and hypoventilation leading to pneumo- nia). The key to treatment is local pain relief, best achieved by nerve block. Beware of the wrong answers that call for strapping or binding.
45
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. RESONANT to percussion. Dx? Diagnostic Test? Tx (specific)?
(2) trauma review head to toe (chest) Dx: Plain pneumothorax Diagnostic Test: There is time to get a chest X-Ray if the option if offered Treatment: Chest tube to underwater seal and suction, high in the pleural cavity
46
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. DULL to percussion. Dx? Diagnostic Test? Tx?
(3) trauma review head to toe (chest) Dx: Hemothorax Diagnostic Test: Chest X-Ray Treatment: Chest tube on the right, at the base of the pleural cavity
47
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. DULL to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 cc in the next hour. Dx? Further Tx?
(4) trauma review head to toe (chest) Dx: Hemothorax Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards
48
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. DULL to percussion. A chest tube placed at the right pleural base recovers 1250 cc of bloodﾐ(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on). Dx? Further Tx?
(5-6) trauma review head to toe (chest) Dx: Hemothorax Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably intercostal) will need Thoracotomy to ligate the vessel
49
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level. Dx? Tx?
(7) trauma review head to toe (chest) Dx: Hemo-pneumothorax Tx: Chest tube, surgery only if bleeding a lot
50
A worker has been injured at an explosion in a factory. He has multiple cuts and lacerations from flying debris, and he is obviously short of breath. The paramedics at the scene of the accident ascertain that he has a large, flaplike wound in the chest wall, about 5 cm in diameter, and he sucks air through it with every inspiratory effort. Dx? Tx?
(8) trauma review head to toe (chest) The classic sucking chest wound. It needs to be covered to prevent further air intake (Vaseline gauze is ideal), but it must be allowed to let air out. Taping the dressing on three sides, creating a one-way flap (this time in the proper direction) is an option. Once in the hospital, he will need a chest tube.
51
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales. Dx? Next step if she is going to OR? Next step if not doing well?
(9) trauma review head to toe (chest) Dx: Flail Chest (paradoxical breathing) to OR: prophylactic Bilateral Chest Tubes (because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic) not well: Intubate and give Positive Pressure ventilation (Flail chest is usually assoc w/ pulmonary contusion, leading to inadequate respiration from pain)
52
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs �white out� on X-Rays and she is in respiratory distress. Dx? Management? (2 together)
(10) trauma review head to toe (chest) Dx: Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma. Management: 1. Fluid restriction (using colloids) and diuretics, 2. Respiratory support: (intubation, mechanical ventilation and PEEP if needed)
53
A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is tympanic to percussion. Dx? Where is the trauma? Management?
(11) trauma review head to toe (chest) Dx: Tension Pneumothorax Where is the penetrating trauma? The fractured ribs can act as a penetrating weapon. Management: Chest Tube to the left immediately!
54
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation. Dx? Further Tests?
(12) trauma review from head to toe (chest) Dx: Sternal fracture (but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta) Further tests: Most important: 1. CT scan 2. Transesophageal echo (or arteriogram looking for aortic rupture) Also work-up for MI: 1. EKG 2. Cardiac enzymes
55
A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest. Dx? Management?
(13) trauma review from head to toe (chest) Dx: Diaphragmatic rupture (It is always on the left) Management: Surgical repair
56
A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar�s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the ER he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum. Dx? Diagnostic Test? Tx?
(14) trauma review from head to toe (chest) Dx: traumatic rupture of the aorta (King size trauma, fracture of a hard-to-break bone...it could be first rib, scapula or sternum...and the tell-tale hint of widened mediastinum) Diagnostic Test: Arteriogram (aortogram) Treatment: Emergency surgical repair
57
A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. Dx? Test for additional findings? Diagnostic test? Tx?
(15) trauma review from head to toe (chest) Dx: Traumatic rupture of the trachea or major bronchus Additional findings: Chest X-Ray would confirm the presence of air in the tissues Diagnostic test: Fiberoptic bronchoscopy (to confirm diagnosis and level of injury and to secure an airway) Tx: Surgical repair
58
A patient who had received a chest tube for a traumatic pneumothorax is noted to be putting out a very large amount of air through the tube (a large arr leak), and his collapsed lung is not expanding. dx?
(16) trauma review from head to toe (chest) Another presentation for a major bronchial injury.
59
A patient who sustained a penetrating injury of the chest has been intubated and placed on a respirator, and a chest tube has been placed in the appropriate pleural cavity. The patient had been hemodynamically stable throughout, but then suddenly goes into cardiac arrest. dx/management?
(17) trauma review from head to toe (chest) A typical scenario for air embolism, from an injured bronchus to a nearby injured pulmonary vein, and from there to the left ventricle. Immediate management includes cardiac massage and Trendelenburg position, followed by thoracotomy.
60
During the performance of a supraclavicular node biopsy under local anesthesia, suddenly a hissing sound is heard, and the patient drops dead. dx?
(18) trauma review from head to toe (chest) air embolism. [Other thoracic calamities, like tension pneumothoraxor continued bleeding, will produce severe deterioration of vital signs -but there will be a sequence from being okay to becoming terribly ill. When vignettes give you sudden death, think of air embolism.]
61
A patient who is receiving total parenteral nutrition through a central venous line becomes frustrated because the nurses are not answering his call button, so he gets up and out of bed, and disconnects his central line from the IV tubing. With the open catheter dangling, he takes two steps in the direction of the nurses station, and drops dead. dx?
(19) trauma review from head to toe (chest) air embolism. [Other thoracic calamities, like tension pneumothoraxor continued bleeding, will produce severe deterioration of vital signs -but there will be a sequence from being okay to becoming terribly ill. When vignettes give you sudden death, think of air embolism.]
62
A patient who sustained severe blunt trauma, including multiple fractures of long bones, becomes disoriented about 12 hours after admission. Shortly thereafter he develops petechial rashes in the axillae and neck, fever, and tachycardia. Afew hours later he has a full-blown picture of respiratory distress with hypoxemia. Chest x-ray shows bilateral patchy infiltrates, and his platelet count is low. dx/management?
(20) trauma review from head to toe (chest) dx: fat embolism syndrome This is not a chest injury, but it is included here because its main problem is respiratory distress. You probably recognized already the fat embolism syndrome. It is not clear how specific is the laboratory finding of fat droplets in the urine, but it does not matter: the mainstay of therapy is respirator support- which would be needed regardless of the etiology of the respiratory distress- Heparin, steroids, alcohol, and low-molecular-weight dextran have all been used, but are of questionable value.
63
A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender. Management (specific)?
(21) Abdominal Trauma Management: A penetrating wound of the abdomen gets exploratory laparotomy every time. preparations prior to surgery: an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics.
64
A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. Examination shows clean, punched-out entrance and exit wounds in the transverse colon. whats the management?
(22) Abdominal Trauma Technical details of what to do at surgery are not going to be asked in the USMLE, but if a prevailing view dominates surgical thinking - and that view is a recent departure from older, longheld dogma-- there may be a temptation to ask. In this case, it used to be thought that injuries of the colon ALWAYS needed a colostomy, but now everybody agrees that primary repair is okay.
65
A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam is difficult to do. Management?
(23) Abdominal Trauma Management: The point here is to remind you of the boundaries of the abdomen. Although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes, they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap
66
A 42-year-old man is stabbed in the belly by a jealous lover. The wound is lateral to the umbilicus, on the left, and omentum can be seen protruding through it. whats the management?
(24) Abdominal Trauma The general rule is that penetrating abdominal wounds get a laparotomy. That is true for gun- shot wounds, but it is also true for stab wounds if it is clear that peritoneal penetration took place.
67
Inthecourseofadomesticfight,a38-year-oldobesewomanisattackedwith a 4-inch-long switchblade. In addition to several superficial lacerations, she was stabbed in the abdomen. She is hemodynamically stable, and does not have any signs of peritoneal irritation. whats the management?
(25) Abdominal Trauma This is probably the only exception to the rule that penetrating abdominal wounds have to be surgically explored - and that is because this in fact may not be penetrating at all! (The blade was short, the woman is well padded.) Digital exploration of the wound tract in the ER may show that no abdominal surgery is needed.
68
A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants. Dx? Management?
(26) Abdominal Trauma Dx: Blood (and possible feces) in the belly Management: Exploratory lap
69
A 31 year old lady smashes her car against a wall. Her abdomen is tender with guarding and rebound tenderness present in all quadrants Dx? Management?
(27) Abdominal Trauma Dx: Ruptured bowel Management: Exploratory lap, and repair of the injuries
70
A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low. Dx? Diagnostic Test if stable? Unstable? (2 possible) Tx?
(28) Abdominal Trauma Dx: Abdominal bleed Diagnostic test: Patient is stable: CT scan Unstable: 1. Diagnostic Peritoneal Lavage or 2. Ultrasound in ER Tx: Exploratory Lap
71
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128. Dx? Diagnostic test if stable? Diagnostic test if crashing? (2) Tx?
(29) Abdominal Trauma Dx: Ruptured spleen Management if Stable: CT Scan (if he responds promptly to fluid administration, and does not require blood; further management in that case may well be continued observation with serial CT scans) Management if �crashing�: Peritoneal Lavage or Sonogram followed by (Tx)Exploratory Laparotomy
72
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and an exploratory laparotomy where a ruptured spleen is found and it is not salvagable. Further Management?
(30) Abdominal Trauma Further Management: administration of Pneumovax and some would also Immunize for Hemophilus Influenza B and Meningococcus
73
A multiple trauma patlent is receiving massive blood transfusions as the surgeons are attempting to repair many intraabdominal injuries. It is then noted that blood is oozing from all dissected raw surfaces, as well as from his IV line sites. His core temperature is normal. management?
(31) Abdominal trauma Signs of coagulopathy in this setting require a shotgun approach to treatment. Empiric admin- istration of both fresh-frozen plasma and platelet packs is recommended.
74
During the course of a laparotomy for multiple trauma the patient develops a significant coagulopathy, a core temperature below 34ﾭC, and refractory acidosis. management?
(32) Abdominal trauma This combination of hypothermia, coagulopathy, and acidosis requires that the abdomen be closed immediately and that no further operating be done (not even a formal abdominal clo- sure). The standard approach is to pack all bleeding surfaces and close the abdomen temporar- ily with towel clips
75
An exploratory laparotomy for multiple intraabdominal injuries has lasted 3.5 hours, during which time multiple blood transfusions have been given, and several liters of Ringer lactate have been infused. When the surgeons are ready to close the abdomen they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen. management?
(33) Abdominal trauma This is the so-called abdominal compartment syndrome. All the fluid that has been infused has kept the patient alive, but at the expense of creating a lot of edema in the operative area. Forced closure would produce all kinds of problems. The bowel cannot be left exposed to the outside either, so the standard approach is to close the wound with an absorbable mesh over which for- mal closure can be done later, or with a nonabsorbable plastic cover that will be removed later.
76
In the first postoperative day, a trauma patient develops a very tense and distended abdomen, and the retention sutures are cutting through the abdominal wall. He also develops hypoxia and renal failure. management?
(34) Abdominal trauma This is also the abdominal compartment syndrome that was not obvious at the end of the oper- ation, but has developed thereafter. The abdomen will have to be decompressed by opening the incision and using a temporary cover as described above.
77
In a rollover car accident, a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined that she has a pelvic fracture. She arrived hypotensive, but responded promptly to fluid administration. CT scan shows no intraabdominal bleeding, and a pelvic hematoma. management?
(35) Pelvic Fractures Nonexpanding pelvic hematomas in a patient who has become hemodynamically stable are left alone. Depending on the type of fracture, the orthopedic surgeons may eventually do some- thing to stabilize the pelvis, but at this time the main issue is to rule out the potential associat- ed pelvic injuries: rectum, bladder, and vagina. Physical examination and a Foley catheter will do it
78
In a rollover car accident, a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined by physical examination that she has a pelvic fracture. She arrived hypotensive and did not respond to fluid resuscitation. Hemodynamic parameters have continued to deteriorate. Sonogram performed at the ER shows no intraabdominal bleeding. management?
(36) Pelvic Fractures A tough situation. People can bleed to death from pelvic fractures, and thus it seems that we ought to do something about it. But that is easier said than done. Surgical exploration is not the answer; these injuries are typically not in the surgical field afforded by a laparotomy. Several steps have been proposed, but there is no universal agreement as to their effectiveness.External fixation is considered the right answer by many, whereas others think that arteriographic embolization is the way to go (it is effective for arterial bleeding, but not for venous hemorrhage).
79
A young man is shot point blank in the lower abdomen, just above the pubis. He has blood in the urine, and no evidence of rectal injury. dx/management?
(37) Urologic Injuries The hallmark of urologic injuries is blood in the urine after trauma. These two are clear-cut. The therapy is also clear. Penetrating urologic injuries are like most penetrating injuries else- where: they need surgical repair.
80
A woman is shot in the flank, and when a Foley catheter was inserted in ER, the urine was found to be grossly bloody. dx/management?
(38) Urologic Injuries The hallmark of urologic injuries is blood in the urine after trauma. These two are clear-cut. The therapy is also clear. Penetrating urologic injuries are like most penetrating injuries else- where: they need surgical repair.
81
A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus. Dx? (2 possible) Diagnostic test?
(39) Urologic Injuries Dx: Bladder or Urethral injury (pelvic fracture plus blood in the meatus) Diagnostic test: Retrograde Urethrogram (because urethral injury would be compounded by insertion of a Foley catheter)
82
A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a �high riding prostate�. Dx? Diagnostic Test? Management?
(40) Urologic Injuries Dx: Posterior Urethral injury. Diagnostic test: Retrograde Urethrogram Management: Suprapubic catheter (and the repair is delayed 6 months)
83
A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury. Management?
(41) Urologic Injuries Management: Anterior urethral injuries are repaired right away
84
A 22-year-old man involved in a high-speed automobde collision has multiple injuries, including a pelvic fracture. At the initial physical examination, blood is seen at the meatus. insertion of a Foley catheter is attempted, but resistance is met.
(42) Urologic Injuries Back out! Although the blood at the meatus or the perineal hematoma were not there to warn you, this is also a urethral injury. Do the retrograde urethrogram
85
A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria. Dx? Diagnostic test?
(43) Urologic Injuries Dx: Bladder injury (Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact) Diagnostic test: Retrograde Cystogram
86
A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal. Dx? Diagnostic Test?
(44) Urologic Injuries Dx: Kidney injury (Lower injuries have been ruled out) Diagnostic test: CT scan (They will not ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria does not need surgery even if the kidney is smashed. They operate only if the renal pedicle is avulsed or the patient is exsanguinating)
87
A patient involved in a high-speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is hematuria, and retrograde cystogram is normal. CT scan shows renal injuries that do not require surgery. Six weeks later the patient develops acute shortness of breath and a flank bruit. what happened?
(45) Urethral injuries What is it? This is a weird one, but so fascinating that some medical school professor may not be able to resist the temptation to include it. The patient developed a traumatic arteriovenous fistula at the renal pedicle, and subsequent heart failure.
88
A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria. Management?
(46) Urologic Injuries Management: Gross traumatic hematuria in the adult always has to be investigated
89
A 4 year old falls from his tricycle. In the ensuing evaluation he is found to have microscopic hematuria. Management?
(47) Urologic Injuries Management: Microhematuria in kids needs to be investigated, as it often signifies congenital anomaliesﾐparticularly if the magnitude of the trauma does not justify the bleeding. Start with a Sonogram
90
A 14 year old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit. What should be the physician's concern? Diagnostic test? Management?
(48) Urethral injuries Concern: The issue in scrotal hematomas is whether the testicle is ruptured or not. Diagnostic test: Sonogram Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment
91
A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans. Dx? Tx?
(49) Urethral injuries Dx: Fracture of the tunica albuginea (including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top) Tx: this is one of the few urological emergencies. Surgical repair is needed
92
A 25-year-old man is shot with a 22-caliber revolver. The entrance wound is in the anteriolateral aspect of his thigh, and the bullet is seen by x-rays to be embedded in the muscles, posterolateral to the femur. management?
(1) trauma to extremities Apart from the obvious need to fix a bone that might have been shattered by a bullet, the issue in low-velocity gunshot wounds (or stab wounds) of the extremities is the possibility of injury to major vessels. In the first vignette, the anatomy precludes that possibility. Thus that patient only needs cleaning of the wound and tetanus prophylaxis. The bullet can be left where it is.
93
A 25-year-old man is shot with a 22-caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is in the posterolateral aspect of the thigh. He has normal pulses in the leg, and no hematoma at the entrance site. X-rays show the femur to be intact. management?
(2) trauma to extremities the anatomy of the area makes vascular injury very likely, and lack of symptoms does not exclude that possibility. At one time, all of these would have been surgically explored. Nowadays arteriogram is preferred.
94
A 25-year-old man is shot with a 22-caliber revolver. The entrance wound is in the anteromedral aspect of his upper thigh, and the exit wound is in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper, inner thigh. The bone is intact. management?
(3) trauma to extremities it is clinically obvious that there is a vascular injury. Surgical exploration is in order. Arteriogram preceding surgical exploration is done only in parts of the body where the very specific site of the vascular injury dictates the use of a particular incision versus another (for instance at the base of the neck and thoracic outlet).
95
A young man is shot through the arm with a .38-caliber revolver. The path of the bullet goes right across the extremity, from medial to lateral sides. He has a large hematoma in the inner aspect of the arm, no distal pulses, radial nerve palsy, and a shattered humerus. management?
(4) trauma to extremities That he will need surgery is clear, but the issue here is what to do first. A very delicate vascular repair, and an even more fragile nerve reanastomosis, would be at risk of disruption when the orthopedic surgeons start manipulating, hammering, and screwing the bone. Thus the usual sequence begins with fracture stabilization, then vascular repair (both artery and vein if possible), and last nerve repair. The unavoidable delay in restoring circulation will make a fasciotomy mandatory.
96
n a hunting accident, a young man is shot in the leg with a high-powered, big game hunting rifle. He has an entrance wound in the upper outer thigh that is 1 cm in diameter, and an exit wound in the posteromedial aspect of the thigh that is 8 cm in diameter. The femur is shattered. management?
(5) trauma to extremities Even though the major vessels are not in the path of this bullet, this young man will need to go to the operating room to have extensive debridement of the injured tissues. High-velocity bullets (military weapons and big-game hunting rifles) produce a cone of destruction.
97
A 6-year-old girl has her hand, forearm, and lower part of the arm caught in the wringers of an old-fashioned washing machine. The entire upper extremity looks bruised and battered, although pulses are normal and the bones are not broken. management?
(6) trauma to extremities Crushing injuries lead to two concerns; the myoglobinemia- myoglobinuria- acute renal failure issue, and the delayed swelling that may lead to a compartment syndrome. For the first, plenty of fluids, osmotic diuretics (mannitol), and alkalinization of the urine help protect the kidney. For the latter, fasciotomy is the answer.
98
You get a phone call from a frantic mother. Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in the background. Management?
(7) burns Management: The point of this question is that chemical injuries � particularly alkalis-need copious, immediate, profuse irrigation. Instruct the mother to do so right at home with tap water, for at least 30 minutes before rushing the girl to the E.R
99
While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side. Tx? What can occur from this event? Management of this? (3)
(8) burns Management: Extensive surgical Debridement (there is deep tissue destruction) What can occur? Myoglobinemia (leading to myoglobinuria and to Renal Failure) Management: 1. lots of IV fluids, 2. Osmotic Diuretics (Mannitol), 3. Alkalinization of the urine
100
A man is rescued by firemen from a burning building. On admission it is noted that he has burns around the mouth and nose, and the inside of his mouth and throat look like the inside of a chimney. Dx? Diagnostic Test? Management?
(9) burns Dx: Inhalation burns Diagnostic test: Bronchoscopy Management: Respiratory support
101
A patient has suffered third degree burns to both of his arms when his shirt caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly anesthetic, and circumferential all around arms and forearms. What is main problem? Management? (2)
(10) burns Problem: Circumferential burns (The leatherly eschar will not expand, while the are under the burn will develop massive edema, thus circulation will be cut off or in the case of circumferential burns of the chest, breathing will be compromised) Management: Compulsive monitoring of peripheral pulses and capillary filling. Escharotomies at the bedside at the first sign of compromised circulation
102
A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are exquisitely painful to touch. The story is that the kid accidentally pulled a pot of boiling water over himself. what type of burn? What should the physician question? Management? (2)
(11) burns Dx: Second degree burn (Note that in kids third degree is deep bright red, rather than white leatherly as in the adult) Question: How did it really happen? Burns in kids always bring up the possibility of child abuse, particularly if they have the distribution that you would expect if you grabbed the kid by arms and legs and dunked him in a pot of boiling water. Management: Silvadene cream. Possibly reporting to authorities for child abuse
103
An adult male who weight �X� Kgs. Sustains second and third degree burns over ---whatever--- The burns will be depicted in a drawing, indicating what is second degree (moist, blisters, painful) and what is third degree (white, leatherly, anesthetic). What is the equation for proper fluid resuscitation management? What fluid and how much in first 8 hours?
(12-14) burns Management: 4cc per Kg. of body weight per percentage of burned area (up to 50%) (if pt is 70kg and 18% burned, then 70x4x18) Fluid: Ringers Lactate (half of the calculated dose goes in during first 8 hours)
104
After suitable calculations have been made, a 70-kg adult with extensive third- degree burns is receiving Ringer lactate at the calculated rate. In the first 3 hours his urinary output is 15, 22, and 18 ml. Are IVF at an adequate rate?
(15) burns Most experts aim for an hourly urinary output of at least 0.5 rnllkg, or preferably 1 rnllkg body weight per hour. For patients with electrical burns the flow should be even higher (1 to 2 rnllkg per hour); thus by any criteria this fellow needs more fluid.
105
After suitable calculations have been made, a 70-kg adult with extensive third- degree burns is receiving Ringer lactate at the calculated rate. In the first 3 hours his urinary output is 325, 240, and 270 ml. Are IVF at an adequate rate?
(16) burns The opposite of the previous vignette. Somebody is trying to drown this poor guy. The calculation was too generous; the rate of administration has to be scaled back.
106
During the first 48 hours after a major burn, a 70-kg patient received vigorous fluid resuscrtation and maintained a urinary output between 45 and 110 ml/h. On the third postburn day- after IV flutds have been discontinued- his urinary output reaches 270 to 350 ml/h. Are IVF at an adequate rate?
(17) burns This is the expected. Fluid is coming back from the burn area into the circulation. He does not need more IV fluids to replace these losses
107
An 8-month-old baby who weighs x kilograms is burned over...areas (depicted in a front-and-back drawing). Second-degree burn will look the same as in the adult; third-degree burns will look deep bright red. how do child burn calculations differ from adult?
(18) burns In babies the head is bigger and the legs are smaller, thus the head has two 9%s, whereas both legs add up to three (rather than four) 9% Proportionally fluid needs are greater in children than in adults; thus, if asked for the rate in the first hour, it should be 20 rnllkg, and if asked for 24-hour calculations, the formula calls for 4 to 6 ml/kg/%.
108
A patient with second- and third-degree burns over 65% of his body surface is undergoing proper fluid resuscitation. The question asks about management for the burned areas, and other supportive care?
(19) burns First of all, tetanus prophylaxis. Then suitable cleaning, and use of topical agents. The standard one is silver sulfadiazine. If deep penetration is desired (thick eschar, cartilage), mafenide acetate is the choice (do not use everywhere; it hurts and can produce acidosis). Burns near the eyes are covered with triple antibiotic ointment. Pain medication is given IV. After about 2 or 3 weeks, grafts will be done to the areas that did not regenerate. After an initial day or two of NG suction, intensive nutritional support is needed (via the gut, high calorielhigh nitrogen). Rehabilitation starts on day one.
109
A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leatherly, anesthetic. Tx?
(20) burns Tx: Early excision and skin grafting (in very small third degree burns)
110
A 6-year-old child tries to pet a domestic dog while the dog is eating, and the child is bitten by the dog management?
(21) Bites & Stings This is considered a provoked attack, and as far as rabies is concerned only observation of the pet is required (for development of signs of rabies). Tetanus prophylaxis and standard wound care is all that is needed for the child.
111
During a hunting trip, a young man is bitten by a coyote. The animal is captured and brought to the authorities alive. management?
(22) Bites & Stings Observation of a wild animal for behavioral signs of rabies is impractical. But having the ani- mal mailable will allow it to be killed and the brain examined for signs of rabies, thus hopeful- ly sparing the hunter the necessity of getting vaccinated.
112
While exploring caves in the Texas hill country, a young man is bitten by bats (that promptly fly away). management?
(23) Bites & Stings Now we do not have the animal to examine. Rabies prophylaxis is mandatory (immunoglobulin + vaccine).
113
Duringahuntingtr~pahunterisbitteninthelegbyasnake.Hiscompanion, who is an expert outdoorsman, reports that the snake had elliptical eyes, pits behind the nostrils, big fangs, and rattlers in the tail. The patient arrives at the hospital 1 hour after the bite took place. Physical examination shows two fang marks about 2 cm apart, and there is no local pain, swelling, or discoloration. management?
(24) Bites & Stings The description of the snake is indeed that of a poisonous rattlesnake, but even when bitten by a poisonous snake, up to 30% of patients are not envenomated. The most reliable signs of envenomation are excruciating local pain, swelling, and discoloration (usually fully developed - within half an hour) all that is needed, plus the standard wound care (including tetanus prophylaxis).
114
During a hunting trip, a hunter is bitten in the leg by a snake. His companion, who is an expert outdoorsman, reports that the snake had elliptical eyes, pits behind the nostrils, big fangs, and rattlers in the tail. The patient arrives at the hospital 1 hour after the bite took place. Physical examination shows two fang marks about 2 cm apart, as well as local edema and ecchymotic discoloration. The area is very painful and tender to palpation. management?
(25) Bites & Stings This fellow is envenomated. Blood should be drawn for typing and crossmatch, coagulation studies, and renal and liver function. The mainstay of therapy is antivenin, of which several vials have to be given (figure at least 5, but if the description of the local site and systemic symptoms are alarming, pick 10, or even 20). Surgical excision of the bite site and fasciotomy are only needed in extremely severe cases.
115
While playing in the backyard of her south Texas home, a 6-year-old girl is bitten by a rattlesnake. At the time of hospital admission she has severe signs of envenomation. management?
(26) Bites & Stings The point of this vignette is to remind you that snake antivenin is one of the very few medicines for which the dose is not calculated on the basis of the size of the patient. The dose of antivenin depends on the amount of venom injected, regardless of the size and age of the victim. This lit- tle girl may need 10 vials, or even more if she is very sick
116
During a picnic outing, a young girl inadvertently bumps into a beehive and is stung repeatedly by angry bees. She is seen 20 mmutes later and found to be wheezing, hypotensive, and madly scratching an urticarial rash. management?
(27) Bites & Stings Epinephrine is the drug of choice (0.3 to 0.5 rnl of 1:1000 solution). The stingers have to be carefully removed.
117
While rummaging around her attic, a lady is bitten by a spider that she describes as black, with a red hourglass mark in her belly. The patient has nausea and vomiting and severe generalized muscle cramps. management?
(28) Bites & Stings Black widow spider bite. The antidote is IV calcium gluconate. Muscle relaxants also help.
118
A patient seeks help for a very painful ulceration that he discovered in his forearm on arising this morning. Yesterday he spent several hours cleaning up the attic, and he thinks he may have been "bitten by a bug." The ulcer is 1 cm in diameter, with a necrotic center with a surrounding halo of erythema. management?
(29) Bites & Stings Probably a brown recluse spider bite. Dabsone will help. Local excision and skin grafting may be needed, but do not do until the full extent of the damage is obvious (up to one week)
119
A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car. Dx? Management?
(30) Bites & Stings Dx: The description is classical for a human bite. No, nobody actually bit him, he did it by punching someone in the mouth...and getting cut with the teeth that were smashed by his fist. The imaginative cover story usually comes with this kind of lesion. Management: human bites are bacteriological the dirtiest that one can get. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required.
120
In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a �click�, and returned to normal position with a �snapping�. Dx? Management?
(1) Ortho - hip Dx: Developmental Dysplasia of the hip Management: Abduction splinting (Don�t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything)
121
A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded. Dx? Diagnostic test? Management?
(2) Ortho - hip Dx: Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis) [Remember that hip pathology can show up with knee pain] Diagnostic test: AP and lateral X-Rays for diagnosis Management: Contain the femoral head within the acetabulum by casting and crutches
122
A 13 year old boy complains of pain in the groin (it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally Dx? Diagnostic test? Tx?
(3) Ortho - hip Dx: Slipped Capital Femoral Epiphysis (Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency) Diagnostic test: AP and lateral X-Rays Tx: The orthopedic surgeons will pin the femoral head in place
123
A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate Dx? Management? (2 steps)
(4) Ortho - hip Dx: Septic Hip (orthopedic emergency) Management: 1. Under general anesthesia the hip is aspirated to confirm the diagnosis, and 2. Open arthrotomy is done for drainage
124
A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone. Dx? Diagnostic test?
(5) Ortho - other Dx: Acute Hematogenous Osteomyelitis Diagnostic test: Bone Scan (don�t fall for the X-Ray option. X-Ray will not show anything for two weeks)
125
A 2-year-old child is brought in by concerned parents because he is bowlegged. Dx? Management?
(6) Ortho - other Genu varum (bow-leg) is normal up to the age of 3. Genu valgus (knock-knee) is normal between the ages of 4 and 8. Thus neither of these children need therapy. Should the varum deformity (bow-legs) persist beyond its normal age range (i.e., beyond age 3), Blount disease is the most common problem (a disturbance of the medial proximal tibial growth plate), and surgery can be performed for it.
126
A 5-year-old child is brought in by concerned parents because he is knock- kneed. Dx? Management?
(7) Ortho - other Genu varum (bow-leg) is normal up to the age of 3. Genu valgus (knock-knee) is normal between the ages of 4 and 8. Thus neither of these children need therapy. Should the varum deformity (bow-legs) persist beyond its normal age range (i.e., beyond age 3), Blount disease is the most common problem (a disturbance of the medial proximal tibial growth plate), and surgery can be performed for it.
127
A 14-year-old boy says he injured his knee while playing football. Although there is no swelling of the knee joint, he complains of persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. Physical examination shows localized tenderness right over the tibial tubercle Dx? Management?
(8) Ortho - other This is another one with a fancy name: Osgood-Schlatter disease (osteochondrosis of the tibia1 tubercle). It is usually treated with immobilization of the knee in an extension or cylinder cast for 4 to 6 weeks.
128
A baby boy is born with both feet turned inward. Physical examination shows that there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia. Dx? Management?
(9) Ortho - other This is the complex deformity known as club foot (fancy name: talipes equinovarus). The child needs serial plaster casts started in the neonatal period. The sequence of correction starts with the adducted forefoot, then the hindfoot varus, and finally the equinus. About half the patients respond completely and need no surgery. Those who require surgery are operated on after the age of 6-8 months, but before 1-2 years of age.
129
A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a �hump� is noted over her right thorax. The patient has not yet started to menstruate. Management? (3 steps)
(10) Ortho - other Management: 1. Baseline x-rays to monitor progression 2. Bracing may be needed to arrest progression 3. Pulmonary function could be limited if there is large deformity (The point is that scoliosis may progress until skeletal maturity is reached. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go)
130
A 4-year-old falls down the stairs and fractures his humerus. He is placed in a cast at the nearby "doc ~nthe box," and he is seen by his regular pediatrician two days later. At that time he seems to be doing fine, but AP and lateral x-rays show significant angulation of the broken bone. Management?
(11) Ortho- Fractures Nothing else is needed. Children have such tremendous ability to heal and remodel broken bones that almost any reasonable alignment and immobilization will end up with a good result. In fact, fractures in children are no big deal - with a few exceptions that are illustrated in the next few vignettes.
131
An 8-year-old boy falls on his right hand with the arm extended, and he breaks his elbow by hyperextension. X-rays show a supracondylar fracture of the humerus. The distal fragment is displaced posteriorly. Management?
(12) Ortho- Fractures This type of fracture is common in children, but it is important because it may produce vascular or nerve injuries - or both- and end up with a Volkmann contracture. Although it can usually be treated with appropriate casting or traction (and rarely needs surgery), the answer revolves around careful monitoring of vascular and nerve integrity, and vigilance regarding development of a compartment syndrome.
132
A child sustains a fracture of a long bone, involving the epiphyses and growth plate. The epiphyses and growth plate are laterally displaced from the metaphyses, but they are in one piece, i.e., the fracture does not cross the epiphyses or growth plate and does not involve the joint. Management?
(13) Ortho- Fractures even though the dreaded growth plate is involved, it has not been divided by the fracture. Treatment by closed reduction is sufficient.
133
A child sustains a fracture of a long bone that extends through the joint, the epiphyses, the growth plate, and a piece of the metaphyses. Management?
(14) Ortho- Fractures there are two pieces of growth plate. Unless they are very precisely aligned, growth will be disturbed. Open reduction and internal fixation will be needed.
134
A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with �sunburst� pattern and periosteal �onion skinning�. Dx? (2 possible) Management?
(15-16) Ortho- tumors Dx: Osteogenic Sarcoma or Ewing�s Sarcoma Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors
135
A 66 year old lady picks up a bag of groceries and her arm snaps broken Dx? Diagnostic test? (3 steps)
(17) Ortho- adults Dx: A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of cases will be metastatic. Diagnostic test: 1. Get X-Rays to diagnose this particular broken bone, 2. whole body Bone Scans to identify other mets, 3. start looking for the primary cancer site (In women, breast. In men, prostate. In heavy smokers, lung...and so on)
136
A 60yo M c/o fatigue and pain at specific places on several bones. He is found to be anemic, and x-rays show multiple punched out lytic lesions throughout the skeleton Dx?
(18) Ortho- adults Multiple lytic lesions in an old anemic man suggest multiple myeloma. The only bone tumor in which x-rays are a better diagnostic tool than bone scan, and one with a whole constellation of other diagnostic tests: Bence-Jones protein in the urine and abnormal immunoglobulins in the blood. The latter are detectable by serum electrophoresis and better yet by immunoelectrophoresis.
137
A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8cm in diameter Dx? Diagnostic test?
(19) Ortho- adults Dx: Soft tissue sarcoma is the concern Diagnositic test: MRI (Leave biopsy and further management to the experts)
138
A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order. What are the rules for ordering x-rays? (3)
(20) Ortho- general Here are the rules: 1. Always get X-Rays at 90 degrees to each other (for instance, AP and lateral) 2. Always include the joints above and below 3. if appropriate (this case is) check the other bones that might be in the same line of force (here the lumbar spine)
139
While playing football, a college student fractures his clavicle. The point of tenderness is at the junction of the middle and distal thirds of the clavicle. tx?
(21) General Ortho Treat it with a figure-of-eight device for 4 to 6 weeks.
140
A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle. Dx? Diagnostic test? Tx?
(22) General Ortho Dx: Anterior Dislocation of the Shoulder, with Axillary nerve damage Diagnostic test: Get AP and lateral X-Rays Tx: Reduce
141
After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by �Doc in a Box�, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a �normal� (i.e., not externally rotated, but internally rotated) position Dx? Diagnostic test? (specific)
(23) General Ortho Dx: Posterior Dislocation of the Shoulder (Very easy to miss on regular X-Rays) Diagnostic test: Get X-Rays again but order Axillary view or Scapular Lateral
142
An elderly woman with osteoporosis falls on her outstretched hand. She comes in with a deformed and painful wrist that looks like a "dinner fork." X- rays show a dorsally displaced, dorsally angulated fracture of the distal radius and small, nondisplaced fracture of the ulnar stylus. tx?
(24) General Ortho The famous Colles fracture. It is treated with close reduction and long arm cast.
143
During a rowdy demonstration and police crackdown, a young man is hit with a nightstick on his outer forearm that he had raised to protect himself. He is found to have a diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head tx?
(25) General Ortho Another classic with a fancy name: Monteggia fracture. He needs close reduction of the radial head, and open reduction and internal fixation of the ulnar fracture.
144
Another victim of the same melee has a fracture of the distal third of the radius and dorsal dislocation of the distal radioulnar joint. tx?
(26) General Ortho This one is Galeazzi fracture, which is quite similar to the previous one in terms of the resultant instability. This one is treated with open reduction and fixation of the radius, and casting of the forearm in supination to reduce the dislocated joint.
145
A young adult falls on an outstretchedhand and comes in complaining of wrist pain. On physical examination, he is distinctly tender to palpation over the anatomic snuff-box. AP and lateral x-rays are read as negative. tx?
(27) General Ortho Another classic (blissfullydevoid of eponym). This is a fracture of the scaphoid bone (carpal navicular). They are notorious because x-rays will not show them for 2 or 3 weeks, and they are also infamous because of a high rate of nonunion. The history and physical findings (the ten- derness in the snuff-box) are sufficient to indicate the use of a thumb spica cast, with repeat x- rays 3 weeks later.
146
Ayoungadultfallsonanoutstretchedhandandcomesincomplainingofwrist pain. On physical examination, he is distinctly tender to palpation over the anatomic snuff-box. AP, lateral, and oblique x-rays show a displaced and angulated fracture of the scaphoid. tx?
(28) General Ortho Displaced and angulated; will need open reduction and internal fixation.
147
During a bar room fight, a young man throws a punch at somebody, but misses and ends up hitting the wall. He comes in with a swollen and tender right hand. X-rays show fracture of the fourth and fifth metacarpal necks. tx?
(29) General Ortho Metacarpal necks, typically the fourth or the fifth (or both), take the brunt of your anger when you try to hit somebody but miss. Treatment depends on the degree of angulation, displace- ment, or rotary malalignment. Closed reduction and ulnar gutter splint for the mild ones, Kirschner-wireor plate fixation for the bad ones.
148
A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture Dx? Tx?
(30) General Ortho Dx: Hip fracture Tx: Metal prosthetic surgery (The point of this vignette is that blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rather than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal)
149
A 77-year-old man falls in the nursing home and hurts his hip. He shows up with the affected leg shortened and externally rotated. X-rays show that he has an intertrochanteric fracture. tx?
(31) General Ortho These can be fixed with less concern about avascular necrosis. Open reduction and pinning are usually performed. Immobilization in these old people often leads to deep venous thrombosis and pulmonary embolus; thus an additional choice for postoperative anticoagulation may be offered in the question.
150
The unrestrained front-seat passenger in a car that crashes sustains a closed fracture of the femoral shaft. tx?
(32) General Ortho Intramedullary rod fixation is the standard treatment for these.
151
The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80 over 50, a pulse rate of 110, and a venous pressure of 0.The rest of his physical examination and x-ray survey (chest, pelvis) are unremarkable, and sonogram of the abdomen done in the ER was likewise negative. management?
(33) General Ortho A throwback to the trauma vignettes to remind you that femur fractures may bleed into the tis- sues sufficiently to cause hypovolemic shock. Fixation will diminish the blood loss, and fluid resuscitation and blood transfusions will take care of the shock.
152
The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Twelve hours after admission, he develops disorientation, fever, and scleral petechia. Dyspnea is evident shortly thereafter, at which time blood gases show a Po, of 60. dx? management?
(34) General Ortho Another repeated topic: fat embolism. Respiratory support is the centerpiece of the treatment.
153
A college student is tackled while playing football, and he develops severe knee pain. When examined shortly thereafter, the knee is swollen, and he has pain on direct palpation over the medial aspect of the knee. With the knee flexed at 30ﾾﾚ, passive abduction elicits pain in the same area, and the leg can be abducted further out than the normal, contralateral leg (valgus stress test). dx? management?
(35) General Ortho The medial collateral ligament is injured. A hinged cast is the usual treatment for either isolated injury. When several ligaments are torn, surgical repair is preferred.
154
A college student is tackled while playing football, and he develops severe knee pain. When examined shortly thereafter, the knee is swollen, and he has pain on direct palpation over the lateral aspect of the knee. With the knee flexed at 30ﾾﾚ, passive adduction elicits pain in the same area, and the leg can be adducted further out than the normal, contralateral leg (varus stress test). dx? management?
(36) General Ortho Dx: an injury to the lateral collateral ligament. tx: A hinged cast is the usual treatment for either isolated injury. When several ligaments are torn, surgical repair is preferred.
155
A college student is tackled while playing football, and he develops severe knee swelling and pain. On physical examination with the knee flexed at 90ﾭ, the leg can be pulled anteriorly, like a drawer being opened. A similar finding can be elicited with the knee fixed at 20" by grasping the thigh with one hand, and pulling the leg with the other. dx? management?
(37) General Ortho This is a lesion of the anterior cruciate ligament, shown by the anterior drawer test and the Lachman test. Further definition of the extent of internal knee injuries can be done with MRI. Sedentary patients may be treated just with immobilization and rehabilitation, but athletes require arthroscopic reconstruction.
156
A college athlete injured his knee while playing basketball. He has been to several physicians who have prescribed pain medication and a variety of splints and bandages, but he still has a swollen knee and knee pain. He describes catching and locking that limit his knee motion, and he swears that when his knee is forcefully extended there is a "click" in the joint. He has been told that his x-rays are normal. dx? management?
(38) General Ortho Meniscal tears may be difficult to diagnose clinically, but MRI will show them beautifully. Arthroscopic repair is done, trying to save as much of the meniscus as possible. If complete meniscectomy is done, late degenerative arthritis will ensue.
157
A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal Dx? Management? (2 steps)
(39) General Ortho Dx: Stress Fracture (The lesson here is that stress fractures will not show up radiologically until 2 weeks later) Management: 1. Treat the guy as if he had a fracture (cast) 2. Repeat the X-Ray in 2 weeks
158
A pedestrian is hit by a car. Physical examination shows the leg to be angulated midway between the knee and the ankle. X-rays confirm fractures of the shaft of the tibia and fibula. dx? management?
(40) General Ortho Casting takes care of the ones that can be easily reduced. Intramedullary nailing is needed for the ones that cannot be aligned.
159
A pedestrian is hit by a car. Physical examination shows the leg to be angulated midway between the knee and the ankle. X-rays confirm fractures of the shaft of the tibia and fibula. Satisfactory alignment is achieved, and a long leg cast applied. In the ensuing 8 hours the patient complains of increasing pain. When the cast is removed, the pain persists, the muscle compartments feel tight, and there is excruciating pain with passive extension of the toes.
(41) General Ortho Compartment syndrome is a distinct hazard after fractures of the leg (the forearm and the lower leg are the two places with the highest incidence of compartment syndrome). Fasciotomy is needed here.
160
An out-of-shape, recently divorced 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" IS heard (like a gunshot), and the man falls to the ground clutching his ankle. He limps off the courts, with pain and swelling in the back of the lower leg, but still able to flex his foot in the plantar position. When he seeks medical help the next day, palpation of his Achilles tendon reveals an obvious defect right beneath the skin.
(42) General Ortho A classic presentation for rupture of the Achilles tendon. Casting in equinus position will allow healing after several months, or open surgical repair may do it sooner.
161
While running to catch a bus, an old man twists his ankle and falls on his inverted foot. AP, lateral, and mortise X-rays show displaced fractures of both malleoli.
(43) General Ortho A very common injury. When the foot is forcefully rotated (in either direction), the talus pushes and breaks one malleolus and pulls off the other one. Open reduction and internal fixation is needed.
162
A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal Dx? Tx?
(44) Ortho emergencies Dx: Compartment syndrome Tx: Emergency Fasciotomy
163
A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture Management?
(45) Ortho emergencies Management: Remove the cast (The point of this vignette is that you never give pain medication and do nothing else for pain under a cast. The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin)
164
A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration Management?
(46) Ortho emergencies Management: Reduction in the OR within 6 hours (The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first...abdominal bleeding, intracranial hematomas, chest tubes, etc, but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury)
165
A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated. Dx? Diagnostic test? Tx?
(47) Ortho emergencies Dx: Posterior Dislocation of the Hip. (Emergency: The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis) Diagnostic test: X-Rays Tx: Emergency reduction
166
A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation. Dx? Management? (3 steps: 1 med, 1 surgery, 1 other)
(48) Ortho emergencies Dx: Gas gangrene Management: 1. Tons of IV penicillin 2. Immediate surgical debridement of dead tissue 3. followed by a trip to the nearest hyperbaric chamber for hyperbaric O2 treatment
167
A 48-year-old man breaks his arm when he falls down the stairs. X-rays demonstrate an oblique fracture of the middle to distal thirds of the humerus. Physical examination shows that he cannot dorsiflex (extend) his wrist.
(49) Ortho emergencies Fractures of the humeral shaft can injure the radial nerve, which courses in a spiral groove right around the posterior aspect of that bone. However, surgical exploration is not usually needed. Hanging arm cast or coaptation splint are used, and the nerve function returns eventually. However, if the nerve was okay when the patient came in, and becomes paralyzed after closed reduction of the bone, the nerve is entrapped and surgery has to be performed.
168
A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee. Management? (3 steps)
(50) Ortho emergencies Management: 1. Check pulses 2. Arteriogram 3. Reduction (The point here is that posterior dislocation of the knee can nail the popliteal artery. Attention to integrity of pulses, arteriogram and prompt reduction are the key issues)
169
A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and x-rays show comminuted fractures of both calcanei. what other injuries need to be considered following this accident?
(51) Ortho injury patterns Compression fractures of the thoracic or lumbar spine are the associated, hidden injuries that have to be looked for in this case.
170
In a head-on automobile collision, the unrestrained front-seat passenger strikes the dashboard and windshield. He comes In with facial lacerations, upper extremity fractures, and blunt trauma to his chest and abdomen. what other injuries need to be considered following this accident?
(52) Ortho injury patterns In the confusion of dealing with multiple trauma, less-obvious injuries may be missed. In this particular scenario, as the knees strike the dashboard, the femoral heads may drive backward into the pelvis, or out of the acetabulum.
171
The unrestrained front-seat passenger in a car that crashes at hlgh speed is brought into the ER with multiple facial fractures and a closed head injury. what other injuries need to be considered following this accident?
(53) Ortho injury patterns We have dealt with this one before, but it is worth repeating it. The ultimate hidden injury (because of the devastating complications if missed) is the fracture of the cervical spine. This scenario demands that appropriate x-rays or CT scans be done to rule it out.
172
A 43-year-old female secretary who does a lot of typing complains about numbness and tingling in her hand, particularly at night. On physical examination, when asked to hang her hand limply in front of her, numbness and tingling are reproduced over the distribution of the median nerve (the radial side 3 112 fingers). The same happens when her median nerve is pressed over the carpal tunnel, or when it is percussed. dx? management?
(54) Ortho - Hand Carpal tunnel syndrome is diagnosed clinically, and this vignette is typical. The American Academy of Orthopedic Surgery recommends that wrist x-rays (including carpal tunnel view) be done, primarily to rule out other things. Initial treatment is splints and antiinflammatories. If surgery is needed, electromyographyshould precede it.
173
A 58-year-old woman describes that she wakes up at night with her right middle finger acutely flexed, and she is unable to extend it. She can do it only by pulling on it with her other hand, at which time she feels a painful "snap. dx? management?
(55) Ortho - Hand Trigger finger. Steroid injections are tried first. Surgery is performed if needed.
174
Ayoungmothercomplainsofpainalongtheradialsideofthewristandthe first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. dx? management?
(56) Ortho - Hand De Quervain tenosynovitis. Splints and antiinflammatories can help, but steroid injection is best. Surgery is rarely needed.
175
A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and be placed flat on a table. Palmar fascia1 nodules can be felt. dx? management?
(57) Ortho - Hand Dupuytren contracture. Surgery is the only effective treatment.
176
A 33-year-old carpenter accidentally drives a small nail into the pulp of his index finger, but he pays no attention to the injury at the time. Two days later he shows up in the ER, with throbbing pulp pain, fever, and all the signs of an abscess within the pulp of the affected finger. dx? management?
(58) Ortho - Hand This kind of abscess is called a felon, and like all abscesses it has to be drained. But there is a cer- tain urgency to do it, because the pulp is a closed space and the process is equivalent to a com- partment syndrome.
177
A young man falls while skiing, and as he does so he jams his thumb into the snow. Physical examination shows collateral laxity at the thumb metacarpophalangeal joint. dx? management?
(59) Ortho - Hand This one is "gamekeeper's thumb." The injury was to the ulnar collateral ligament of the thumb. If not treated it can be dysfunctional and painful, and can lead to arthritis. Casting is usually done.
178
Two hoodlums grab a woman's purse and run away with it. She tries to grab one of the offenders by his jersey, but he pulls away, hurting the woman's hand in the process. When she makes a fist now, the distal phalanx of her ring finger does not flex with the others. dx? management?
(60) Ortho - Hand classic tendon injury - jersey finger (to the flexor) - Splinting is usually the first line of treatment.
179
While playing volleyball, a young lady injures her middle finger. She cannot extend the distal phalanx. dx? management?
(61) Ortho- hand classic tendon injury - mallet finger (injury to the extensor).Splinting is usually the first line of treatment.
180
While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. dx? management?
(62) Ortho - hand Replantation of severed digits is no longer "miracle surgery." It is commonly done at specialized centers, and regular physicians should know how to handle the amputated part. The answer is to clean it with sterile saline, wrap it in a saline-moistened gauze, place it in a plastic bag, and place the bag on a bed of ice. The digit should not be placed in antiseptic solutions or alcohol, put in dry ice, or allowed to freeze.
181
A 45-year-old man gives a history of aching back pain for several months. He has been told that he had muscle spasms, and was given analgesics and muscle relaxants. He comes in now because of the sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is like an electrical shock that shoots down his leg, it is aggravated by sneezing, coughing, or straining, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg-raising gives excruciating pain. dx? management?
(63) Ortho - back pain What is it? Lumbar disk herniation. The peak age incidence is 45, and virtually all of these are at either L4-L5 or L5-S1. If the "lightning" exits the foot by the big toe, it is L4-L5, if it exits by the little toe, it is L5-S1. Management. MRI for diagnosis. Bed rest will take care of most of these. Neurosurgical inter- vention only if there is progressive weakness or sphincteric deficits.
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A 46-year-old man has sudden onset of very severe back pain that came on when he tried to lift a heavy object. The pain is like an electrical shock that shoots down his leg, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg-raising test gives excruciating pain. He has a distended bladder, flaccid rectal sphincter, and perineal saddle area anesthesia. dx? management?
(64) Ortho - back pain The cauda equina syndrome is a surgical emergency.
183
A young man began to have chronic back pain at age 34. Pain and stiffness have been progressive. He describes morning stiffness, and pain that is worse at rest, but improves with activity. dx? management?
(65) Ortho - back pain Think ankylosing spondylitis. X-rays will eventually show "bamboo spine." Antiinflammatory agents and physical therapy are used.
184
A72-year-oldmanhashada20-poundweightloss,andhecomplainsoflow back pain. The pain 1s worse at night and is unrelieved by rest or positional changes. dx? management?
(66) Ortho - back pain Suggestive of metastatic malignancy. If advanced, xrays will show it. If not, bone scan is more sensitive (but less specific).
185
A 67-year-old diabetic has an indolent, unhealing ulcer at the heel of the foot. dx? management?
(67) Ortho - leg ulcers What is it? Ulcer at a pressure point in a diabetic is caused by neuropathy, but once it has hap- pened it is unlikely to heal because the microcirculation is poor also. Management. Control the diabetes, keep the ulcer clean, keep the leg elevated- and be resigned to the thought that you may end up amputating the foot.
186
A 67-year-old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity. dx? management?
(68) Ortho - leg ulcers What is it? Ischemic ulcers are at the farthest away point from where the blood comes. Management. Doppler studies looking for pressure gradient, arteriogram. Revascularization may be possible, and then the ulcer may heal.
187
A44-year-oldobesewomanhasanindolent,unhealingulceraboveherright medial malleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins. dx? management?
(69) Ortho - leg ulcers What is it?Venous stasis ulcer. Management. Unna boot, support stockings. Varicose vein surgery may ultimately be needed.
188
A40-year-oldmanhashadachronicdrainingsinusinhislowerlegsincehe had an episode of osteomyelitis at age 12. In the last few months he has developed an indolent, dirty-looking ulcer at the site, with "heaped up" tissue growth at the edges. dx? management?
(70) Ortho - leg ulcers Both of these are classic vignettes for the development of squamous cell carcinoma at long- standing, chronic irritation sites. The name Marjolin ulcer has been applied to these tumors. Obviously biopsy is the first diagnostic step, and wide local excision (with subsequent skin grafting) is the appropriate therapy.
189
Ever since she had an untreated third-degree burn to her lower leg at the age of 14, a 38-year-old immigrant from Latin America has had shallow ulcerations at the scar site that heal and break down all the time. In the last few months she has developed an indolent, dirtylooking ulcer at the site, with "heaped up" tissue growth around the edges, which is steadily growing and shows no sign of healing. dx? management?
(71) Ortho - leg ulcers Both of these are classic vignettes for the development of squamous cell carcinoma at long- standing, chronic irritation sites. The name Marjolin ulcer has been applied to these tumors. Obviously biopsy is the first diagnostic step, and wide local excision (with subsequent skin grafting) is the appropriate therapy.
190
An older, overweight man complalns of dlsabllng, sharp heel paln every trme his foot strlkes the ground. The pain is worse in the mornings, preventing hlm from putting any weight on the heel. X-rays show a bony spur matching the location of his pain, and physical exam shows exquisite tenderness right over that heel spur. dx? management?
(72) Ortho - foot pain Although all the signs point to that bony spur as the culprit, this is in fact plantar fasciitis- a very common but poorly understood problem that needs symptomatic treatment until it resolves spontaneously within 12 to 18 months.
191
A woman who usually wears high-heeled, pointed shoes complains of pain in the forefoot after prolonged standing or walking. Physical examination shows a very tender spot in the third interspace, between the third and fourth toes. dx? management?
(73) Ortho - foot pain 'This one is a Morton neuroma, which is an inflammation of the common digital nerve. If conservative management (more sensible shoes, among other things) does not suffice, the neuroma may be excised.
192
A55-year-oldobesemansuddenlydevelopsswelling,redness,andexquisite pain at the first metatarsal-phalangeal joints. dx? management?
(74) Ortho - foot pain Gout. The diagnosis of the acute attack is done with identification of uric acid crystals in fluid from the joint. Treatment of the acute attack relies on indomethacin and colchicine. Long-term control of serum uric acid levels is done with allopurinol or probenecid.
193
A 72-year-old man with a history of multiple myocardial mfarctions is scheduled to have an elective sigmoid resection for diverticular disease. A preoperative radionuclide ventriculography shows an ejection fraction of less than 0.35. dx? management?
(1) Preop - Cardiac risk This is a "no-go" situation in which cardiac risk in noncardiac surgery is prohibitive. With this ejection fraction, the incidence of perioperative MI is 75 to 85%, and the mortality for such an event is around 55 to 90%. Probably the only option here is not to operate, but to continue with medical therapy for the diverticular disease. Should he develop an abscess, percutaneous drainage would be the only possible intervention.
194
A 72-year-old chronically bedridden man is being considered for emergency cholecystectomy for acute cholecystitis that is not responding to medical management. He had a transmural MI 4 months ago, and currently has atrial fibrillation, 8 to 10 premature ventricular beats per minute, and jugular venous distention. dx? management?
(2) Preop - Cardiac risk This fellow is a compendium of almost all of the items that Goldman has compiled as predic- tors of operative cardiac risk. In fact he adds up to 50 points, and anything above 25 points (class IV) gives a mortality in excess of 22%. Here again the best option would be to treat the cholecystitis in a different way (percutaneous radiologic tube cholecystostomy being the obvi- ous choice).
195
A 72-year-old man is scheduled to have an elective sigmoid resection for diverticular disease. In the preoperative evaluation it is noted that he has venous jugular distention. dx? management?
(3) Preop - Cardiac risk Now we have fewer items, but congestive heart failure is the worst one on the list (the other one here is his age). The failure has to be treated first: calcium-channel blockers, beta-blockers, dig- italis, and diuretics.
196
A 72-year-old man is scheduled to have an elective sigmoid resection for diverticular disease. In the preoperative evaluation it is ascertained that he had a transmural MI 2 months ago. dx? management?
(4) Preop - Cardiac risk The next worst Goldman finding is the recent MI ( all the cardiac parameters.
197
A 72-year-old man who needs to have elective repair of a large abdominal aortic aneurysm has a history of severe, progressive angina. dx? management?
(5) Preop - Cardiac risk This one is more tractable than the others. His coronary revascularization should precede the aneurysm repair.
198
A 61-year-old man with a 60 pack-year smoking history and physical evidence of chronic obstructive pulmonary disease (COPD) needs elective surgical repair of an abdominal aortic aneurysm. He currently smokes one pack per day. dx? management?
(6) Preop - Pulm risk Smoking is by far the most common cause of increased pulmonary risk, and the main problem is compromised ventilation (high Pco, and low FEV1) rather than compromised oxygenation. Cessation of smoking for 8 weeks and intensive respiratory therapy (physical therapy, expecto- rants, incentive spirometry, humidified air) should precede surgery.
199
A cirrhotic is bleeding from a duodenal ulcer. Surgical intervention is being considered. His bilirubin is 3.5, his prothrombin time is 22 seconds, his serum albumin is 2.5, and he has encephalopathy. can this patient undergo surgery?
(7) Preop - Pulm Risk Please don't! Any one of those items alone (bilirubin above 2, albumin below 3, prothrombin above 16, and encephalopathy) predicts a mortality of over 40%. If three of them are present, the number is 85%, and with all four we are talking about 100%.
200
A cirrhotic with a blood ammonia concentration above 150 ngldl needs an operation. A cirrhotic with an albumin level below 2 needs an operation. A cirrhotic with a bilirubin above 4 needs an operation. can these patients undergo surgery?
(8-10) Preop - hepatic risk Another way to look at liver risk is to see if any one of the previously listed findings is deranged to an even greater degree. Any one of these three examples would carry a mortality of about 80%. A deranged prothrombin time is slightly kinder to the patient, predicting only a 40-60% mortality. Death, incidentally, occurs with high-output cardiac failure with low peripheral resis- tance.
