Test 2: Laparoscopy, Suturing, and Burns Flashcards
Kaolin, a compound used in quick-clot inhibits what two clotting factors?
10 and 11
What is the max mg/kg dose of 1% lidocaine?
5 mg/kg maximum
What is the max mg/kg dose of 1% w/ epi lidocaine?
7 mg/kg maximum
What does adding a buffer to lidocaine accomplish?
Less burning/pain on infusion by increasing the pH of the lidocaine (less acidic)
Sutures are which of the following…
a) more accurate skin closure, for deeper cuts
b) for superficial lacerations
c) quick, for deeper cuts
a) more accurate skin closure, and for deeper cuts
Glue (Indermil) is which of the following…
a) more accurate skin closure, for deeper cuts
b) for superficial lacerations
c) quick, for deeper cuts
b) for superficial lacerations (hold the approximation for 30 seconds)
Staples are which of the following…
a) more accurate skin closure, for deeper cuts
b) for superficial lacerations
c) quick, for deeper cuts
c) quick, for deeper cuts
What is the preferred method to covering a sutured or closed up wound?
Gauze, then a roll of gauze or ace bandage
When approximating and suturing/glueing wound edges, they should be…
a) inverted
b) everted
b) everted
Which of these is NOT a use for Indermil?
a) Microbial protection for external sutures?
b) Laparoscopic port sites
c) Abdominal incision protection
d) Facial lacerations
e) Sternotomy incision protection
f) Fasciotomy incisions
f) Fasciotomy incisions
Polysorb, an absorbable synthetic braided suture gives_____ weeks of wound support, and ____to____days to fully absorb
3 weeks
56-70 days to fully absorb
Caprosyn, an uncoated synthetic monofilament is used for only _____days of wound support, and absorbs in under_____ days.
10 days of wound support
Absorbs fully in < 56 days.
Maxon, an uncoated synethetic monofilament has the most protection with _____ weeks of wound support, and takes _____days to fully absorb
6 weeks of wound support
180 days to fully absorb
(great for fascia)
Describe the basic difference between gut and chromic gut, and how are they both absorbed?
Chromic gut lasts longer, both are broken down by proteolytic enzymes fairly quickly. Gut sutures are made naturally from bovine intestine.
Describe the key differences between gut and MSA/BSAs?
Gut is good for internal structures that can heal fast. Gut sutures sometimes causes a local tissue reaction. MSA/BSA’s are good for longer healing times, and will degrade by hydrolysis.
Which of these is a BSA (Braided Synthetic Suture) versus an MSA (Monofilament Synthetic Absorbable)?
a) Polysorb
b) Caprosyn
c) Biosyn
d) Maxon
a) Polysorb
Caprosyn, Biosyn, and Maxon are monofilament synthetics
What types of sutures are these?
Novafil, Monosof, Surgipro, Surgilon, Vascufil, Ti-Cron, Steel, Sofsilk, Silk
Non-absorbable
What type of suture is Prolene (not in his slides)
A synthetic non-absorbable monofilament
What are the three anatomical areas of the needle?
The point, body, and swage (the blunt end)
for the most part, every part of the face will get a _-0 nonabsorbable suture.
6-0 nonabsorbable
with the eyelid you can go smaller like a 7-0
for the most part the extremities and feet will get what three possible suture sizes?
3, 4, and 5-0
where are staples commonly used?
the scalp (no need to worry about train tracks, the hair will hide them)
single stiches, individually knotted for uncomplicated laceration repairs is called…
simple interrupted
This type of suture it best used for the heart or tendons…
Horizontal mattress
With TiCron
This “baseball stitch” is simple continuous stitch can be a useful technique for skin closure when speed is important, e.g. closing a scalp laceration on a screaming child.
Continuous running (but more difficult to adjust if approximation is off or the stitch breaks)
What type of suture is “far, far, near near” for approximating deeper wounds
Vertical mattress
This type of suture leaves no skin markings and can help close deeper tissues, and when aesthetics are important.
Subcuticular “subdermal” suture.
However, very difficult to adjust or correct if approximation is off or the suture breaks.
Which is NOT a benefit of doing a lap surgery?
a) morbidity reduction
b) reduced handling of bowel
c) reduced adhesion formation
d) exposure to drying and bacteria
e) reduction in electrosurgical risk
e) reduction in electrosurgical risk
other lap difficulties: suturing, depth perception, and limited space
What is the best position to operate large and small bowel?
a) supine
b) head up tilt
c) trendelenburg
d) lateral tilt
a) Supine
What is the best position for operating on the stomach, liver, and spleen?
a) supine
b) head up tilt
c) trendelenburg
d) lateral tilt
b) Head up tilt
What is the best position for operating on the paracolic gutters?
a) supine
b) head up tilt
c) trendelenburg
d) lateral tilt
d) Lateral tilt
What is the best position for operating on the pelvic cavity?
a) supine
b) head up tilt
c) trendelenburg
d) lateral tilt
c) Trendelenburg
reduce bleeding
you should prep your patient for laparoscopy from ______all the way up to the____ _____in case you have to insert new lines.
From mid-thigh to nipple line.
they also need a foley, NG tube, and grounding pad
What gas is inserted to create a pneumoperitoneum, and at what pressure?
a) o2 @ 12mmHg
b) Argon @ 18mmHg
c) Co2 @ 16mmHg
d) CO @ 8mmHg
Co2 (between 12-16 mmHg)
The most common access into the intra-abdominal cavity is with what type of needle?
Varess needle. Then elevate the abdomen and cut a 1mm incision with an 11 blade, then infuse saline. If saline enters, your in the abdominal cavity and can insert your trocar.
What MUST you palpate every time BEFORE you insert your trocar?
Palpate the aorta.
The trocar should be inserted how deep and at what angle?
Insert 2-3cm and angled at 45 degrees sacral (caudal)
To reduce the chance of abdominal lap adhesions, you could insert the lateral trocars where?
9th intercostal space, anterior axillary line
not sure if this is correct
another word for laparotomy
Celiotomy
The most laparascopic complication in general
a) GI injury
b) Post-op hemorrhage
c) Ureteral and bladder injury
d) Intra-abdominal infection
e) Injury to large vessels
a) GI Injury
port site hernias can also occur
In a lap you suddenly suspect retroperitoneal hemorrhage, immediately decrease co2 insufflation to______mmHg, and perform a ________procedure.
decrease to 8mmHg, and perform a midline laparotomy to clamp anything, then call vacular surgery ASAP.
Who refined the electrical generator?
William T. Bovie
What type of current is used in a bovie?
Monopolar VHF current (very high frequency?)
(bipolar can work in only instruments with a send and return
When cutting (vaporizing), do you….
a) hit the pedal then apply pressure to tissue
b) apply pressure, then hit the pedal
a) hit the pedal, then apply pressure to where you are cutting. (light pain brush pressure)
What does fulgeration do?
it coagulates
How do you dessicate tissue?
Touch the bovie to the hemostat forceps or whatever metal instrument you are using that’s holding the tissue
What type of cut is all cut, and minimal coag with the needle held just off the tissue, and the most minimal lateral tissue damage?
a) pure
b) blend
c) coag
a) pure
What type of cut has less cell explosion, and a moderate amount of dessication (coag)
a) pure
b) blend
c) coag
b) blend
What type of cut has no constant waveform, where tissue heats up and denatures proteins, causing dessication or fulgeration, and has the highest amount of collateral cell damage?
a) pure
b) blend
c) coag
c) coag
This type of cutting is with the tip NOT in direct contact with tissue, an arch is made to target tissue, and eschar forms.
fulgeration
This instrument uses a special gas to conduct monopolar RF current to the tissue. Less smoke and eschar (good for the liver). But can’t cut, can overheat, and increase intra-abdominal pressure in a lap (7/liters/min)
Argon beam coagulator
This instrument produces vibrations at 55,000 cycles/second, producing less heat than electrosurgery, and no smoke/arc/neuromuscular stimulation/eschar. It can be used in patients with defibrillators.
Harmonic scalpel (cold knife)
What does betadine have in it that can be set on fire?
Alcohol
Chlorhexidine is alternative
How many people receive treatment for burns each year?
450,000
How many people die from burns each year?
3,400
What is your chance of surviving a burn if being treated at a burn center?
96.1%
The most common source of a burn is….
a) scald
b) contact
c) fire/flame
d) electrical
e) chemical
c) fire/flame
in peds 4 is fire/flame
What household item can easily remove tar, but the patient could be allergic to it?
a) Ketchup
b) Mayonnaise
c) Goo-gone
d) Soap and water
e) Simple green
Mayonnaise
good for tree sap too, but not on your car
What risk of complication increases with circumferential burns?
Compartment syndrome (fasciotomy can deal with that)
A patient has burns to the chest and shows poor chest expansion/excursion, what is the best procedure to perform?
a) Chest tube thoracostomy
b) Fasciotomy
c) Escharotomy
d) Needle decompression
c) Escharotomy
what type of electrical current do you want to know when dealing with an electrical burn?
a) Amperage
b) Wattage
c) Voltage
d) Ohms
Voltage (500 and it can damage internal structures)
What vaccine will you likely give them if you can’t get a vaccination history?
Tetanus
More than 100 milliAmps of domestic house AC of 110 volts at 60 Hz is very dangerous to what organ?
the heart (causing v-fib)
(its not in the lecture, just nice to know)
(direct current DC is more likely to cause asystole)
What degree of burns DON’T we use rule of nines?
a) 1st degree
b) 2nd degree
c) 3rd degree
First degree
What method of estimating burns is most specific in pediatrics?
a) Rule of 9’s
b) Rule of palm
c) Lund and Browder Chart
d) Rule of 13’s
Lund and Browder chart
but use the modified rule of nines in the initial evalution
When estimating small burns, how does the rule of palms work?
The patients palmar surface (hands and fingers both) is about 1% of their TBSA.
The entire front of one arm is burned, what is the %?
4.5%
The genitals are burned, what is the %?
Genitals: We are the 1 %
The back of the head and anterior right leg are burned, what is the %?
13.5%
posterior head = 4.5, anterior leg = 9
The entire hand is dipped in hot lava, what is the %?
2% (using palmar method)
The entire body is dipped in hot lava except for one arm holding on to a Skynet microchip, what is the % burned?
91% (100-9)
The font of one arm and the front of one leg is burned, what is the %?
13.5% (4.5 arm, 9 leg)
The torso is burned circumferential, the palmar surface of one hand, and gentials, %?
38%
torso 36, hand 1, genitals 1
The anterior FOREARM ONLY is burned….%?
- 25%
4. 5 if it were the whole anterior arm
Which doctors who tried to save President John F. Kennedy after he was shot in Dallas on Nov. 22 came up with a formula for fluid resuscitation in burn patients?
a) Dr. Baxter
b) Dr. Dubowitz
c) Dr. Morton
d) Dr. Alison Tendler
Dr. Baxter created The Parkland formula. (modified for 2010 ABLS standards)
4ml of LR x Kg x BSA
How much of that initial fluid resuscitation is given in the…..
first 8
second 8 hours
third 8 hours
1/2 within the first 8 hours
1/4 within the second 8 hours
1/4 within the third 8 hours
A patient arrives in your ED with burns to both arms circumferentially plus the genitalia, and the bottom of one foot . You estimate his weight at 50 kg. How much fluid should you administer in the first 8 hours?
a) 4000ml Normal Saline
b) 2000ml Lactated Ringers
c) 2000ml Normal Saline
d) 3,040ml Lactated Ringers
C. 2000mL NS
(He has burned 20% of his body, 9 each arm, 1 for the genitals, and 1 for the bottom of one foot...just to make the math easy) 20% x 50kg x 4ml = 4000ml total 1st 8 hours: 2000ml 2nd 8 hours: 1000ml 3rd 8 hours: 1000ml
The burned area itself should be managed with…
a) Cold water soaks
b) Dry sterile dressing
c) Wet-to-dry dressing
d) Leave open for optimum healing
b) Dry sterile dressing (DSD)
Dry powder on the skin should be….
a) rinsed off with normal saline
b) rinsed off with Lactated ringers
c) brushed off
d) covered with dry sterile dressing
c) brushed off
We have to intubate a burn patient who just arrived to the ED. You have chosen to give succinylcholine as a muscle depolarizer. Is it safe to give?
Yes, but only in the first 24 hours of the initial burn or else they get a big K+ rush.
What is the half life of Carbon Monoxide in the lungs at 100% oxygen?
40 minutes.
Which of these patients WOULDN’T you refer to a burn center?
a) inhalation burn
b) chemical burn
c) 2nd degree burn < 10% of BSA
d) third degree burn
c) 2nd degree < 10% BSA
Which of these burned areas of the body wouldn’t you refer to a burn center?
a) Hands
b) Face
c) Buttock
d) Large joints
e) Feet
f) Genitalia
c) Buttock
Which of these patients wouldn’t you refer to a burn center?
a) burns w/ accompanying co-morbidiites
b) burns w/ trauma, where the burn is the significant factor.
c) pediatric burns in hospitals w/o peds service
d) burns to multiple locations on the body
e) patients w/ social/emotional/rehab needs
d) Burns to multiple locations on the body
its not the number of “locations”, its the % we care about. >10% of BSA 2nd degree will go to burn center
What are the systemic neurogenic effects of a burn injury?
a) Increased PVR, decreased CO
b) Increased PVR, increased CO
c) Decreased PVR, increased CO
d) Decreased PVR, decreased CO
a) Increased PVR, decreased CO
Why would we give FFP or Albumin 24 hours post-burn?
To keep blood colloid osmotic pressure elevated to avoid 3rd spacing (capillary leakage).
Is a lower hematocrit normal in the fluid resuscitated burn patient?
Yes, it’s due to dilutional anemia. An acceptable crit is around 30-35%. DO NOT GIVE RBCs unless you know its due to bleeding or trauma.
Pediatric burns are considered as such under 40kg or less than 14. What is the only thing we change in the revised Parkland formula for them?
We give 3ml (instead of the adult 4ml)
3ml x kg x TBSA
On top of fluid resuscitation in peds burns pts, what other fluid do they need?
A maintenance drip of D5LR (100-50-20 rule) (Glycogen stores are low in kids so they need the D5)
In electrical burns, what is the parkland formula changed to?
Same as regular resuscitation requirements…
4ml LR x kg x TBSA = adult electrical burn
4ml LR x kg x TBSA = adults
3ml LR x kg x TBSA = peds (+ maintenance fluid)
While adults need to put out atleast .5ml/kg/hour of urine. Peds (<40kg) need to output ____/kg/hour
a) .5
b) 1
c) 2
d) Not necessary to measure b/c they are too small to catheterize
b) 1ml/kg/hr
A burn patient’s urine output is less than expected, you should…
a) Administer a bolus infusion of IV fluids
b) Administer diuretics
c) Increase titration rate of current fluids
d) All of the above
c) Increase titration rate
Cellular/tissue damage occurs above what temperature?
111F, 44C
From inside to out of a burn the three zones are…
a) Zone of Stasis, Zone of Hyperemia, Zone of Coagulation
b) Zone of Hyperemia, Zone of Coagulation, Zone of Stasis
c) Zone of Coagulation, Zone of Stasis, Zone of Hyperemia
c) Coag –> Stasis –> Hyperemia
Pain and redness, heals in a few days, outer epithelial cells will peel.
a) 1st degree
b) 2nd degree (aka partial thickness)
c) 3rd degree (aka full thickness)
a) First degree
Entire epidermis and portion of dermis involved, with pain, blisters, cap refill intact. Heals in 2-3 weeks.
a) 1st degree
b) 2nd degree (aka partial thickness)
c) 3rd degree (aka full thickness)
2nd degree (skin graft may help improve function and cosmetics)
Entire thickness of epidermis and dermis, DECREASED pain, ABSENT cap refill. Heals by contracture and epithelial ingrowth.
a) 1st degree
b) 2nd degree (aka partial thickness)
c) 3rd degree (aka full thickness)
3rd degree (definately skin graft them)
If transfer to a burn unit is delayed, which is these should you NOT do?
a) Premedicate with analgesic
b) Debrid loose epidermis and blisters
c) Soap and water wash
d) Apply wet dressings
e) Apply topical antimicrobial such as Silvadene
d) Apply wet dressings
should always be a DSD
Which of these is least helpful as an indication for a peripheral escharotomy or fasciotomy?
a) cyanosis of the distal limb
b) presence of edema
c) unrelenting deep tissue pain
d) progressive numbness
e) progressive decrease/absence of pulse
b) presence of edema
(not in itself an indication for an escharotomy)
(if a multi-incision escharotomy is not sufficient, perform a fasciotomy)
Antibiotic of choice in facial burns
Erythromycin
Diagnotic test of choice in ocular burns
Fluoroscein Stain
True or False: Burns in a child that appear partial-thickness may actually be full thickness.
True
A 130 degree burn will cause sever damage to an adult in 30 seconds, whereas in a child it will occur in ______seconds?
10 seconds
Whats the song for the modified pediatric rule of nines?
15-16-18-10, Legs-chest-head-out-to-my-hand
What movie starred Al Pacino and Robert DeNiro as cops in Bridgeport”s burn unit?
a) The Godfather pt II
b) Heat
c) Ritcheous Kill
d) Weekend at Bernie’s
Ritcheous Kill
A mother brings her badly burned young son into your ER. He has burns to both hands and both feet that end at the wrist and ankle with a well demarcated transverse line, you immediately think…
child abuse
What suture material is the most irritative to local tissue?
Silk
The point of entry of a burn tends to be….
a) scattered and vesicular
b) more extensive and explosive
c) large but not painful
d) depressed and leather
d) depressed and leathery
The exit point of a electrical burn tends to be…
a) depressed and leathery
b) large but not painful
c) more extensive and explosive
d) scattered and vesicular
b) more extensive and explosive
What is best probe and setting to use for a Focused Assesment of Sonography in Trauma scan?
a) Phased Array, 5mHz
b) Linear Probe, 7.5mHz
c) Convex Probe, 3.5mHz
d) Concave Probe 3.5mHz
c) Convex probe, 3.5mHz
2. 5-3.5 range
Which of the following is the worst INITIAL procedure in evaluating hemoperitoneum in blunt abdominal trauma?
a) exploratory laparotomy
b) CT scan
c) DPL
d) FAST scan
a) exploratory laparotomy
What year was ultrasound technology first described?
a) 1954
b) 1971
c) 1997
d) 2009
b) 1971
What year did we coin the phrase Focused Abdominal Assesment for Trauma?
a) 1954
b) 1971
c) 1997
d) 2009
c) 1997
Who studied 1540 patients and reported that ultrasound was the most sensitive and specific modality for the evaluation of hypotensive patients with BAT (sensitivity and specificity, 100%)>
a) Johnson & Johnson
b) S. Wozniack et al
c) Rozycki et al
d) Ditcher, Quick, and Hyde
c) Rozycki et al
When U/S waves contact an organ, some are reflected and some are transmitted through the organ or tissue. Reflected return to the transducer and generate electrical impulses that are converted to the image seen on the monitor, this is known as….
a) Piezoelectric effect
b) Pulse echo principle
c) Path of least resistance principle
d) Tesla phenomenon
b) Pulse echo effect
When crystals expand and contract to interconvert electrical and mechanical energy, this is known as the…
a) Piezoelectric effect
b) Pulse echo principle
c) Flux capacitator principle
d) Drift velocity
a) Piezoelectric effect
The FAST pericardial window is best viewed on which axis?
a) Coronal
b) Transverse
c) Oblique
d) Saggittal
d) Saggital
In a FAST scan, Morrison’s Pouch (perihepatic) and Perisplenic windows are best viewed on which axis?
a) Coronal
b) Transverse
c) Oblique
d) Saggittal
a) Coronal
In a FAST scan, Douglas’ Pouch (bladder) window is best viewed on which axis?
a) Coronal
b) Transverse
c) Oblique
d) Saggittal
b) Transverse
Who developed a scoring system based on the identification of hemoperitoneum in specific areas, to help the FAST scan identify the need for immediate abdominal surgery?
a) Dewey, Screwum, and Howe
b) PT Barnum
c) Nguyen et al
d) Huang et al
d) Huang et al
Which of these is NOT indicated in applying to the burn patient with a delayed transfer to the burn unit?
a) Silver Sulfadiazine
b) Bacitracin
c) Gauze wrap
d) Mefanide Acetate
b) Bacitracin
Silver Sulfadiazine and Mefanide are both antimicrobials, but Bacitracin is not indicated
Which of the following is THE BEST ANSWER regarding the management of inhalation burns?
a) Bleeding is highly likely, prevent via insertion of a Blakemore
b) Airway structures will likely swell significantly, intubate earlier than usual
c) Nausea and vomiting are likely to be aspirated and should be prevented with Ondansetron
d) Do not stabilize the c-spine because of risk to airway occlusion
b) Swelling is likely to occlude the airway, intubate earlier than usual.
What is the most important additional test to perform in the initial assessment of a patient with an electrical burn?
a) Chest x-ray
b) Venous blood gas
c) EKG
d) CT Head and Neck
c) EKG
Although a chest x-ray should be performed in addition to an ABG, it is not the going to evaluate the most serious complication from an electrical injury (arrhythmia, v-fib, asystole)
True or False: Venous CO sampling is just as reliable of an indicator for CO poisoning as Arterial CO sampling?
True
according to two different published studies comparing the two, i didn’t look at the peds test yet
What type of suture is best for deep wounds?
Vertical mattress
desired urine output in hemochromogenuria (red pigmented urine)?
1.0-1.5 typically from high voltage injury or soft tissue mechanical trauma
What carbonic anhydrous inhibitor antimicrobial cream causes lactic acidosis?
Mafenide acetate (Sulfamylon)
