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Absite Review > The Surgical Review- Trauma/Critical Care > Flashcards

The Surgical Review- Trauma/Critical Care Flashcards

1
Q

what are the positive DPL criteria?

A
  1. > 10mL gross blood
  2. Blunt trauma >100,000 RBCs, penetrating >10,000 RBCs
  3. > 500 WBCs
    • Gram stain bacteria, food products
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2
Q

What are the 6T’s and 6H’s of PEA?

A

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

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3
Q

what is battle sign and what is it indicative of??

A

ecchymosis behind the hears, showing basilar skull fracture, can also see raccoon eyes (ecchymosis around eyes)

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4
Q

what are the hard signs of vascular injury? 6

A
  1. Pulsatile bleeding
  2. Expanding hematoma
  3. Palpable thrill
  4. Audible bruit
  5. Regional ischemia
  6. Diminished or absent pulses (ABI
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5
Q

a pressure greater than ___ is assoc with compartment syndrome?

A

> 25mmmHg

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6
Q

what is the only indication for early use of pressers in the hypotensive trauma patient?

A

neurogenic shock-> dopamine used for hypotension and bradycardia

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7
Q

what is cushing triad and when do you see it?

A
  1. Hypertension
  2. Bradycardia
  3. Respiratory depression
    - seen in elevated ICP 2/2 head trauma
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8
Q

what is a normal ICP?

A

15mmHg (pathologic intracranial hypertension usually occurs at 20mmHg)

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9
Q

Cerebral Perfusion Pressure =

A

MAP - ICP, should be kept above 60mmHg in patients w elevated ICP

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10
Q

what are the criteria for brain death? 8

A

Absence of:

  1. response to painful stimuli
  2. Seizure activity
  3. Papillary light reflex
  4. Corneal reflex
  5. Gag reflex
  6. Oculocephalogyric reflex (dolls eyes)
  7. Vestibulo-ocular reflex
  8. resp effort during apnea test
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11
Q

what is an apnea test?

A

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

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12
Q

what is a drawback to volume-cycled ventilation?

A

airway pressures may escalate to harmful levels i.e. barotrauma in poorly compliant lungs (stiff), can lead to alveolar rupture and pneumothorax

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13
Q

Central venous pressure is a measurement of what?

A

right sided heart function and overall volume status, can suggest cariogenic shock

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14
Q

when is CVP best measured?

A

at the end of expiration, because mechanical ventilation increases CVP during the inspiratory phase, and opposite is due in physiologic respiration (decreases w inspiration)

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15
Q

how do you calculate the SVR (systemic vascular resistance)?

A

= (MAP - CVP)/CO

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16
Q

what lab abnormalities occur in prerenal azotemia?

A

serum urea nitrogen levels rise out of proportion to the creatinine level (>20:1)

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17
Q

how do u calculate FENa?

A

[urine Na x plasma Cr] / [ plasma Na x urine Cr]

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18
Q

what is virchow triad?

A

hemostasis
hypercoagulability
endothelial injury

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19
Q

what are the two types of heparin induced thrombocytopenia?

A

type I: acute, Type II: 5-8 days later

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20
Q

when is stress ulcer ppx indicated?

A
  1. Coagulopathy
  2. Severe burns
  3. Head injury
  4. Prolonged ventilator dependence (>48hrs)
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21
Q

what bladder pressure warrants emergent decompression in abdominal compartment syndrome?

A

> 35mmHg warrants emergent,
25-35 - eventually require decompression
15-24 - close observation

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22
Q

workup for suspected adrenal insufficiency?

A
  1. Random cortisol level, if
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23
Q

what is one side effect of IV etomidate?

A

adrenal insufficiency (even a single dose can cause it)

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24
Q

how do you calculate the free water deficit?

A

= 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

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25
Q

what is the free water deficit?

A

used to estimate the volume (L) of water required to correct dehydration during the initial stages of fluid-replacement therapy

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26
Q

what are the clinical classifications of TBI based on GCS?

A

Mild (13-15), moderate (9-12), severe (8 or less)

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27
Q

what component of the GCS is the most important predictor of neurologic severity and recovery?

A

motor component

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28
Q

what are epidural hematoma?

A
  • lens shaped + mass effect

- seen after direct lateral impact to the temporal region with skull fx and laceration to the middle meningeal artery

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29
Q

when is immediate evacuation indicated in epidural hematoma?

A
  1. altered mental status
  2. lesion >1cm in diameter
  3. midline shift on CT
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30
Q

what are subdural hematoma?

A
  • 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
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31
Q

ICP greater than ___ typically requires treatment

A

20mmHg

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32
Q

medical management of increased ICP

A

Mannitol: first bolus with 1g/kg in acute setting, then 0.25h/kg every few hours PRN

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33
Q

with increased ICP, what is your target serum osm?

A

should be maintained below 320mOsm

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34
Q

why should phenylephrine be avoided in neurogenic shock?

A

because it can cause reflex bradycardia, and pts are already bradycardic

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35
Q

how does a tension pneumothorax cause diminished cardiac output?

A

mediastinal shift causes compression of SVC and IVC leading to significantly diminished venous return

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36
Q

treatment of tension pt.?

A

insertion of 12-14 gauge needle into the second intercostal space in the midclavicular line, followed by tube thoracostomy

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37
Q

how much blood is needed to produce pericardial tamponade in an adult?

A

as little as 75-100mL

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38
Q

what is becks triad?

A
  • classic signs of pericardial tamponade
    1. Distended neck veins
    2. Hypotension
    3. Muffled heart tones
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39
Q

what is pulsus paradoxus?

A
  • seen in pericardial tamponade

a decrease in systolic pressure of >10mmHg during inspiration

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40
Q

what is kussmaul sign?

A

seen in pericardial tamponade?

a rise in venous pressure with inspiration

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41
Q

open pneumothorax (sucking chest wound), treatment?

A

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
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42
Q

aortic laceration is most often located where in trauma patients?

A

just distal to the ligament arteriosum, past the left subclavian artery

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43
Q

physical exam findings that clue u into traumatic rupture of the aorta? 3

A
  1. uneven blood pressures in the upper extremity
  2. intrascapular pain/murmur
  3. chest wall contusion
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44
Q

7 radiographic signs of traumatic rupture of the aorta

A
  1. Widened mediastinum (>8cm)
  2. Obliteration of aortic knob
  3. Obliteration of aortopulmonary window
  4. Tracheal deviation to the R
  5. Presence of pleural cap
  6. Depression of the L main stem bronchus (4cm)
  7. Deviation of the esophagus to the R
45
Q

how is a ED thoracotomy performed?

A
  • 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
46
Q

what is the pringle maneuver?

A

occlusion of the portal triad at the hepatoduodenal ligament

47
Q

ongoing hemorrhage after pringle maneuver suggests what?

A

retrohepatic vena caval injury or hepatic venous avulsion

48
Q

rare but grave complication of splenectomy?

A

overwhelming postsplenectomy sepsis (OPSS)

49
Q

how do you manage traumatic major pancreatic ductal injuries?

A

distal pancreatectomy at the point of ductal injury

50
Q

how do you manage severe pancreatic injuries?

A
  1. hemorrhage control
  2. debridement of devitalized tissue
  3. wide closed suction drainage
  4. feeding jejunostomy
51
Q

management of exztraperitoneal bladder injury?

A

foley catheter drainage alone

52
Q

management of intraperitoneal bladder injury?

A

formal operative repair: 2-3 layers with absorbable suture and then foley drainage

53
Q

how do you repair injuries to the renal collecting system?

A

with absorbable suture bc permanent suture is a nidus for stone formation, then drained by ureteral stent or nephrostomy tube

54
Q

management of significant kidney hilar injury?

A

nephrectomy

55
Q

management of ureteral injury?

A

primary repair with absorbable suture over a double J stent after deriding and spatulating the cut ends to avoid stricture

56
Q

whats a chance fracture and what other injuries should you suspect?

A
  • lumbar spine anterior compression fracture bc of hyperflexion
  • assoc with duodenum and proximal jejunum injuries
57
Q

when can you do primary repair to manage penetrating bowel injuries?

A

when less than 50% of the circumference of the bowel is affected

58
Q

Four different types of shock?

A
  1. Hypovolemic
  2. Vasogenic
  3. Neurogenic
  4. Cardiogenic
59
Q

pulmonary capillary wedge pressure provides an indirect measurement of what?

A

left atrial pressure

60
Q

what is a normal left atrial pressure?

A

8-10mmHg

61
Q

formula for Systemic Vascular Resistance?

A

SVR = (MAP - CVP) / CO x80

62
Q

formula for MAP?

A

DBP + 1/2 (SBP-DBP)

63
Q

what is formula for oxygen delivery?

A

CO xHgb x 1.31 x %sat

64
Q

SvO2 is an indirect measurement of what?

A

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

65
Q

how do kidneys respond to hemorrhagic shock?

A

increasing reabsorption of sodium and water

66
Q

what ekg abnormalities do you see in hypOkalemia?

A
  1. U waves
  2. T wave flattening
  3. ST segment changes
  4. Arrhythmias
67
Q

AV block is more common with what metabolic abnormalities?

A

hypercalcemia and hyperkalemia

68
Q

treatment of hypercalcemic crisis? 3

A
  1. calcitonin
  2. bisphosphonates
  3. IV hydration
69
Q

what is a severe short term complication of TURP?

A

severe hyponatremia, from absorption of hypotonic irrigation used intraoperatively

70
Q

how do you treat severe hyponatremia and at what rate?

A

if neurologic symptoms are present, 3% NS at a rate no more than 1 mEq/hr

71
Q

symptoms of severe hypophosphatemia?

A

encephalopathy, cardiac dysfunction, muscle weakness, hemolysis of RBCs

72
Q

diarrhea causes what kind of metabolic disturbance?

A

metabolic acidosis 2/2 loss of bicarbonate in the stool

73
Q

hypomagnesemia is characterized by?

A

Neuromuscular and CNShyperactivity, hyperactive reflexes, muscle tremors, and tetany with positive chvostek sign (like hypocalcemia)

74
Q

symptoms of hypermagnesemia?

A

respiratory and cardiac arrest, with loss of tendon reflexes

75
Q

two types of metabolic alkalosis and causes?

A
  1. Chloride responsive: urine Cl 25, mineralcorticoid excess or potassium depletion
76
Q

most common cancers causing tumor lysis syndrome?

A

poorly differentiated lymphomas and leukemias

77
Q

prolonged QT intervals is seen in assoc with what electrolyte abnormality?

A

hypomagnesemia

78
Q

acute treatment of hypermagnesemia?

A

calcium chloride, if that fails then dialysis

79
Q

management of extraperitoneal rectal injuries?

A

if proximal: primary repair

distal: diverting colostomy

80
Q

management of blunt injury to the renal artery?

A

leave kidney alone unless bilateral or pt only has one kidney

81
Q

arteries for which repair should always be attempted include: 9

A
  1. Carotid
  2. Innominate
  3. Brachial
  4. SMA
  5. Proper hepatic
  6. Iliac
  7. Femoral
  8. Popliteal
  9. Aorta
82
Q

emergent operative repair of right vs left subclavian aa injury?

A

Right: median sternotomy
Left: left anterolateral thoracotomy

83
Q

what is the cattle maneuver? what does it expose?

A

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)
84
Q

what is the kocher maneuver and what does it expose?

A

mobilization and medial rotation of the duodenum

- exposes the suprarenal IVC

85
Q

what is the mattox maneuver? what does it expose?

A
  • medial rotation of the left colon (at the white line of toldt), kidney and spleen
  • exposes the celiac axis
86
Q

when do you do damage control measures w selective packing in a patient w a liver injury?

A

when patient is cold and coagulopathic

87
Q

what is the pringle maneuver?

A

compression of the portal vein and hepatic artery through the foramen of winslow

88
Q

management of simple duodenal hematoma?

A

NGT decompression, parenteral nutrition

89
Q

repair of duodenal lacerations?

A

if 50%: 1st or 4th part of duo- resection with duodenoduodenostomy, if 2nd or 3rd portion: roux-en-y

90
Q

symptoms of central cord syndrome

A

decreased motor function and pain and temperature sensation in the upper extremities only, normal lower extremities

91
Q

what spinal cord injury has the worst prognosis?

A

anterior cord syndrome

92
Q

absolute indications for operative exploration of traumatic kidney injuries?

A
  • renal injury + hemodynamically unstable, pt already being explored
  • rapidly expanding retroperitoneal hematoma overlying kidney or pulsatile
93
Q

what is the cushing reflex?

A

hypertension and bradycardia- seen oftentimes in traumatic intracranial bleeding

94
Q

how do you perform an open cricothyrotomy?

A
  1. the cricothyroid membrane identified immediately below thyroid cartilage
  2. longitudinal skin incision (3cm)
  3. bluntly dissect down to the membrane
  4. transverse incision in the cricothyroid membrane, dilate w blunt end of scalpel
  5. insert a number 5 or 6 ETT and blow up cuff
95
Q

what are the grades of urethral injuries?

A

Grade I: contusions
II: urethral stretch
III: partial disruptions
IV &V: complete disruptions w/wo separation

96
Q

What is becks triad?

A
  1. muffled heart sounds
  2. JVD
  3. Narrowed pulse pressurre
    = cardiac tamponade
97
Q

most commonly injured organ following blunt trauma?

A

liver

98
Q

which types of pelvic fx are more likely to have associated bladder injuries?

A

pubic diastasis and obturator ring fx

99
Q

which organ is the most sensitive to hypothermic changes?

A

heart

100
Q

Coverage, penetration and side effect (s): silver sulfadiazine (SE x3)

A

broad coverage including pseudomonas, doesnt penetrate eschar well
SE: transient neutropenia and thrombocytopenia
methemaglobinemia
contraindicated in G6PD

101
Q

Coverage, penetration and side effect (s): mafenide acetate

A

broad spectrum
penetrates eschar
MOA: inhibits carbonic anhydrase -> metabolic acidosis

102
Q

Coverage, penetration and side effect (s): bacitracin

A

gram positive coverage, optimal on shallow facial burns

103
Q

Coverage, penetration and side effect (s): silver nitrate

A

broad spectrum

electrolyte disturbances: hyponatremia, hypochloremia, hypocalcemia, hypokalemia

104
Q

what is the mechanism for elimination for succinylcholine?

A

pseudocholinesterase

105
Q

two major categories of neuromuscular blockers?

A

depolarizing (succ is only one) and nondepolarizing

106
Q

what is paralytic of choice for RSI?

A

succinylcholine: rapid onset and short half-life

107
Q

what are the side effects of succinylcholine?

A 
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
108
Q

of all the nondepolarizing paralytics, which one is degraded by:
hoffman
renal
hepatic

A 
hoffman = cistracurium
renal = pancuronium
hepatic = rocuronium

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