Surgical Trauma And Emergency Flashcards
Site for needle insertion and chest drain in tension pneumothorax
Adult 5th intercoastal space in mid axillary line
Children 2nd intercoastal space mid clavicular line
Size of chest tube for tension pneumothorax or hemorrhoids
28-32Fr gauze
Burn fluid
For thermal
2ml/kg×surface area
For electrical
4 no/kg×surface area
Type of chest drain in traumatic pneumothorax
Under water seal
Beck’s triad is for what and components
Pulsus paradoxus, also known as paradoxical pulse, is a condition where a person’s systolic blood pressure, stroke volume, and pulse wave amplitude drop abnormally during inhalation. It’s a sign of heart or lung disease and is the opposite of what would normally happen, as blood pressure usually increases when someone inhales.
For cardiac tamponade
Hypotension
Raised JVP
Muffled heart sound
And
There will be a pulsus paradoxus
Boerhaave’s syndrome causes and sign symptoms
Complete rupture at lower thoracic esophagus
Hamman’s sign -
Crunching sound upon auscultation of heart due to pneumomediastinum
Chest pain
Shock
Subcutaneous emphysema
Mallory Weiss syndrome causes and sign symptoms
Incomplete tear only affecting muchos and submucosa
Tear on the gastric side of gastroesophageal junction which may extend to distal esophagus
Repeated vomiting then
Hematemesis
What to do if a patient of perforated peptic ulcers came with sepsis
Approach as ATLS protocol
DD for epigastric pain
Peptic ulcers
Perforated peptic ulcer
Pancreatitis
Cholecystitis
Myocardial infarction
diabetes may cause of DKA
Primary treatment of MI
Antiplatet
Thrombolysis
Angioplasty
Sign symptoms of pulmonary embolism and ECG changes and confirmatory investigation
Hemoptysis
Hypoxia
Small pleural effusion
ECG
S wave in lead 1
Q wave in lead 3
T inversion in lead 3
Investigation
CTPA
Collapsing signs of pulmonary embolism
And management
Chestpain
Hypotension
Tachycardia
Breathlessness
Desaturation
Mx
Patient is in peri arrest state so make thrombolysis with alteplase
Heparin administration upto achieving INR of 2-3. Then stop heparin and start warfarin 4-6 weeks with temporary risk factors
Oral anticoagulant only after confirmation of venous thrombosis
When to suspect fat embolism and
Management
After long bone fractures
Liposuction
Mx
Fat embolism syndrome (FES) is generally treated with supportive care in the hospital, often in the intensive care unit. Treatment focuses on maintaining intravascular volume and ensuring good arterial oxygenation. Some treatments include:
Oxygen
One of the fastest and easiest treatments for respiratory problems. You may be given oxygen or need help breathing with mechanical ventilation.
Intravenous fluids
Helps remove damaging free fatty acids from the body. Human albumin is recommended to restore blood volume and bind to fatty acids to reduce lung injuries.
Drugs
Your doctor may prescribe steroids or the blood thinner heparin, but these drugs have not been proven to be highly effective.
Surgical management
This includes early stabilization of long-bone fractures, rigid fixation within 24 hours, and appropriate surgical technique.
Massive pulmonary embolism Mx
Vs
Small embolism
British thoracic society guideline
Massive
3mg bolus of alteplase
Heparin
Thrombus fragmentation
IVC filter insertion
Small
Heparin if high probability of embolism before imagine like unfractionated heparin in massive pulmonary embolism where rapid reversal is needed. If not then LMWH cause it has the same efficacy and is easier to administer upto reaching INR 2-3
Oral anticoagulant should be used only after confirmation of embolism upto 4-6 weeks with temporary risk factors,3 months for idiopathic,6 months for any other reason
GCS components
Eye 4
Spontaneous
Response to verbal command
Response to pain
No eye opening
Verbal 5
Oriented(knows who and where he is)
Confused(answers,disoriented)
Inappropriate words(no conversation)
Incompetent sounds
No verbal response
Motor 6
Obeys command
Localizes response to pain
Withdrawal response to pain
Flexion to pain(decorticate-flex, int.Rotat)
Extremely to pain(decerebrate-ex,ext.rot)
No motor response
#below 8 intubate
*Inapplicable have
Macroglossia
Laryngeal edema
Puffy eyes
Hematoma eye
Organized hematoma in splenic injury
Don’t disrupt it
Infectious organism after splenectomy
And measures to be taken
Encapsulated
Streptococcus pneumoniae
Hemophylus influenzae
Neisseria meningitidis
Vaccine and penicillin
Hib
Pneumoniae
Meningitis
Blood film post splenectomy
Reticulocyte
Howell jolly bodies
Heinz bodies
Must common cause subarachnoid hemorrhage
Ruptured berry aneurysm
Looks like a berry in a stalk
Along the circle of Willis
Associated with autosomal dominant polycystic kidney disease
Lethal triad
*Injury>exposure>hypothermia >coagulopathy>acidosis
*Injury>haemorrhage>hypoperfusion
>Acidosis>coagulopathy>hypothermia
*Injury>hemorrhage>coagulopathy
>Acidosis>hypothermia
Stages of hypothermia
Mild- conscious, shivering(32-35°C)
Moderate-drowsy, not shivering(28-32)
Severe-uncooked, not shivering (20-28)
Profound-no vital signs (<20)
Response stages of hypothermia
Response stages of hyperthermia
Hypo
Vasoconstriction(aw37:an35.5)>non shivering metabolic thermogenesis(aw36:an35)>shivering thermogenesis(aw35.5:an34)
*N B.aw=awake,an=anesthetized
Hyper
Sweating(aw37:an37.5)>vasodilation (aw37.5:an38)
Rx of hypothermia
ECG changes
Rewarming
Mild- external
Serve -active core : peritoneal lavage, hemostasis, cardiac bypass
ECG
J wave
Arrhythmia
Antidote of prilicaine
IV methylene blue
Antidote of lignocaine
Intralipid
Repeating technique of vessels and type of suture
Figure of 8 with 5-0 prolene
Rate of air change in laminar floor OT
300 times per hour
What to use facial reconstruction
Local flap
Or
Full thickness graft
Adverse effect of central line on lungs
May cause pneumothorax
Which coronary artery may be associated with abdominal aortic aneurysm and ECG finding
Right coronary artery
So
Inferior MI in ECG
Chest x-ray changes in ruptured thoracic aorta confirmatory investigation and Mx
Widening mediastinum
Trachea and esophagus shifted to right
Obliteration of space between aorta and pulmonary artery
May be rib fractures and hemothorax
CT, angiography, aortogram
Tx is emergency endovascular repair
Dx and Tx of achalasia cardiac
Investigation
Ph
Manometry
Barium swallow x-ray
Endoscopy
Tx
Balloon dilatation
Botulinum toxin
Cardiomyotomy
If suspecting intracranial or intracerebral gardenia what to do
First surgery
Then
Antiplatet or anticoagulant
Beck’s triad and cause
Elevated venous pressure
Reduced arterial pressure
Reduced heart sound
And maybe associated with
pulsus paradoxus
Cause
Cardiac tamponade even with 100 ml blood
Le Fort’s classification of mid face fractures
1-no speak
2-no see
3-be hear
Criteria of immediate CT
Loss of consciousness for more than 5 minutes
Amnesia for more than 5 minutes
Abnormal drowsiness
3 or more episodes of discrete vomiting
Clinical suspicious of non accidental inquiry
Part traumas seizure nutty no history of epilepsy
GCS<14 in adults
GCS<15 in children below 1 year old or with bruise/swelling/laceration >5cm
Sign of base of skull fractures -hemotympanum
-CSF otorrhea or rhinorrhea
-battle sign
-halo sign
Focal neurological deficit
Fall from height>3 meter
High speed injury like RTA
Tx of boerhaave’s syndrome
Surgery of within 12 hours
Beyond that controlled fistula
Antidote of opioid toxicity
Naloxone
But risk of rebound pain
*Rebound release of catecholamines may cause hypertension, tachycardia, and ventricular arrhythmias. Pulmonary edema has also been observed after naloxone administration. Small doses of naloxone can precipitate a withdrawal syndrome in subjects that are opioid-dependent.
Compartment syndrome
Compartment syndrome can occur in any muscle, but it’s most common in the forearms and lower legs. Symptoms can be difficult to detect, and can become severe within a few hours of an acute injury. Some early signs of compartment syndrome include:
Pain
Pain that’s more severe than expected from the injury, and that doesn’t go away after taking pain medication or raising the affected area. The pain may feel like a deep ache or burning sensation, and it can get worse when you move the affected body part.
Swelling
The muscle may swell or bulge, or you may have difficulty moving the affected body part.
Other sensations
You may experience numbness, tingling, or a burning feeling under your skin (paresthesia). The skin may also appear pale.
Other signs of compartment syndrome include: tightness, weakness, and pins and needles.
Numbness and paralysis are later signs of compartment syndrome, and usually indicate permanent tissue injury.
Compartment syndrome can be caused by fractures, severe contusions, crush injuries, or reperfusion injury after vascular injury and repair.
Virtual and disarthia suggest what type of vascular injury and if sudden deterioration of consciousness what may be main cause
Posterior circulation
Basilar artery occlusion
Signs of occlusion of anterior circulation
Hemiparesis
Hemisensory loss
Homonymous hemianopia
Higher cognitive dysfunction
Dysphagia
Confirm CSF
Transferrin test
Halo sign on gauze
*Fluid containing CSF is classically described to make a “halo” or “double-ring” pattern on gauze or linen.
Allergic/anaphylactic shock Mx
Remove allergen
ABC survey
Adrenaline 1:1000 IM repeat every 5 minutes if no response
Chlorpheniramine
Hydrocortisone
Causes of Addisonian crisis
Sepsis or surgery causing acute exacerbation of chronic deficiency like Addison’s or hypopituitarism
Adrenal haemorrhage in Waterhouse Fredricksen syndrome
Fulminant meningococcemia
Steroid sudden withdrawal
Mx of Addisonian crisis
Hydrocortisone 100mg IM or IV
Normal saline 1L over 30 to 60 minutes or dextrose if hypoglycemia
Oral replacement after 24 hours with maintainance dose over 3-4 days
ECG in pulmonary embolism
s1 q3 t3 ,tall r in v1,t inversion in v123, peak p pulmonale in inferior leads,RBB, right axis deviation, right ventricular strain, atrial arrhythmia
Cushing triad
Hypertension—due to sympathetic activation after raised ICP
Bradycardia
Bradypnea
