Surgical Emergencies

Question 1

In the repair of ear lacerations, what suture material should you use and what antibiotic for empiric prophylaxis?

Answer 1

5.0-6.0 absorbable chromic gut sutures, suture through the perichondrium and then skin, not through the cartilage to avoid notching and impaired healing

empiric antibiotic coverage should include Pseudomonas therefore ciprofloxacin or ceftazidime

Question 2

How do you manage an infected thyroglossal duct cyst?

Answer 2

Treat with Clindamycin until it cools off, then excision only after complete resolution

Question 3

Which tongue lacerations do you repair and with what?

Answer 3

large (>1cm), deep tongue lacerations, flaps or gaps, ones with involvement of margin that may heal asymmetrically, hemorrhage

use chromic gut sutures, insert deep into the musculature
fast absorbing will dissolve too quickly

Question 4

Describe the Ellis classification of dental fractures

Answer 4

1: enamel only
2: enamel and dentin, too
3: fracture line crosses the pulp of the tooth

1&2 are considered uncomplicated, minimal or painless
3 is diagnosed on visual inspection with a red line, treat with analgesics and consult dentistry

Question 5

How does infantile glaucoma present and what is the treatment?

Answer 5

they present with enlarged cornea and eyes

definitive treatment is with surgery, temporizing measures consist of beta-blockers, miotics, sympathomimetics, alpha-2 adrenergic…

Question 6

What are techniques for mandibular dislocation reduction?

Answer 6

1- sedate and provide analgesia

2- with cotton on molar teeth, provide downward and posterior traction on the mandible with a ‘wrist pivot’
OR
gag
OR
roll 5-10mL syringes between the teeth back and forth

Question 7

How do you manage multiple magnet ingestions?

Answer 7

if in the esophagus and stomach, remove it!
if beyond the stomach an asymptomatic, admit for serial exams, PEG3350 and radiographs q12h.
if symptomatic or no progression, proceed to OR.

Question 8

How do you manage a witnessed or suspected BB ingestion? What size threshold matters?

Answer 8

always get A/P and lateral films, differentiate thickness and double rim of BB

• in the esophagus: go and get it!
• if >20mm and pt <5, it will have a hard time passing, go and get it!
• in the stomach, make sure that it passes with serial abdo flat plates

Question 9

How do you manage priapism in a patient with SCD?

Answer 9

considered ischemic priapism

1) IVF, urination
2) IV opioids
3) if >4hrs, Urology consult for aspiration of the corpus cavernosum

Question 10

What is the definitive treatment for paraphimosis that cannot be reduced?

Answer 10

dorsal slit procedure

Question 11

What are indications to admit a patient with nephrolithiasis?

Answer 11

1) intractable pain
2) obstruction
3) size >0.5cm
4) infection
5) failure of conservative management

Question 12

Name three penile trauma emergencies?

Answer 12

ventral laceration (possible urethra damage)
scrotal lacerations that penetrate Dartos’ fascia
hematomas that compress the testicle
rupture of the tunica albuginea

Question 13

What features of an ovarian cyst promote cystectomy?

Answer 13

cysts >5cm
difficulty controlling pain
persistence

Question 14

Name 7 causes of acute urinary retention

Answer 14

neurologic problems
functional withholding
UTI
constipation
drug side effects
obstruction
local inflammation

Question 15

Describe the three zones of the neck.

What is the management of platysma penetration in zone 2?

Answer 15

zone 1: clavicles to cricoid
zone 2: cricoid to the angle of the mandible
zone 3: angle of the mandible to the base of the skull

platysma penetration in zone 2 means surgical exploration is necessary!

Question 16

Name treatments for corneal abrasions

Answer 16

• NSAIDs
• topical antibiotics
• mydriatic drops like cyclopentolate to help with ciliary muscle spasm (manifested as photosensitivity)

Question 17

Name the preferred technique for removing the following nasal foreign bodies
non-occlusive, soft, compressible objects
smooth / round objects
round, totally occluding the nares

Answer 17

non-occlusive, soft, compressible objects: alligator forceps
smooth / round objects: balloon catheters
round, totally occluding the nares: parent’s kiss or PPV

Question 18

Name examples of caustic alkalis and the approach to management

Answer 18

lye, potassium hydroxide, sodium hydroxide ie: drain or oven cleaners, laundry detergents

if ingested and symptomatic -> esophagoscopy
look for dysphagia, drooling, vomiting, hematemesis, respiratory distress, stridor (even with minimal sxs may have significant injury)

Question 19

Where do foreign bodies usually get stuck and what is the management?

Answer 19

thoracic inlet > gastroesophageal junction > aortic arch
Observe for 8-16hrs for spontaneous passage
repeat x-ray at 12 and 24 hours
complications arise when immobile for 24hrs+

Question 20

What is the usual presentation of traumatic iritis?

Answer 20

24-72hrs after a blunt trauma
development of eye pain, decreased visual acuity, redness, miosis, photophobia
dx confirmed with slit lamp, WBC and flare in the anterior chamber

manage with cycloplegic drops and topical steroids (ophthalmo)

Question 21

What test can you send for on a sample of clear liquid to confirm the presence of CSF?

Answer 21

beta-2-transferrin

Question 22

How to treat a sucking chest wound?

Answer 22

Apply occlusive dressing closed on 3 sides only to create a flutter valve effect
If a thoracostomy tube is in place, okay to seal on all 4

Question 23

What are the best screening tests for myocardial injury?

Answer 23

ECG and troponins

confirm diagnosis with echocardiogram

Question 24

What is commotio cordis and how does it occur?

Answer 24

sudden v-fib following blunt, non-penetrating injury to the precordial area
occurs if impact during the upstroke of the T-wave
treat with CPR and electricity

Question 25

How are anterior penetrating stab wounds managed?

Answer 25

local exploration, only if peritoneum is NOT intact will they go to OR

Question 26

How are posterior penetrating stab wounds managed?

Answer 26

triple contrast imaging (IV, oral, rectal) and admission for observation

Question 27

What are indications for immediate surgical laparotomies with gun shot wounds?

Answer 27

• hemodynamic instability
• abdominal tenderness
• evisceration
• dropping hematocrits
• blood from the NG, vagina or rectum

Question 28

What are the grading of renal injuries and grossly how do you manage them?

Answer 28

1: contusion, subcap hematoma (D/C, serial u/a)
2: hematoma, <1cm, no urinary extravas
3: lac >1cm into cortex w/out collecting system rupture, urinary extravasation
(admit, serial Hcts and u/as, rest, abx)
4: lac to collecting system, renal/vasc injury with contained hemorrhage
5: completely shattered kidney, avulsion renal hilum, devasc kidneys
(under debate re: OR, definitely OR if L-T hemorrhage or renal pedicle avulsion)