trauma continued

Question 1

gunshot wound to abdomen. Next steps?

Answer 1

exploratory lapartoomy for repair of intraabdominal injuries (not necessarily to remove the bullet). Any entrance or exit below the nipple line is said to involve abdomen.

Question 2

stab wound with protruding viscera or HD instability or signs of peritoneal irritation. What about what the two above?

Answer 2

if you have either clear penetration or HD instability or peritoneal irritation-> exploratory laparotomy. if not, exploration of wound in ER (gentle insertion of gloved finger) and observation. If unclear digital exam, get CT scan.

Question 3

how much blood do you have to lose to have drop in BP, fast thready pulse, low CVP, low UP.

Answer 3

25-30% of blood volume. 1500mL. places where this amount could hide are abdomen, thighs, and pelvis.

Question 4

how to make dx of intrabdominal bleeding in HD stable pt? in HD unstable pt?

Answer 4

HD stable: do CT scan. HD unstable: diagnostic peritoneal lavage or FAST exam.

Question 5

blunt abdominal trauma-> left rib fx-> bleeding. why? next steps?

Answer 5

spleen rupture. every effort is made to repair it given the immunologic function, especially in children. if you have remove it, need post op immunization against encapsulated bacterior- pneumococcus, H. flu, meningococcus

Question 6

intrap development of coagulopathy during proloned abdominal surgery for multiple trauma with multiple transfusions. tx?

Answer 6

treat empirically with platelet packs and FFP, approximately 10 units of each.

Question 7

intrap development of coagulopathy and hypothermia and acidosis during proloned abdominal surgery for multiple trauma with multiple transfusions. tx?

Answer 7

close the laparotomy promptly with packing of bleeding surfaces and temporary closure. the operation can be resumed later when the pt has been warmed and the coagulopathy treated.

Question 8

prolonged laparotomy and you have given lots of fluid and blood. what do you worry about? solution?

Answer 8

abdominal compartment syndrome. all the tissues are swollen and the abdominal wall cannot be closed without undue tension. solution: temporary cover placed over abdominal contents.

Question 9

pt s/p abdominal surgery and lots of fluids. POD2: dissension, retention sutures cutting through tissue, hypoxia secondary to inability to breathe, renal failure form pressure on vena cava. tx?

Answer 9

abdominal compartment syndrome that develops after surgery. tx: abdomen opened and temporary cover

Question 10

pelvic fracture. how do you rule out associated injuries?

Answer 10

rectal exam and proctoscopy, bladder test, pelvic exam in women, retrograde urethrogram in men

Question 11

man with pelvic fracture, blood at the urethral meatus, scrotal hematoma, high riding prostate on pelvic exam, sensation of wanting to void but not being able to do so. next steps?

Answer 11

urethral injury. DONT PUT IN FOLEY. do retrograde urethrogram.

Question 12

how to evaluate bladder injury

Answer 12

retrograde cystogram. x-ray must include postpaid films, to see exztraperitoneal leaks at the base of the bladder that might be obscured by bladder full of dye. if the latter are found, can be treated by placing a Foley. for intraperiotneal leaks, surgical repair is done and protected with a suprapubic cystostomy

Question 13

lower rib fracture. CT scan shows renal injury. patient then develops CHF. why?

Answer 13

injury to renal pedicale-> AV fistula-> CHF

Question 14

blunt renal injury-> renal artery stneosis

Answer 14

renovascular HTN

Question 15

next steps for very large scrotal hematoma

Answer 15

do not need specific intervention unless testicle is rupture. the latter can be assessed with sonogram.

Question 16

embarrassed man says that toilet seat lid fell on him. large penile shaft hematoma with normal appearing glans.

Answer 16

fracture of the penis (corpora cavernous, tunica albuginea) from vigorous sex (woman on top). emergency surgical repair- if not done, impotence will develop as AV shunts develop

Question 17

penetrating injury of extremities near major vessels.

Answer 17

if asymptomatic, do doppler studies or CT angio. if obvious vascular injury (absent distant pulses, expanding hematoma), surgical exploration needed.

Question 18

combined injury of artery, nerve and bone in extremity injury.

Answer 18

stabilize bone first, then do delicate vascular repair, leave nerve for last. d fasciotomy because prolonged ischemia can lead to compartment syndrome.

Question 19

crushing extremity injury_. hyperkalemia, myoglobinemia, myoglobinuria, renal failure. next steps?

Answer 19

vigorous fuid administration, osmotic diuretics, alkalinization of urine are good preventive measures

Question 20

next steps for chemical burn

Answer 20

irrgiation as soon as possible where incur occurred. don’t try to neutralize the agent. alkaline burns are worse than acid burns

Question 21

high voltage electrical burns. concerns? tx?

Answer 21

always deeper and worse than they appear to be. massive debridements or amputations may be required. also concern for myoglobinemia-myoglobinuria renal failure. give plenty of fluids and osmotic diuretics. concern for ortho injury secondary to muscle contractions and late development of cataracts and demyelinization syndromes

Question 22

pt after flame burn in a care with burns around mouth o soot inside the throat.

Answer 22

suspect respiration burns. dx confirmed with fiberoptic bronchoscopy. key issue: need for respirator? check blood gas. intubate if worried about adequacy of airway. monitor levels of carboxyhemoglobin and if elevated, 100% oxygen will shorten its half life.

Question 23

circumferential burn of extremity or chest. concern?

Answer 23

can lead to cutoff of the blood supply as edema accumulates underneath the unyielding eschar. need escharotomy (at bedside with no need for anesthesia) to immediately provide relief. in chest, concern for mechanical problem with breathing.

Question 24

fluid goals after burn

Answer 24

usually start with 1L/hr LR in adult and then adjust to have hourly urinary output of 1-2 ml/kg/hr, while avoiding CVP>15mmHg.

Question 25

wha type of fluids to give in burns

Answer 25

start with LR (without sugar to avoid osmotic diuresis from glycosuria).

Question 26

use of topical agents in burns. standard?

Answer 26

standard= silver sulfadiazine.

Question 27

topical agent for burn with deep penetration required, such as in thick eschar or cartilage

Answer 27

mafenide acetate. do not use it anywhere else bc it hurts can produce acidosis

Question 28

burn near eye. topical ointment?

Answer 28

triple antibiotic ointment- silver sulfadiazine is irritating to the eyes

Question 29

nutrition/pain meds in burn care

Answer 29

early period- all pain meds are given IV. after a day or two of NG suction, give intensive nutritional support, preferably via the gut, with high calorie/high nitrogen diets.

Question 30

grafting in burn wounds.

Answer 30

concept of early excision and grafting whenever possible to minimize pain, suffering, and complications. Removal in OR on day 1 of burned areas with immediate skin grafting for fairly limited burns under 20% that are obviously 3rd degree. After 2-3 weeks, graft wounds that have not yet regenerated

Question 31

unprovoked dog bite

Answer 31

if animal is available- kill and examine brain for signs of rabies. otherwise rabies ppx is mandatory- immunoglobulin plus vaccine

Question 32

snake bite envenomation. next steps? tx?

Answer 32

up to 30% of bitten pts are no envenomated. reliable signs: severe local pain, swelling, discoloration within 30 minutes of bite. if present, draw blood for typing and crossmatch, coagulation studies, liver and renal function. tx: antivenin with CROFAB (several vials related to size of envenomation, not size of pt). can splint extremity during transport but no surgery or fasciotomy.

Question 33

bee sting wheezing and rash and hypotension tx

Answer 33

epinephrine 0.3-0.5 mL of 1:1000 solution. remove stingers without squeezing them.

Question 34

black widow spider. sxs? tx?

Answer 34

black, with red hourglass on belly. sxs: n/v severe generalized muscle cramps. tx: calcium gluconate. muscle relaxants help.

Question 35

1 day s/p hiking, pt gets a skin ulcer with a necrotic center and surrounding halo of erythema.

Answer 35

brown recluse spider bites. dapsone is helpful. surgical excision may be needed but should be delayed as much as one week until full extent of damage is visible. skin grafting may be needed.

Question 36

dirtiest bites? next steps?

Answer 36

human bites. extensive irrigation nd debridement in the OR. need specialized oath care. e.g.: sharp cut on knuckles.

Question 37

a patient with pyloric obstruction has vomiting-> K is 2.9. how to best rehydrate him

Answer 37

normal saline with KCl

Question 38

young man is shot point blank in the lower abdomen, just above pubis. he has gross hematuria and no evidence of recent injury. evaluation of hematuria would be best done by

Answer 38

exploratoy lapartomy (for penetrating urological injury)

Question 39

18 year old man is in a car accident and gets an broken leg ORIF. he is then found to have microscopic hematuria. next steps.

Answer 39

if after trauma, don’t need to work up hematuria, especially in young patient. otherwise you have to rule out cancer of kidney, ureter or bladder by CT scan-> cystoscopy.

Question 40

26 yo woman sustains multiple injuries in a car accident including a pelvic fracture. initial evaluation shows normal vital signs and no vaginal or rectal injuries. when a foley is inserted, bloody urine is recovered. the best way to evaluate her urological injury would be? next steps?

Answer 40

retrograde cystogram including post void films. need to see experitoneal leaks at the base of the bladder that might be obscured by the bladder full of dye. if they are found, they can be treated by putting a foley in. for intraperitoneal leaks, surgical leaks done and protected with a suprapubic cystostomy.

Question 41

dehydrated man with serum sodium of 155. how to correct his problem?

Answer 41

every 3 meq/L that serum sodium is above 140 represents 1 L of fluid lost. 5L for this man. correct volume rapidly but nudge tonicity by using D5 1/2NS. infused over 6 hours?