Trauma

Question 1

Pt w/ multiple stab wounds, fully conscious, normal voice, expanding hematoma in neck. Next step?

Answer 1

Intubation to protect against imminent airway compromise.

Question 2

Pt w/ multiple stab wounds, fully conscious, normal voice, subcutaneous emphysema in neck and upper chest. Next step?

Answer 2

Intubation to protect against imminent airway compromise AND fiberoptic bronchoscopy.

Question 3

Pt unconscious, breathing spontaneously, breathing sounds gurgled and noisy. Next step?

Answer 3

Orotracheal intubation

Question 4

Most common indication for intubation in trauma?

Answer 4

Altered mental status (unconscious patients can’t protect an airway)

Question 5

Airway protection in potential cervical spine injury?

Answer 5

Orotracheal intubation with manual in-line cervical immobilization or over a flexible bronchoscope. Nasotracheal intubation an option if not precluded by facial injury.

Question 6

Extensive facial fractures, bleeding briskly into the airway, voice masked by gurgling sounds. Next step?

Answer 6

Cricothyroidotomy is the best option. Percutaneous transtracheal ventilation (IV catheter in trachea with high-pressure O2 delivery) is a possibility. NOT emergency tracheostomy.

Question 7

Unconscious pt with multiple facial fractures, brisk bleeding into the mouth and throat, gurgling, irregular, labored breathing. Next step?

Answer 7

Cricothyroidotomy. NOT percutaneous transtracheal ventilation (does not eliminate CO2 well, and need to avoid hypoventilation in unconscious head trauma for fear of increased ICP)

Question 8

Three conditions that might produce inadequate breathing in trauma

Answer 8

Plain pneumothorax, tension pneumothorax, flail chest with underlying pulmonary contusion

Question 9

Most common causes of shock in trauma?

Answer 9

Bleeding (hypovolemic) most common, followed by pericardial tamponade and tension pneumothorax (both require chest involvement).

Question 10

“Picture of shock”

Answer 10

Diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water, low blood pressure, fast weak pulse

Question 11

Management of hypovolemic shock in trauma

Answer 11

Big-bore IV lines, Foley catheter, IV antibiotics (if abdominal trauma) in preparation for ex-lap, then fluid and blood administration (i.e. control the bleeding site first if surgery is called for)…if no surgery needed, fluid resuscitation first in part as a diagnostic test.

Question 12

Approach to shock in multiple gunshot wound pt in the field?

Answer 12

Don’t attempt to start an IV on site–time is better spent getting the patient to a trauma center for ex lap (“scoop and run”)…unless center is very far away from center, then start fluid resuscitation with Ringer’s lactate (a couple of liters in the first 20-30 minutes).

Question 13

Groin gunshot wound, BP 90/70, HR 105, bright red blood squirting from wound. First step?

Answer 13

Direct local pressure (gloved finger or sterile pressure dressing), NOT tourniquet or blind clamping. Volume restoration later.

Question 14

Car accident victim, unconscious, spontaneous but noisy breathing, BP 80/60, HR 95. No vein distention. First steps?

Answer 14

Intubation, central line for CVP measurement, chest/abdomen exam, two large peripheral lines pouring in Ringer’s lactate (can also use percutaneous femoral vein catheter or saphenous vein cut-down)

Question 15

Child shot in arm, bleeding controlled by local pressure, hypotensive and tachycardic, peripheral IVs unsuccessful. Next step?

Answer 15

Intraosseous cannulation in proximal tibia, then bolus of Ringer’s lactate (20 mL/kg)

Question 16

Multiple gunshot wounds to chest and abdomen, diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. BP 60/40, HR 150, pulse barely perceptible. Next steps?

Answer 16

Likely hypovolemic shock, but can’t rule out pericardial tamponade or tension pneumothorax. Look for distended neck veins (or high CVP) in both, and respiratory distress, tracheal deviation, and absent breath sounds on a hyperresonant hemithorax in tension pneumo.

Question 17

Management of suspected pericardial tamponade?

Answer 17

Clinical diagnosis, no x-rays needed, find and evacuate the blood in the pericardial space via pericardiocentesis, tap, tube, or pericardial window. If positive, follow with thoracotomy and then ex-lap. Fluid resuscitation or blood transfusion helps tamponade as a temporizing measure.

Question 18

Stab wound with 6-inch blade, entry wound left of sternal border at 4th intercostal space. BP 80/50, HR 110, cold, pale, perspiring heavily. Distended neck and facial veins, normal breathing and breath sounds. Next steps?

Answer 18

This is pericardial tamponade, need median sternotomy to open the pericardial sac and relieve the tamponade (can skip pericardiocentesis or pericardial window)

Question 19

Management of suspected tension pneumothorax?

Answer 19

Immediate big-bore needle or IV catheter placed into the pleural space, followed by a chest tube to the affected side. No time for chest x-ray.

Question 20

Automobile collision, pt in coma with fixed, dilated pupils and multiple obvious fractures in both upper extremities and right lower leg. BP 70/50, barely perceptible pulse of 140. Where is the bleeding?

Answer 20

Obvious head injury present, but the shock here is caused by bleeding which cannot be intracranial. Need to lose a liter and a half to go into shock.

Question 21

Pt with severe chest pain, cold, diaphoretic, BP 80/65, irregular, feeble pulse at a rate of 130, neck and forehead veins distended, short of breath. Management?

Answer 21

Cardiogenic shock from massive MI. Need to verify high CVP, ECG, enzymes, coronary care unit, thrombolytic therapy. Don’t “drown” with fluids.

Question 22

Characteristics, examples, and management of vasomotor shock?

Answer 22

Massive vasodilation, loss of vascular tone; pt warm and flushed, CVP low; can occur in anaphylaxis, spinal block; management is vasoconstrictors and volume replacement.

Question 23

Management of penetrating wounds?

Answer 23

As a rule, internal damage will need to be repaired surgically. Do not remove embedded “weapon” at scene of accident or in ER.

Question 24

Management of skull fractures?

Answer 24

Closed, asymptomatic = leave alone; open, not comminuted or depressed = clean and close laceration in ER; open, comminuted or depressed = OR for cleaning, repair, and possible craniotomy

Question 25

Management of head trauma with transient loss of consciousness?

Answer 25

Head CT to look for hematoma; if CT and neuro exam are normal, pt can go home as long as someone can wake them up frequently to make sure they are not going into coma

Question 26

4 signs of basal skull fracture

Answer 26

Raccoon eyes, clear fluid dripping out the nose, clear fluid dripping from the ear, ecchymosis behind the ear (all individually diagnostic)

Question 27

Management of basal skull fracture

Answer 27

Pt may be in a coma...needs head CT. CSF leak will stop by itself, nothing done about fractures. Be sure to evaluate cervical spine as well.

Question 28

Signs of acute epidural hematoma?

Answer 28

Head trauma, transient LOC, recovery, recurrent LOC after ~1 hr, unilateral pupil fixation and dilation, signs of contralateral hemiparesis

Question 29

Diagnosis and management of acute epidural hematoma?

Answer 29

CT scan (lens-shaped hematoma and deviation of midline structures); management is emergency surgical decompression (craniotomy)

Question 30

Automobile collision, pt unconscious at scene, regains consciousness briefly in ambulance, arrives in ER in coma with fixed, dilated right pupil and contralateral hemiparesis. Next diagnostic and management steps?

Answer 30

Could be acute epidural hematoma but more likely subdural (sicker pt). Diagnosis is by CT scan. Management is emergency craniotomy, but prognosis is usually poor due to parenchymal injury. Don't forget to check the cervical spine!

Question 31

Pt in coma with no lateralizing signs. CT shows crescent-shaped hematoma without deviation of midline structures. Management?

Answer 31

Subdural hematoma, surgery not indicated without lateralizing signs or midline displacement. Management should be aimed at controlling ICP.

Question 32

Pt in deep coma with bilateral fixed, dilated pupils. CT shows diffuse blurring of gray-white mass interface and multiple small punctate hemorrhages. No single large hematoma or displacement of midline structures. Diagnosis and treatment?

Answer 32

Diffuse axonal injury. Prognosis is terrible, surgery cannot help. Need to lower ICP. First line is head elevation, hyperventilation, and avoidance of fluid overload. Second line is mannitol and furosemide (but don't go too far and produce hypotension, which would decrease brain perfusion). Lowered oxygen demand may help (hypothermia).

Question 33

Pt becomes senile over 3-4 weeks after possible head trauma. Diagnosis and management?

Answer 33

Chronic subdural hematoma, diagnosed by CT scan, managed with surgical decompression (craniotomy)

Question 34

Management of penetrating neck wounds in an unstable patient (deteriorating vital signs)?

Answer 34

Immediate surgical exploration

Question 35

Gunshot wound to neck, entrance wound in anterior left side at level of thyroid cartilage, bullet embedded in right scalene muscle. Pt is spitting and coughing blood and has an expanded hematoma. BP responds promptly to fluid administration and pt is stable. Management?

Answer 35

Penetrating wound in the middle of the neck (zone II) needs surgical exploration even though pt is stable.

Question 36

Gunshot wound to neck, entrance and exit wounds above the level of the angle of the mandible. Steady trickle of blood from both wounds, not responding to local pressure. Pt drunk and combative but otherwise stable. Management?

Answer 36

Angiography is best choice for diagnosis and potential embolization. No tracheal or esophageal involvement possible this high in the neck, pharyngeal injuries inconsequential. Vascular injuries possible, but not easy to explore surgically.

Question 37

Gunshot wound to neck, entrance and exit wounds above the clavicles but below cricoid cartilage. Pt is hemodynamically stable. Management?

Answer 37

Standard workup includes angiography, soluble-contrast esophagogram (followed by barium if negative), esophagoscopy, and bronchoscopy, even in asymptomatic patients. Surgical repair probably indicated.

Question 38

Stab wound to neck in front of sternocleidomastoid at level of thyroid cartilage. Pt asymptomatic, vital signs normal. Management?

Answer 38

Observation for 12 hours (only true for stab wounds of upper and middle zones without symptoms)

Question 39

Pt thrown from vehicle, multiple facial lacerations but otherwise stable, persistent neck pain and tenderness to palpation over posterior midline, neuro exam normal. Management?

Answer 39

AP/lateral cervical spine films (including T1) along with odontoid views. If negative and suspicion remains, then CT scan.

Question 40

Brown-Sequard syndrome (spinal cord hemisection)

Answer 40

Paralysis and loss of proprioception distal to injury on the ipsilateral side to injury, loss of pain perception distal to injury on contralateral side.

Question 41

Burst fracture of vertebral body can produce?

Answer 41

Anterior cord syndrome (loss of motor function and loss of pain and temperature sensation on both sides distal to injury with preservation of vibratory sense and position)

Question 42

Neck hyperextension can produce?

Answer 42

Central cord syndrome (paralysis and burning pain on both upper extremities while maintaining good motor function in legs)

Question 43

Diagnosis and management of spinal cord injuries?

Answer 43

X-rays and CT for looking at cervical bones, MRI for looking at spinal cord, high dose corticosteroids may help minimize permanent damage.

Question 44

Management of rib fracture?

Answer 44

Local pain relief, best achieved by nerve block (NOT strapping or binding). Dangerous in elderly as splinting and hypoventilation lead to pneumonia.

Question 45

Stab wound to right chest, pt moderately short of breath with stable vital signs, no breath sounds on right, hyperresonant to percussion. Next steps?

Answer 45

Plain pneumothorax, diagnosed by CXR, managed with chest tube (high in pleural cavity) to underwater seal and suction.

Question 46

Stab wound to right chest, pt moderately short of breath with stable vital signs, no breath sounds on right at base with faint distant sounds at apex, dull to percussion at base. Next steps?

Answer 46

Hemothorax, diagnosed by CXR, managed with chest tube (at base of pleural cavity) to prevent empyema

Question 47

When does a hemothorax need exploratory surgery?

Answer 47

Recovery of more than 1000-1500 mL of blood by chest tube (indicates systemic or major pulmonary vessel damage, rather than lung parenchyma bleeding), thoracotomy needed to ligate vessel

Question 48

Stab wound to right chest, pt moderately short of breath with stable vital signs, no breath sounds on right, hyperresonant to percussion at apex, dull at base, CXR shows single air-fluid level. Management?

Answer 48

Hemopneumothorax, managed with chest tube at base to make sure blood is drained

Question 49

Management of sucking chest wound?

Answer 49

Needs to be covered to prevent air intake but allow air outflow (vaseline gauze taped on three sides to create a one-way flap), chest tube in hospital

Question 50

Flail chest management?

Answer 50

Rule out aortic rupture and abdominal injuries (CXR, spiral CT, aortogram, sonogram). Treat underlying pulmonary contusion (fluid restriction, diuretics, colloid, respiratory support), NOT mechanical stabilization of chest wall. Bilateral chest tubes if intubation required to prevent tension pneumothorax.

Question 51

Respiratory distress and "white out" on CXR two days post-rib fractures...diagnosis and management?

Answer 51

Pulmonary contusion, managed with fluid restriction (using colloid), diuretics, respiratory support (intubation, mechanical ventilation, PEEP).

Question 52

Pt in automobile collision, gasping for breath, cyanotic at lips, flaring nostrils, tenderness suggestive of multiple fractured ribs. BP 60/45, pulse 160 and feeble, distended neck and forehead veins, diaphoretic. No breath sounds in left hemithorax, hyperresonant to percussion. Diagnosis and management?

Answer 52

Tension pneumothorax caused by penetrating trauma from fractured ribs, managed with needle through upper anterior chest wall followed by chest tube. (NOT CXR FIRST)

Question 53

Management of sternal fracture?

Answer 53

High risk for myocardial contusion and traumatic rupture of aorta. Need ECG, troponins, and arrhythmia control. Spiral CT looking for aortic rupture (also aortogram if widened mediastinum seen on CXR)

Question 54

Pt in automobile collision, in moderate respiratory distress, no breath sounds over entire left chest, percussion unremarkable. CXR shows multiple air fluid levels in left chest. Diagnosis and management?

Answer 54

Traumatic diaphragmatic rupture (always on left), may see NG tube or loops of bowel curling up into left chest. Management is surgical repair.

Question 55

Pt with stable vital signs, multiple extremity fractures, fracture of left first rib and widened mediastinum on CXR. Diagnosis and management?

Answer 55

Traumatic rupture of the aorta (hard-to-break bone plus widened mediastinum), managed with spiral CT and possible aortogram, followed by emergency surgical repair

Question 56

"Hard-to-break" bones

Answer 56

First rib, scapula, sternum

Question 57

Progressive subcutaneous emphysema in upper chest and lower neck?

Answer 57

3 possibilities: esophageal rupture (always after endoscopy), tension pneumothorax, or traumatic rupture of trachea or major bronchus

Question 58

Diagnosis and management of tracheal or bronchial rupture?

Answer 58

CXR showing air in tissues, followed by fiberoptic bronchoscopy and surgical repair

Question 59

Pt with chest tube for traumatic pneumothorax noted to be putting out a very large amount of air through the tube and collapsed lung is not expanding. Diagnosis and management?

Answer 59

Major bronchial injury, diagnosed by CXR and fiberoptic bronchoscopy followed by surgical repair.

Question 60

Sudden cardiac arrest in hemodynamically stable patient with penetrating chest injury who had been intubated, placed on respirator, with appropriate chest tube. Diagnosis and management?

Answer 60

Air embolism from injured bronchus to nearby injured pulmonary vein to LV. Managed with cardiac massage and trendelenburg followed by thoracotomy.

Question 61

Pt with severe blunt trauma including multiple long bone fractures becomes disoriented 12 hrs after admission, developing petechial rashes in axillae and neck, fever, and tachycardia. A few hours later pt has full-blown respiratory distress and hypoxemia. CXR shows bilateral patchy infiltrates, and platelet count is low. Diagnosis and management?

Answer 61

Fat embolism syndrome. Mainstay of therapy is respiratory support, possible benefit seen with heparin, steroids, alcohol, and dextran.

Question 62

When does penetrating wound of abdomen get ex-lap?

Answer 62

Every time, as long as peritoneal penetration is present. Always prepare for surgery with an indwelling bladder catheter, large-bore venous line for fluids, and broad-spectrum antibiotics.

Question 63

Indications for ex-lap in blunt abdominal trauma?

Answer 63

"Acute abdomen" signs of tenderness, guarding, and rebound. Remember solid organs bleed, hollow viscera spill their contents.

Question 64

Who can get a CT scan?

Answer 64

Only hemodynamically stable patients (i.e. those who respond promptly to fluid administration)

Question 65

Evaluation of suspected abdominal bleeding?

Answer 65

CT scan best, if patient is stable; otherwise sonogram in ER or diagnostic peritoneal lavage

Question 66

Most likely source of clinically significant bleeding in patient with blunt abdominal trauma?

Answer 66

Ruptured spleen (look for tenderness over 8th, 9th, 10th ribs on L side)

Question 67

Management of ruptured spleen?

Answer 67

Attempt surgical repair, especially in children. If splenectomy required, need Pneumovax and immunization for Haemophilus influenza B and meningococcus

Question 68

Signs of coagulopathy (oozing blood) in trauma surgery. Management?

Answer 68

Empiric administration of both fresh-frozen plasma and platelet packs

Question 69

When should coagulopathy require immediate surgical closure?

Answer 69

When combined with hypothermia and acidosis

Question 70

What is abdominal compartment syndrome and how is it managed?

Answer 70

Swelling of belly wall and abdominal contents secondary to massive fluid infusion (may see hypoxia and renal failure if abdominal closure has already been done), creating edema in operative area and preventing abdominal closure. Managed by decompression and closing wound with absorbable mesh or nonabsorbable plastic cover to be removed later with proper closure.

Question 71

Management of pelvic hematomas?

Answer 71

If non-expanding and pt hemodynamically stable, leave them alone and rule out associated injuries to bladder, rectum, vagina (PE and Foley); if pt is deteriorating, external fixation of pelvic fracture possible, as is arteriographic embolization.

Question 72

Hallmark and management of traumatic urologic injury?

Answer 72

Blood in urine after trauma, managed with surgical repair.

Question 73

Pelvic fracture plus blood at the meatus in a male. Evaluation and management?

Answer 73

Likely urethral injury, possibly bladder. Evaluate with retrograde urethrogram (urethral injury is compounded by Foley insertion).

Question 74

Pelvic fracture, blood at the meatus, scrotal hematoma, sensation of wanting to urinate but cannot, high-riding prostate on rectal exam. Diagnosis and management?

Answer 74

Posterior urethral injury, evaluated with retrograde urethrogram. Management with suprapubic catheter and delayed urethral repair in 6 months (anterior urethral injuries repaired immediately)

Question 75

Pelvic fracture without blood at the meatus. Resistance met on attempted Foley insertion. Next step?

Answer 75

Back out with the Foley, urethral injury is indicated. Retrograde urethrogram instead.

Question 76

Pelvic fracture without blood at the meatus, easy Foley insertion showing gross hematuria. Diagnosis and management?

Answer 76

Bladder injury, evaluated with retrograde cystogram. If negative, think about kidney injury, evaluated with CT scan.

Question 77

Acute shortness of breath and flank bruit in patient with recent abdominal trauma (~6 weeks) and prior CT showing non-surgical renal injury. Diagnosis?

Answer 77

Traumatic arteriovenous fistula at the renal pedicle leading to subsequent heart failure

Question 78

When and how does traumatic microhematuria need to be investigated?

Answer 78

In children (often represents congenital anomalies), start with sonogram or intravenous pyelogram

Question 79

Boy with scrotal trauma, hematoma the size of a grapefruit, normal urination without hematuria. Evaluation and management?

Answer 79

Need sonogram to look for ruptured testicle. If ruptured, surgery required, otherwise symptomatic treatment.

Question 80

Large penile shaft hematoma with normal appearing glans. Diagnosis and management?

Answer 80

Fracture of tunica albuginea (fracture of corpora cavernosa)...usually have a cover story of slipping in the shower, but actually always happen during sex. Urologic emergency, requires prompt surgical repair.

Question 81

Gunshot wound to thigh, anterolateral entrance, posterolateral embedding of bullet. Management?

Answer 81

No danger of large vessel involvement, needs only wound cleaning and tetanus prophylaxis. Leave the bullet where it is.

Question 82

Gunshot wound to thigh, anteromedial entrance, posterolateral exit. Normal pulses, no hematoma, intact femur. Management?

Answer 82

Likely vascular injury, first step is arteriogram, possibly followed by surgery.

Question 83

Gunshot wound to thigh, anteromedial entrance, posterolateral exit. Large expanding hematoma in upper, inner thigh. Intact femur. Management?

Answer 83

No arteriogram necessary, go straight to surgical exploration.

Question 84

Gunshot wound to arm, medial to lateral path, large hematoma in inner aspect of arm, no distal pulses, radial nerve palsy, shattered humerus. Management?

Answer 84

First stabilize the fracture, then repair the vasculature (both artery and vein if possible), and nerve repair last. Patient will need fasciotomy due to delay in restoring circulation.

Question 85

Crush injury of hand, forearm, and lower arm. Bruising and battering of entire upper extremity, but normal pulses and no broken bones. Concerns and management?

Answer 85

Concerning for myoglobinemia/myoglobinuria/acute renal failure and delayed swelling/compartment syndrome. Manage with fluids, osmotic diuretics (mannitol), and alkalinization of urine to protect kidney. Fasciotomy for compartment syndrome.

Question 86

Chemical injury with alkaline substance. Immediate management?

Answer 86

Copious, immediate, profuse irrigation for at least 30 minutes before coming to ER.

Question 87

Management of electrical burns?

Answer 87

Always much bigger than they appear to be, involving deep tissue destruction, requiring extensive surgical debridement. Beware of myoglobinemia/myoglobinuria/renal failure. Lots of IV fluids, osmotic diuretics (mannitol), alkalinization of urine. Rule out posterior dislocation of shoulder and vertebral compression fractures (from violent muscle contraction) and look for late development of cataracts and demyelinization syndromes.

Question 88

Burns around mouth and nose, inside of mouth looks like a chimney. Management?

Answer 88

Possible CO poisoning, look at caroxyhemoglobin and put pt on 100% O2. Respiratory burns of tracheobronchial tree evaluated with bronchoscopy, blood gas monitoring, treat with respiratory support.

Question 89

Third degree burns from clothing caught on fire. Burned areas dry, white, leathery, anesthetic, and circumferential all around arms and forearms. Concerns and management?

Answer 89

Concern is non-expansion of leathery eschar leading to massive edema and circulation compromise. Management is compulsive monitoring of peripheral pulses and capillary filling, with bedside escharotomy at first sign of compromised circulation. Fasciotomy may be needed for deep wounds.

Question 90

Classic description of second degree burns?

Answer 90

Moist burns with blisters, exquisitely painful to touch.

Question 91

Appearance of third degree burns in kids? In adults?

Answer 91

In kids, deep bright red burns; in adults, white and leathery.

Question 92

Managment of second degree burns?

Answer 92

Silvadene (silver sulfadiazine) cream

Question 93

What is the rule of 9's in burn management for adults?

Answer 93

In the adult, the head is 9% of body surface, each arm is 9%, each leg has two 9%s, and the trunk has four 9%s.

Question 94

What is the threshold for fluid resuscitation in third degree burn management? How much fluid is given and at what initial rate?

Answer 94

Threshold = 20% of body surface area. Fluid (Ringer's lactate) is started at 1000 mL/hr. Total amount of fluid on first day = 4 mL per kg body weight per % burned area up to 50%...plus about 2 L D5W for maintenance. Fine tune according to urine output.

Question 95

What is ideal urine output for a patient being resuscitated after burns?

Answer 95

At least 0.5 mL/kg/hr, ideally closer to 1, and even higher for patients with electrical burns. On day 3 (after IVF is discontinued), expect brisk diuresis as fluid from the burn area re-enters circulation.

Question 96

What is the rule of 9's in burn management for babies?

Answer 96

Two 9's for the head, three 9's for the two legs combined, four for the torso and one for each of the arms.

Question 97

How does fluid resuscitation in burn management change in kids?

Answer 97

Fluid needs are proportionally greater in children, start resuscitation at 20 mL/kg/hr, total amount 4-6 mL/kg/%

Question 98

Management of large burned areas and supportive care beyond fluid resuscitation?

Answer 98

First priority is tetanus prophylaxis. Then suitable cleaning and topical agents, usually silvadene (silver sulfadiazine) cream or mafenide acetate for deep penetration. Use triple antibiotic ointment on the eyes. IV pain meds, eventual grafts after 2-3 weeks, initial NG suction followed by intensive nutritional support via the gut.

Question 99

Management of small third degree burns (<20%)?

Answer 99

Early excision and grafting

Question 100

Child tries to pet a dog while it is eating and gets bitten. Next steps?

Answer 100

Provoked attack. Observe pet for development of signs of rabies, give child tetanus prophylaxis and standard wound care.

Question 101

Man bitten by a coyote. Animal captured and brought to authorities. Next steps?

Answer 101

Kill the animal and examine the brain for signs of rabies. If present, vaccinate patient and give immunoglobulin. If not, tetanus prophylaxis and standard wound care.

Question 102

Man bitten by bats. Animals unable to be captured. Next steps?

Answer 102

Mandatory rabies prophylaxis (immunoglobulin plus vaccine).

Question 103

Signs that a snake is venomous?

Answer 103

Elliptical eyes, pits behind the nostrils, big fangs, rattlers in the tail.

Question 104

Most reliable signs of envenomation?

Answer 104

Excruciating local pain, swelling, and discoloration, usually fully developed within half an hour.

Question 105

Management of envenomation?

Answer 105

Draw blood for typing and crossmatch, coagulation studies, and renal/liver function. Give several vials of antivenin (at least 5, up to 10 or 20). Dose of antivenin is dependent on amount of venom injected, not on size of patient. In extreme cases, surgical excision of bite site and fasciotomy.

Question 106

Girl stung repeatedly by angry bees, developing urticarial rash, wheezing, and hypotension. Next steps?

Answer 106

Epinephrine (0.3-0.5 mL of 1:1000 solution) and removal of stingers.

Question 107

Black widow spider bite signs and management?

Answer 107

Bite from a black spider with a red hourglass on the belly, producing nausea, vomiting, and severe generalized muscle cramps. Antidote is IV calcium gluconate. Muscle relaxants help.

Question 108

Brown recluse spider bite signs and management?

Answer 108

Often in patients who were working in "reclusive" spots (attic, shed, etc.), described as a bug bite that develops into a painful ulceration ~1 cm in diameter with a necrotic center and surrounding halo of erythema. Management is with dabsone, possibly local excision and grafting once extent of damage is obvious.

Question 109

Signs and management of "human bites"?

Answer 109

Small, 1 cm deep sharp cut over the knuckle with a cover story (usually from punching someone in the mouth). Human bites are the dirtiest bacteriologically and need surgical exploration.