The Surgical Review- Trauma/Critical Care Flashcards
what are the positive DPL criteria?
- > 10mL gross blood
- Blunt trauma >100,000 RBCs, penetrating >10,000 RBCs
- > 500 WBCs
- Gram stain bacteria, food products
What are the 6T’s and 6H’s of PEA?
T”s: Trauma, Tension PTX, tamponade, toxins (drugs/overdose), thrombosis- coronary, thrombosis - pulmonary
H’s: Hypovolemia, hypothermia, hypoxia, hyper/hypokalemia, hydrogen ion (acidosis), hypo/hyperglycemia
what is battle sign and what is it indicative of??
ecchymosis behind the hears, showing basilar skull fracture, can also see raccoon eyes (ecchymosis around eyes)
what are the hard signs of vascular injury? 6
- Pulsatile bleeding
- Expanding hematoma
- Palpable thrill
- Audible bruit
- Regional ischemia
- Diminished or absent pulses (ABI
a pressure greater than ___ is assoc with compartment syndrome?
> 25mmmHg
what is the only indication for early use of pressers in the hypotensive trauma patient?
neurogenic shock-> dopamine used for hypotension and bradycardia
what is cushing triad and when do you see it?
- Hypertension
- Bradycardia
- Respiratory depression
- seen in elevated ICP 2/2 head trauma
what is a normal ICP?
15mmHg (pathologic intracranial hypertension usually occurs at 20mmHg)
Cerebral Perfusion Pressure =
MAP - ICP, should be kept above 60mmHg in patients w elevated ICP
what are the criteria for brain death? 8
Absence of:
- response to painful stimuli
- Seizure activity
- Papillary light reflex
- Corneal reflex
- Gag reflex
- Oculocephalogyric reflex (dolls eyes)
- Vestibulo-ocular reflex
- resp effort during apnea test
what is an apnea test?
the patient is pre oxygenated before ventilator is stopped and hypercarbia is permitted
- paco2 should rise at least 20mmHg or exceed 60mmHg before the absence of rest effort is considered confirmatory
what is a drawback to volume-cycled ventilation?
airway pressures may escalate to harmful levels i.e. barotrauma in poorly compliant lungs (stiff), can lead to alveolar rupture and pneumothorax
Central venous pressure is a measurement of what?
right sided heart function and overall volume status, can suggest cariogenic shock
when is CVP best measured?
at the end of expiration, because mechanical ventilation increases CVP during the inspiratory phase, and opposite is due in physiologic respiration (decreases w inspiration)
how do you calculate the SVR (systemic vascular resistance)?
= (MAP - CVP)/CO
what lab abnormalities occur in prerenal azotemia?
serum urea nitrogen levels rise out of proportion to the creatinine level (>20:1)
how do u calculate FENa?
[urine Na x plasma Cr] / [ plasma Na x urine Cr]
what is virchow triad?
hemostasis
hypercoagulability
endothelial injury
what are the two types of heparin induced thrombocytopenia?
type I: acute, Type II: 5-8 days later
when is stress ulcer ppx indicated?
- Coagulopathy
- Severe burns
- Head injury
- Prolonged ventilator dependence (>48hrs)
what bladder pressure warrants emergent decompression in abdominal compartment syndrome?
> 35mmHg warrants emergent,
25-35 - eventually require decompression
15-24 - close observation
workup for suspected adrenal insufficiency?
- Random cortisol level, if
what is one side effect of IV etomidate?
adrenal insufficiency (even a single dose can cause it)
how do you calculate the free water deficit?
= 0.6 x weight [1 - (140/serum Na)]
- remember to correct for hyperglycemia, thus add 1.6mmol Na/L for each 100mg/dL of glucose over 100
what is the free water deficit?
used to estimate the volume (L) of water required to correct dehydration during the initial stages of fluid-replacement therapy
what are the clinical classifications of TBI based on GCS?
Mild (13-15), moderate (9-12), severe (8 or less)
what component of the GCS is the most important predictor of neurologic severity and recovery?
motor component
what are epidural hematoma?
- lens shaped + mass effect
- seen after direct lateral impact to the temporal region with skull fx and laceration to the middle meningeal artery
when is immediate evacuation indicated in epidural hematoma?
- altered mental status
- lesion >1cm in diameter
- midline shift on CT
what are subdural hematoma?
- crescent shaped
- due to rupture of bridging veins
- have worse prognosis because 2/2 high force of impact and assoc w direct brain injury and axonal shearing
ICP greater than ___ typically requires treatment
20mmHg
medical management of increased ICP
Mannitol: first bolus with 1g/kg in acute setting, then 0.25h/kg every few hours PRN
with increased ICP, what is your target serum osm?
should be maintained below 320mOsm
why should phenylephrine be avoided in neurogenic shock?
because it can cause reflex bradycardia, and pts are already bradycardic
how does a tension pneumothorax cause diminished cardiac output?
mediastinal shift causes compression of SVC and IVC leading to significantly diminished venous return
treatment of tension pt.?
insertion of 12-14 gauge needle into the second intercostal space in the midclavicular line, followed by tube thoracostomy
how much blood is needed to produce pericardial tamponade in an adult?
as little as 75-100mL
what is becks triad?
- classic signs of pericardial tamponade
1. Distended neck veins
2. Hypotension
3. Muffled heart tones
what is pulsus paradoxus?
- seen in pericardial tamponade
a decrease in systolic pressure of >10mmHg during inspiration
what is kussmaul sign?
seen in pericardial tamponade?
a rise in venous pressure with inspiration
open pneumothorax (sucking chest wound), treatment?
if resp distress or hemodynamic instability, intubate with positive pressure ventilation
- occlude chest wall defect with 3 sided occlusive dressing to act as flutter valve
- definitive tx: tube thoracostomy + completely occlusive dressing
aortic laceration is most often located where in trauma patients?
just distal to the ligament arteriosum, past the left subclavian artery
physical exam findings that clue u into traumatic rupture of the aorta? 3
- uneven blood pressures in the upper extremity
- intrascapular pain/murmur
- chest wall contusion
7 radiographic signs of traumatic rupture of the aorta
- Widened mediastinum (>8cm)
- Obliteration of aortic knob
- Obliteration of aortopulmonary window
- Tracheal deviation to the R
- Presence of pleural cap
- Depression of the L main stem bronchus (4cm)
- Deviation of the esophagus to the R
how is a ED thoracotomy performed?
- left anterolateral thoracotomy below the nipple at the fourth intercostal space or in the inframammary crease in females
- incision made from posterior axillary line to right side of the sternum
- pericardium incised anterior longitudinally and parallel to the phrenic nerve
what is the pringle maneuver?
occlusion of the portal triad at the hepatoduodenal ligament
ongoing hemorrhage after pringle maneuver suggests what?
retrohepatic vena caval injury or hepatic venous avulsion
rare but grave complication of splenectomy?
overwhelming postsplenectomy sepsis (OPSS)
how do you manage traumatic major pancreatic ductal injuries?
distal pancreatectomy at the point of ductal injury
how do you manage severe pancreatic injuries?
- hemorrhage control
- debridement of devitalized tissue
- wide closed suction drainage
- feeding jejunostomy
management of exztraperitoneal bladder injury?
foley catheter drainage alone
management of intraperitoneal bladder injury?
formal operative repair: 2-3 layers with absorbable suture and then foley drainage
how do you repair injuries to the renal collecting system?
with absorbable suture bc permanent suture is a nidus for stone formation, then drained by ureteral stent or nephrostomy tube
management of significant kidney hilar injury?
nephrectomy
management of ureteral injury?
primary repair with absorbable suture over a double J stent after deriding and spatulating the cut ends to avoid stricture
whats a chance fracture and what other injuries should you suspect?
- lumbar spine anterior compression fracture bc of hyperflexion
- assoc with duodenum and proximal jejunum injuries
when can you do primary repair to manage penetrating bowel injuries?
when less than 50% of the circumference of the bowel is affected
Four different types of shock?
- Hypovolemic
- Vasogenic
- Neurogenic
- Cardiogenic
pulmonary capillary wedge pressure provides an indirect measurement of what?
left atrial pressure
what is a normal left atrial pressure?
8-10mmHg
formula for Systemic Vascular Resistance?
SVR = (MAP - CVP) / CO x80
formula for MAP?
DBP + 1/2 (SBP-DBP)
what is formula for oxygen delivery?
CO xHgb x 1.31 x %sat
SvO2 is an indirect measurement of what?
tissue oxygenation: taken from pulmonary artery, mixed blood of vena cava and the coronary sinus
normal = 60-80%
the percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart
how do kidneys respond to hemorrhagic shock?
increasing reabsorption of sodium and water
what ekg abnormalities do you see in hypOkalemia?
- U waves
- T wave flattening
- ST segment changes
- Arrhythmias
AV block is more common with what metabolic abnormalities?
hypercalcemia and hyperkalemia
treatment of hypercalcemic crisis? 3
- calcitonin
- bisphosphonates
- IV hydration
what is a severe short term complication of TURP?
severe hyponatremia, from absorption of hypotonic irrigation used intraoperatively
how do you treat severe hyponatremia and at what rate?
if neurologic symptoms are present, 3% NS at a rate no more than 1 mEq/hr
symptoms of severe hypophosphatemia?
encephalopathy, cardiac dysfunction, muscle weakness, hemolysis of RBCs
diarrhea causes what kind of metabolic disturbance?
metabolic acidosis 2/2 loss of bicarbonate in the stool
hypomagnesemia is characterized by?
Neuromuscular and CNShyperactivity, hyperactive reflexes, muscle tremors, and tetany with positive chvostek sign (like hypocalcemia)
symptoms of hypermagnesemia?
respiratory and cardiac arrest, with loss of tendon reflexes
two types of metabolic alkalosis and causes?
- Chloride responsive: urine Cl 25, mineralcorticoid excess or potassium depletion
most common cancers causing tumor lysis syndrome?
poorly differentiated lymphomas and leukemias
prolonged QT intervals is seen in assoc with what electrolyte abnormality?
hypomagnesemia
acute treatment of hypermagnesemia?
calcium chloride, if that fails then dialysis
management of extraperitoneal rectal injuries?
if proximal: primary repair
distal: diverting colostomy
management of blunt injury to the renal artery?
leave kidney alone unless bilateral or pt only has one kidney
arteries for which repair should always be attempted include: 9
- Carotid
- Innominate
- Brachial
- SMA
- Proper hepatic
- Iliac
- Femoral
- Popliteal
- Aorta
emergent operative repair of right vs left subclavian aa injury?
Right: median sternotomy
Left: left anterolateral thoracotomy
what is the cattle maneuver? what does it expose?
medial visceral rotation of the cecum and ascending colon
- achieved by incising the peritoneal reflection at the white line of toldt
- exposes the right retroperitoneal structures (IVC and R ureter)
what is the kocher maneuver and what does it expose?
mobilization and medial rotation of the duodenum
- exposes the suprarenal IVC
what is the mattox maneuver? what does it expose?
- medial rotation of the left colon (at the white line of toldt), kidney and spleen
- exposes the celiac axis
when do you do damage control measures w selective packing in a patient w a liver injury?
when patient is cold and coagulopathic
what is the pringle maneuver?
compression of the portal vein and hepatic artery through the foramen of winslow
management of simple duodenal hematoma?
NGT decompression, parenteral nutrition
repair of duodenal lacerations?
if 50%: 1st or 4th part of duo- resection with duodenoduodenostomy, if 2nd or 3rd portion: roux-en-y
symptoms of central cord syndrome
decreased motor function and pain and temperature sensation in the upper extremities only, normal lower extremities
what spinal cord injury has the worst prognosis?
anterior cord syndrome
absolute indications for operative exploration of traumatic kidney injuries?
- renal injury + hemodynamically unstable, pt already being explored
- rapidly expanding retroperitoneal hematoma overlying kidney or pulsatile
what is the cushing reflex?
hypertension and bradycardia- seen oftentimes in traumatic intracranial bleeding
how do you perform an open cricothyrotomy?
- the cricothyroid membrane identified immediately below thyroid cartilage
- longitudinal skin incision (3cm)
- bluntly dissect down to the membrane
- transverse incision in the cricothyroid membrane, dilate w blunt end of scalpel
- insert a number 5 or 6 ETT and blow up cuff
what are the grades of urethral injuries?
Grade I: contusions
II: urethral stretch
III: partial disruptions
IV &V: complete disruptions w/wo separation
What is becks triad?
- muffled heart sounds
- JVD
- Narrowed pulse pressurre
= cardiac tamponade
most commonly injured organ following blunt trauma?
liver
which types of pelvic fx are more likely to have associated bladder injuries?
pubic diastasis and obturator ring fx
which organ is the most sensitive to hypothermic changes?
heart
Coverage, penetration and side effect (s): silver sulfadiazine (SE x3)
broad coverage including pseudomonas, doesnt penetrate eschar well
SE: transient neutropenia and thrombocytopenia
methemaglobinemia
contraindicated in G6PD
Coverage, penetration and side effect (s): mafenide acetate
broad spectrum
penetrates eschar
MOA: inhibits carbonic anhydrase -> metabolic acidosis
Coverage, penetration and side effect (s): bacitracin
gram positive coverage, optimal on shallow facial burns
Coverage, penetration and side effect (s): silver nitrate
broad spectrum
electrolyte disturbances: hyponatremia, hypochloremia, hypocalcemia, hypokalemia
what is the mechanism for elimination for succinylcholine?
pseudocholinesterase
two major categories of neuromuscular blockers?
depolarizing (succ is only one) and nondepolarizing
what is paralytic of choice for RSI?
succinylcholine: rapid onset and short half-life
what are the side effects of succinylcholine?
Muscle pain rhabdomyolysis ocular HTN malignant hyperthermia hyperkalemia * dont give in pts w spinal cord injuries, large burns, upper and lower motor neuron disease, renal failure, prolonged immobility
of all the nondepolarizing paralytics, which one is degraded by:
hoffman
renal
hepatic
hoffman = cistracurium renal = pancuronium hepatic = rocuronium
