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ABSITE > trauma & cric care > Flashcards

trauma & cric care Flashcards

1
Q

Crash 3 trial

A

TXA is safe in patients with traumatic brain injury and that treatment within 3 hours of injury reduces head injury–related death.

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2
Q

TXA dosing?

A

1g within 3 hours then
1g given over 8 hours

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3
Q

PROMMTT study

A

early administration of balanced blood products leads to a decreased 6-hour mortality rate

1:1:1 red blood cells:platelets:plasma is recommended

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4
Q

LD50 fall from height

A

4 stories

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5
Q

indication for hemostatic resucitation?

A

4+ U RBC in 1 hour
or 10+U in 24 hours

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6
Q

timing of acute traumatic coagulopathy?

A

immediate, happens before ED arrival.

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7
Q

FAST locations?

A

perihepatic (MC to see blood), perisplenic, pelvis, pericardium (START WITH PERICARDIUM)

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8
Q

when to use low v high frequency FAST US?

A

low: good for tissue penetration
high: good for resolution

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9
Q

FAST cannot detect fluid < ?

A

<80 cc.

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10
Q

FAST scan misses what?

A

hollow viscus injury, rp bleeding

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11
Q

when is local wound exploration OK in penetrating abdominal trauma?

A

if no fascial violation (after ruled out peritonitis/evisceration)

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12
Q

bladder pressure in abdominal compartment syndrome?

A

25-30 mm Hg.

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13
Q

ED thoracotomy

A

4th or 5th IC space
open pericardium ant to phrenic
cross clamp aorta; watch anterior esophagus

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14
Q

epidural (lenticular) or subdural (crescent) hematoma OR indication?

A

midline shift > 5 mm

epidural > 15mm

sundural >10mm

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15
Q

MC bleed in head trauma?

A

Intraparenchymal hemorrhage.

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16
Q

normal cerebral perfusion pressure

A

60+ mm Hg

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17
Q

Cerebral perfusion pressure calculation?

A

CPP = MAP - ICP

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18
Q

Main regulator of CPP?

A

PaCO2 (this autoregulation is lost in TBI)

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19
Q

normal ICP?

A

10 mm Hg (keep <20 mm Hg)

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20
Q

Co2 and Na goals in increased ICP?

A

CO2 (relative hyperventilation) 30-35 pCO2
Na goal 140-150

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21
Q

mannitol in increased ICP? Side effect?

A

1 g/kg; give 0.25 mg/kg q4h after that

Side effect: HYPOTENSION

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22
Q

ICP monitor indication and types?

A

GCS < 8 with abnormal CT.

Ventriculostomy into ventricle.
BOLT into parenchyma. (cannot drain CSF)

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23
Q

Golden rule of Head Trauma?

A

Avoid HYPOtension and HYPOxia (to avoid secondary brain injury and HYPER&HYPOglycemia

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24
Q

Cushing’s in increased ICP

A

bradycardia (intermittent = impending herniation)
hypertension
low respiratory rate

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25
Q

How to quickly treat increased ICP?

A

HOB 30 elevation, ventilate to CO2 35, mannitol, HTS, sedate, paralyze.

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26
Q

when is peak ICP due to swelling?

A

48-72 hours

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27
Q

raccoon eyes

A

peri orbital ecchymosis (anterior fossa fracture = basal skull fx)

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28
Q

battle sign

A

mastoid ecchymosis (middle fossa fx = basal skull fx)
look for facial nerve injury

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29
Q

Adjuncts to give in head trauma?

A
  1. Keppra x 1 wk BID for EARLY Sz ppx
  2. EARLY feeding 24-48hr
  3. Correct COAGULOPATHY

Avoid steroids.

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30
Q

CM site of facial injury in temporal skull fx?

A

geniculate ganglion

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31
Q

nerves affected in temporal skull fx?

A

VII and VIII.

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32
Q

coagulopathy with TBI?

A

release of tissue thromboplastin

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33
Q

Jefferson fracture = C1 BURST FX

A

caused by axial loading
tx: rigid collar
tx burst fx = spinal fusions

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34
Q

Hangmans fx = C2 fx

A

caused by distraction/extension
tx: traction and halo

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35
Q

dens

A

odontoid process

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36
Q

thoracolumbar spine columns

A

anterior: ALL to ante 1/2 vert body
middle: post 1/2 to PLL
posterior: facets, lamina, spinous processes, interspinous ligaments

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37
Q

compression = wedge fx (spine)

A

typically anterior column
tx: TLSO

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38
Q

upright fall injuries

A

calcaneus, lumbar, wrist/forearm injuries

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39
Q

lefort I

A

max fracture straight across
tx: reduction, stabilization, possible wires

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40
Q

lefort II

A

lateral to nasal bone, diagnoal toward maxilla
tx: reduction, stabilization, possible wires

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41
Q

lefort III

A

lateral orbital walls
tx: suspension wiring

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42
Q

nasoethmoidal orbital fx

A

70% have CSF leak (tau protein)… try to wait it out 2 wks then may need epidural catheter or surgical dura closure

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43
Q

mgmt posterior nose bleed (INTERNAL MAXILLARY ARTERY>ethmoidal)

A

angioembolization or foley catheter

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44
Q

neck zone I

A

clavicle to cricoid

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45
Q

neck zone II

A

cricoid to angle of mandible

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46
Q

neck zone III

A

angle of mandible to base of skull

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47
Q

which zone MUST YOU ALWAYS OR?

A

zone 2.

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48
Q

traumatic esophageal or hypopharyngeal repair leak rate?

A

20%; leave drains next to all

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49
Q

traumatic thyroid injury?

A

suture bleeders and DRAIN. don’t resect.h

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50
Q

where can you reimplant the RLN if injured traumatically?

A

into cricoarytenoid muscle

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51
Q

what % of common carotid ligation leads to stroke?

A

20%

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52
Q

Thoracotomy indication after CTb?

A

1.5L initial, 200cc/hr x 4 hours

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53
Q

mgmt of sucking PTX

A

(>2/3 diameter of trachea); cover with gauze taped on 3 sides

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54
Q

Flail chest dx

A

3+ consec ribs broken at 2+ sites
can have 48 hours of good before resp decomp

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55
Q

Treatment flail chest?

A

Supportive
Consider epidural
Consider PPV (contusions cause respiratory compromise)
Consider plating if not improving

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56
Q

traumatic diaphragmatic hernia repair appraoch?

A

acute < 1 wk: transabdominal
chronic >1wk: chest to bring down adhesions

strangulation can occur at any time.

consider PTFE mesh

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57
Q

what % of aortic tears will show on XR?

A

5%. need CTA.

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58
Q

distal R SCA injury approach?

A

midclavicular incision with resection of medial clavicle

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59
Q

cause of death after myocardial contusion?

A

Vtach and Vfib, esp in first 24 hours.

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60
Q

MC arrhythmia overall in myocardial contusion?

A

SVT.
MC finding is ST or PVCs

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61
Q

consider aortic transection with which rib fx?

A

1st and 2nd.

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62
Q

pelvic fx type I

A

unstable (CRUSH)
20-30% mortality; 10+U EBL, high complication risk

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63
Q

pelvic fx type II

A

unstable (noncrush)
8-12% mortality, 2-10U EBL, med complication

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64
Q

pelvic fx type III

A

stable <5% mortality, 1-4U EBL, 10-20% complications

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65
Q

anterior pelvic fx manifestation?

A

venous bleeding mostly from pelvic venous plexus
tx: just tamponade

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66
Q

posterior pelvic fx manifestation?

A

more likely arterial….

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67
Q

MC associated injury with pelvic fx in trauma?

A

head injury

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68
Q

pelvic fx open book mgmt

A

stable: angiography
unstable: preperitoneal packing in OR

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69
Q

MC traumatic injury to duo?

A

D2 > LoT

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70
Q

intraop duodenal hematoma?

A

mostly at D3 (overlying spine); need to open if 2+cm any mechanism.

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71
Q

CT scan finding on old paraduodenal hematoma?

A

stacked coin or coiled spring; presents as SBO
tx: NGT TPN until hematoma resorbed.

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72
Q

traumatic duodenal injury?

A

try to primarily repair.
consider pyloric exclusion and GJ, consider J tube, place many drains.

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73
Q

if D2 and can’t primarily repair?

A

jejunal serosal patch until Whipple
need pyloric eclusion and GJ, J tube

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74
Q

trauma whipple

A

don’t do it.

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75
Q

MC organ injured in penetrating abdominal trauma?

A

small bowel > liver

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76
Q

what circumference and lumen diameter to consider bowel resection and anastomosis in traumatic injury?

A

50% circumference and 1/3 lumen diameter.

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77
Q

hematomas to explore in OR?

A

2cm+ (mesenteric, duodenal, etc.)

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78
Q

R and T colon injuries?

A

primarily repair if <50% circumference injured and without devascularization. no diversion.

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79
Q

L colon injury and intraabdominal rectum mgmt?

A

primary without diversion < 50% and no devascularization.

if colectomy/LAR required, DLI if gross contamination, 6 hrs to repair, 6+U RBC given.

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80
Q

extraperitoneal rectal injury

A

midde rectum: end colostomy only without APR (rly hard to reach)

low rectum: primarily with transanal approach & end colostomy only without APR if cannot access it or too hard to primarily repairx

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81
Q

MC organ injured in blunt abdominal trauma?

A

liver > spleen.

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82
Q

portal triad hematoma?

A

explore all.

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83
Q

retrohepatic IVC Injury? how to perfuse while repairing?

A

can place an atriocaval shunt.

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84
Q

traumatic CBD injuyr?

A

<50%: repair over stent.
>50%: choledochojejunostomy
consider IOC

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85
Q

portal vein injury

A

repair with lateral venorrhaphy
may need to perform distal panc to get to portal vein

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86
Q

mortality with ligation of portal vein

A

50%.

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87
Q

pringle maneuver clamp time?

A

15-20 min.

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88
Q

indication to OR or IR for stable blunt liver injury?

A

4+U RBC or becomes unstable.

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89
Q

bed rest in liver or splenic injury, blunt?

A

5 days.

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90
Q

postsplenectomy sepsis highest risk after splenectomy?

A

2 yrs

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91
Q

timing of vax postsplenectomy?

A

pneumococcus
meningococcus
H. flu
within 30 days after splenectomy (best if before discharge)

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92
Q

indication to OR or IR for stable splenic injury?

A

2+U RBC or becomes unstable

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93
Q

pancreatic injury mgmt?

A

only operative if duct is involved.
any hematoma needs to be explored.

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94
Q

pancreatic duct injury managment?

A

if close to SMV, need to placed drains and Whipple later
if far from SMV, distal panc

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95
Q

major signs of vascular injury?

A
  1. active hemorrhage
  2. pulse deficit
  3. expanding/pulsatile hematoma
  4. distal ischemia
  5. bruit or thrill
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96
Q

minor signs of vascular injury?

A
  1. hx hemorhage
  2. large stable/nonpulsatile hematoma
  3. ABI < 0.9
  4. unequal pulses …

they all need CTA.

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97
Q

when GSV graft needed?

A

2+cm defect in vessel.

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98
Q

indication for fasciotomy?

A

ishcemia > 4-6 hrs

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99
Q

compartment syndrome dx?

A

20+mm Hg in compartment
6 P’s
pulselessness
pain
paresthesia
paralysis
poikilothermia
pallorh

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100
Q

how to access posterior wall injury to IVC?

A

cut into anterior wall and repair through anterior approach.

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101
Q

all knee dislocations need what vascular study?

A

formal angiogram unless pulse absent.. then just go to OR

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102
Q

anterior shoulder dislocation associated injury?

A

ax nerve

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103
Q

prox humerus fx injury?

A

ax nerve

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104
Q

posterior shoulder dislocation injury?

A

ax artery

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105
Q

midshaft humerus fx or spiral humerus fx injury?

A

radial nerve.

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106
Q

distal supracondylar humerus fx

A

brachial artery

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107
Q

elbow dislocation injury?

A

brachial artery

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108
Q

distal radius fx

A

median nerve

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109
Q

anterior hip dislocation injury?

A

femoral artery & fem fx

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110
Q

posterior hip dislocation injury?

A

sciatic nerve, peroneal nerve/injury

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111
Q

distal supracondylar femur fx

A

pop artery

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112
Q

posterior knee dislocation injury?

A

pop artery

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113
Q

fibula neck fx

A

peroneal nerve

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114
Q

hematuria in trauma

A

all need CT scan.

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115
Q

L renal vein ligation?

A

near IVC is fine.. has adrenal and gonadal collaterals unlike R RV.

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116
Q

Ant to post renal hilum?

A

vein, artery, pelvis. VAP.

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117
Q

meatal or scrotal hematoma/bleeding?

A

need CT cystogram

extraperitoneal: starbursts. (just need FOLEY)
intraperitoneal: leak seen (need OR and FOLEY)b

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118
Q

bladder injury… mostly blunt or pen?

A

mostly blunt. (pelvic fx lacerates)

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119
Q

ureteral trauma… mostly blunt or pen?

A

mostly penetrating.

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120
Q

how to dx ureteral trauma?

A

IVP (multishot) or retrograde pyelogram.

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121
Q

traumatic upper or middle third ureteral injury > 2cm?

A

perc nephrostomy, tie off both ends of defect
later: ileal conduit or tran UUostomy

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122
Q

traumatic lower third ureteral injury > 2cm?

A

reimplant +/- hitch.

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123
Q

<2cm upper and middle ureteral injury?

A

primary over stent

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124
Q

<2cm lower third ureteral injury?

A

reimplant into bladder

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125
Q

blood supply location to ureter?

A

upper 2/3: medial
lower 1/3: lateral

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126
Q

drainage after ureteral injury repair?

A

all need DRAINS.

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127
Q

urethral injury suspected over bladder? (free floatig prostate, scrotal hematoma, pelvic fx, meatal blood)

A

need RUG.

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128
Q

mgmt urethral trauma: anterior vs posterior, small vs large

A

Anterior, small: explore, debride, primary closure over foley catheter
Posterior: perc suprapubic catheter drainage

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129
Q

genital trauma

A

erectaile body fx… may need to repair tunica albuginea or Buck’s fascia

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130
Q

pediatric trauma vital sign considerations?

A

increased risk of hypothermia, increased risk head injury, BP is not good indicator of shock (last thing to go)

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131
Q

respiratory changes in pregnant mom

A

CHRONIC COMPENSATED RESP ALKALOSIS
increased Tv, decreased FRC, increased O2 consumption

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132
Q

blood loss permitted in pregnant lady before sx seen?

A

1/3 total loss without signs!

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133
Q

Rhogam in pregnant trauma?

A

RhoGAM if mother Rh- (in case baby +)

look for fetal blood cells in mom blood. “Kleihauer Betke test” = preterm labor associated with placenta abruption

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134
Q

fetal maturity dx?

A

lecithin:sphingomyelin LS ratio > 2:1
positive phosphatyidylcholine in amniotic fluid

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135
Q

Fetal monitoring at what week gestation?

A

24 weeks+

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136
Q

MC cause placental abruption in trauma setting? 50% will die.

A

shock > mechanical forces

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137
Q

zone 2 hematoma penetrating vs blunt?

A

explore all PEN, explore if BLUNT expanding

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138
Q

zone 1 hematoma

A

explore all (PEN AND BLUNT)

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139
Q

zone 3 hematoma

A

probably just angioembolize (pelvic)

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140
Q

black widow bite

A

n/v, cramps
treat: IV calcium gluconate, muscle relaxants, morphine if no cramp

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141
Q

brown recluse spider bite

A

skin ulcer with necrotic center and surrounding erythema
treat: dapsone, skin graft NO ANTIVENIN LIKE BLACK WIDOW OR CORAL SNAKE

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142
Q

human bite ppx?

A

yes. Augmentin

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143
Q

viperidae snake bite presentation

A

hematologic effects
thrombocytopenia, coagulopathy, and DIC
Rhabdomyolysis and compartment syndrome

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144
Q

elapidae snake bite

A

toxic neurologic effects
irreversible binding at the acetylcholine receptors
generalized weakness and fasciculations
respiratory paralysis and death

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145
Q

every bite needs?

A

tetanus

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146
Q

cat bite

A

needs 3-5 days of ppx abx and irrigation

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147
Q

EF ejection fraction equation?

A

SV/LVEDV

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148
Q

atrial kick percentage of LVEDV?

A

20%

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149
Q

anrep effect

A

automatic increase in contractility secondary to increased afterload

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150
Q

bowditch effect

A

automatic increase in contractility secondary to increased HR

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151
Q

normal O2 delivery to consumption ratio

A

4:1

152
Q

right shift (decreased affinity) on oxygen-hemoglobin dissociation curve.

A

increase CO2 (bohr effect)
increase temp
increase ATP
increase 2 3 DPG
decrease pH

153
Q

where to place swan ganz catheter

A

zone III; lower lung (less resp influence)

154
Q

swan ganz hemoptysis

A

pulmonary artery bleed…
1. mainstem
2. fogarty affected side or thoracotomy/lobectomy

155
Q

only absolute contraindication to swan ganz?

A

mechanical heart valve on RIGHT side

156
Q

distance to wedge. RSV R IJ, LSVC L IJ

A

R SCV: 45 cm
R IJ 50 cm
L SCV 55 cm
L IJ 60 cm

157
Q

when to calculate the wedge pressure

A

at end expiration.

158
Q

determinant for myocardial oxygen consumption

A
  1. ventricular wall tension&raquo_space;» heart rate
159
Q

normal alveolar-arterial gradient?

A

10-15 mm Hg

160
Q

blood with highest and lower oxygen saturation

A

coronary sinus blood LOWEST
renal veins HIGHEST

161
Q

Classes of hemorrhagic shock?

A

I: 0-15% (no signs)
II: 15-30% (tachycardic, narrow PP)
III: 30-40% (hypotension)
IV: >40%

162
Q

hemorrhagic shock
effect on wedge, CO, SVR?

A

decrease wedge, decrease CO, increase SVR

163
Q

septic shock
effect on wedge, CO, SVR?

A

decrease wedge, increase CO, decrease SVR

164
Q

cardiac shock
effect on wedge, CO, SVR?

A

wedge increase, decrease CO, increase SVR

165
Q

neurogenic shock
effect on wedge, CO, SVR?

A

wedge decrease, decrease CO, decrease SVR

166
Q

adrenal insufficiency
effect on wedge, CO, SVR?

A

wedge decrease, decrease CO, decrease SVR

167
Q

Becks triad

A

hypotension, muffled heart sounds. jugular venous distension

168
Q

pulsus paradoxus

A

in cardiac tamponade;
decrease 10mm+ SBP with inspiration

169
Q

early sepsis triad?

A

hyperventilation, confusion, hypotension

170
Q

sudan red stain for fat embolism

A

can light up fat in sputum and urine

171
Q

Fat embolism sx?

A
  1. Petechial rash
  2. AMS
  3. Resp distress
172
Q

2 criteria for fat emboli dx?

A

Gurd & Wilson’s (2 major, or 1 maj+4min)
Schoenfeld (5+ = dx)

173
Q

mgmt fat emboli?

A

supportive only

174
Q

positioning for air embolus?

A

left lateral decubitus; keep air in the R heart

175
Q

iABP placement

A

tip distal to L SCA 1-2 cm below top of arch; infaltes on T wave (diastole), deflates on P wave (systole)

176
Q

dobutamine receiptors?

A

B-1 (increase contractility)

177
Q

dopamine receptors?

A

DA (renal), B-adrenergic (increase contractility), a-adrenergic (increase BP)

178
Q

milrinone receptors?

A

phosphodiesterase inhibitro (increase cAMP)
increase Ca and contractility… cause vascular smooth muslce relaxation and pulm vasodilation

179
Q

neo MOA

A

a-1 vaoconstriction

180
Q

levo MOA

A

a1 and a2&raquo_space; B1

181
Q

epi MOA

A

B1 and B2 –> a1 and a2 (high doses)

182
Q

isoproterenol MOA

A

B1 and B2
very arrhythmiogenic

183
Q

nipride MOA

A

arterial vasodilator…
check thiocyanate levels for toxicity

184
Q

nipride toxicity mgmt

A

amyl nitrite then sodium nitrite

185
Q

weaning parameters for extubation?

A

NIF > 20
FiO2 < 40%
PO2 > 60
PCO2 < 50
7.3507.45
can follow commands

186
Q

total lung capacity

A

FVC + RV

187
Q

FVC forced vital capacity

A

maximal exhalation after maximal inhalation

188
Q

RV

A

lung volume after maximal expiration (20% TLC)

189
Q

functional residual capacity FRC

A

lung volume after normal exhalation ERV + RV

190
Q

ERV vs IRV

A

additional inspired or expired after normal tidal volume

191
Q

restrictive lung disease FEV1

A

can be normal with decrease FVC

192
Q

obstructive lung disease FEV1

A

decreases, with normal FVC

193
Q

dead space vs shunt

A

dead space is ventilated and not perfused
high V/Q dead space increase PCO2

shunt is perfused. decreased PO2 low V/Q

194
Q

ARDS criteria

A

acute onset
bilateral pulmonary infiltrates
PaO2/FiO2 < 300
absence of heart failure; wedge < 18 mm Hg

195
Q

phases of ARDS

A
  1. EXUDATIVE: proteinaceous fluid into alveolar space (WBC in, oxygen can’t get in)
  2. FIBROPROLIFERATIVE: fibrosis and collagen formation = noncompliant
    this is REVERSIBLE
  3. RESOLUTION: remodeling and clearing the edema
196
Q

mendelsons syndrome in aspiration?

A

chemical pneumonitis from aspiration of gastric secretions

197
Q

MC site of aspiration?

A

sup seg RLL

198
Q

how much renal destruction before renal dysfunction occurs?

A

70%

199
Q

best to diagnose and find etiology for azotemia

A

fena
urine Na/Cr / plasma Na/Cr
>3% parenchymal
<1% prerenal

200
Q

MC cause of renal ATN and postop low UOP?

A

intraop hypotension

201
Q

renin released why?

A

decrease BP (JG apparatus) and hypernatremia (macula densa), hyperkalemia, B-adrenergic stimulation

202
Q

where does aldosterone act after stim in cortex by ace II

A

DCT to reabsorb water by upregulating NaK ATPase on membrane

203
Q

ang II autoregulation

A

vasoconstricts and inhibits renin release

204
Q

ANP atrial naturetic peptide

A

released from atrial wall when distended
inhibits na and water resorption and is a vasodilator

205
Q

what stimulates posterior pituitary gland to release ADH?

A

high osmolality; increase water resorption at CDs

206
Q

SIRS

A
  1. temp <36, ,>38
  2. HR > 90
  3. RR > 20 or PAcO2 < 32
    WBC > 12 or <4
207
Q

brain death exam requirements

A

unresponsive to pain, absent cold caloric oculovestibular reflexes, absent oculocephalic reflex (no tracing), no spontaneous respirations, no corneal reflx, no gag reflex, fixed and dilated pupiles, positive apnea

208
Q

DTR in brain death

A

can still be present

209
Q

apnea test

A

CO 2 > 60 mm Hg or increase by 20 mm Hg after 10 min disconnection

SCORE: “repeat ABG 8 min showing the above^”

210
Q

CO affinity for Hgb compared to o2

A

250 stronger

211
Q

CO affect on Hgb dissociation curve

A

left shift

212
Q

abnl carboxyHgb in smokers vs normal

A

20% vs 10%

213
Q

methemoglobinemia cause

A

nitrites (hurricaine spray, fertilizer, nitrites)

214
Q

mgmt methemoglobinemia

A

methylene blue

215
Q

methemoglobinemia sat O2?

A

85%

216
Q

mgmt cyanide toxicity

A

amyl nitrite then Na nitrite, or hydroxycobalamin

217
Q

TRICC trial

A

Transfusion Requirements in Critical Care (TRICC) trial
only transfuse > 7 g/dL

218
Q

UTI dx on UA; LE and nitrites?

A

Leukocyte esterase is directly related to #WBC; may be negative in patients with recent Foley catheter insertion.

Nitrites are a by-product of nitrate metabolism by Enterobacteriaceae and do not accurately account for Staphylococcus, Enterococcus, or Candida spp.

219
Q

Decrease CAUTI?

A

48 hours max.

220
Q

STOPIT trial

A

antibiotic treatment for 4 days = 10 days of therapy

primary endpoint of the study:
surgical site infection
recurrent intra-abdominal infection
deaths

221
Q

how much Ca to infuse with transfusion?

A

If 10% calcium gluconate is used, 10 to 20 mL should be infused per 500 mL of blood transfused.
If 10% calcium chloride is used, only 2 to 4 mL should be infused per 500 mL of blood transfused.

222
Q

how to minimize tracheal stenosis after prolonged intubation

A

maintain trach cuff pressures < 30 mm Hg
small ETT size

223
Q

femoral vein localization/identification on US
use GSV

A

medially/distally: GSV find. trace up to femoral vein can be a useful confirmatory maneuver.

224
Q

best pacing mode for intraop

A

‘OO’ - asynchronous

225
Q

delirium after OR; risk factor

A

MMSE mild dementia < 25 score

226
Q

amanita mushroom causing acute liver failurew

A

Cerebral edema and intracranial hypertension are unique to acute liver failure (ALF) – neurologic exams

The coagulopathy should not be corrected unless the patient is spontaneously bleeding, which is very rare. Unless going to OR for CNS.

227
Q

dpl op note

A

open cut down vs Seldinger
10 cc of blood/bile/food is +
1L of warm saline in adult
10 cc/kg in children
drain to gravity
if 100K RBC or 500 WBC or bacteria, bile/food.. POSTIIVE DPL.

228
Q

dpl contraindication

A

pregnancy, unstable, previous abdominal operations, pelvic ring fracture** though last two are relative conrtraindications

229
Q

damage control operation indication

A

<34C
>12L or 10U x 24 hours
Base Def > 15
pH < 7.2

230
Q

Cricothyroidotomy landmarks?

A

Triangle with cricothyroid muscle “V” below and cricoid cartilage below.
Superiorly thyroid cartilage.

231
Q

Pupillary exam abnormalities and their meanings?

A

Fixed and dilated unilaterally: IPSILATERAL blood compressing CN II.

Bilateral pinpoint pupils: PONTINE hemorrhage.

232
Q

Rapid warfarin reversal?

A

PCC.

Can give FFP and Vit K.

233
Q

Central cord syndrome?

A

CAPE/GLOVE weakness (UE)

2/2 spinal stenosis.

234
Q

Brown Sequard syndrome?

A

IPSILATERAL motor, CONTRALATERAL pain/temperature.

Hemisection 2/2 SW

235
Q

Anterior cord syndrome?

A

MOTOR deficit alone.

2/2 vascular injury to anterior spinal artery

236
Q

SCIWORA?

A

Spinal cord injury without radiographic abnormality.

in peds.

237
Q

Spinal shock vs neurogenic shock?

A

Spinal: SENSORY/MOTOR (not hemodynamics)
- absent bulbocavernosus and cremasteric reflex
- functions can return with spinal shock so if reflexes are GONE, then all deficits are permanent.

Neurogenic: HEMODYNAMIX (brady/hypo)

238
Q

What to consider with sternal fx?

A

Blunt cardiac injury (get EKG)

Echo if instability or new arrhythmia

MC abnormalities: sinus tachycardia and PVCs

239
Q

Traumatic aortic injury (MC: lig arteriosum) sx?

A

Hypotension, upper extremity hypertension, unequal blood pressures

240
Q

CXR findings in aortic injury?

A
  1. Widened mediastinum >8cm
  2. Depressed mainstem bronchus
  3. Deviated NGT to right
  4. Apical cap, disruption of calcium ring “broken halo” …

Get CTA CHEST!

241
Q

Aortic injury grading

A

Type I: intimal tear
Type II: intramural hematoma
Type III: pseudoaneurysm
Type IV: rupture

242
Q

Anterior stab wound management - what to look for on local exploration?

A

Anterior rectus sheath violation

243
Q

If violated anterior rectus sheath, WTD?

A

Observe if HDS and good exam.

Dx lap if unexaminable or concerning exam/vitals.

244
Q

What injury in FLANK stab wound?

A

RP structure (get CT IV/PR/PO contrast)

245
Q

What injury in THORACOABDOMINAL stab wound?

A

Diaphragm injury (get dx lap even if imaging/exam good)

246
Q

Bowel injury in trauma?

A

<50% primary repair if palp pulses
>50% resect and anastomosis unless damage control.

247
Q

Penetrating colon injury management?

A

Primary repair if non-destructive
Resect if destructive.

248
Q

Bucket handle injury repair?

A

Resect

249
Q

Pancreatic HEAD injury (+/- duct injury)

A

Drain only.

250
Q

Pancreatic distal injury with duct injury?

A

Distal panc +/- splenectomy depending on HDStability

251
Q

Pancreatic distal injury without duct injury?

A

Drainage only

252
Q

Zones of RP?

A

I: central (aorta, cava)
II: lateral (renals)
III: pelvic (iliacs)

253
Q

Penetrating injury to all RP zones?

A

EXPLORE ALL.

254
Q

Blunt RP injuries based on zones

A

I: explore
II: explore if expanding
III: pack and angio

255
Q

Triad of death?

A

Hypothermia, coagulopathy, acidosis

256
Q

Abdominal compartment syndrome first signs?

A

Increased peak pressures on vent and decreased UOP

257
Q

Diagnostic abdominal compartment syndrome?

A

Absolute bladder pressure > 20

258
Q

Treatment of ACS? In burn patient?

A

Decompressive laparotomy

In burn, HIGH mortality. Consider drain placement for ascites instead.

259
Q

Factor VII in trauma

A

DO not give.

260
Q

TEG: thromboelastrography
vs
ROTEM rotational thromboelastometry

A

TEG manual pipetting
ROTEM automated pipetting

261
Q

ROTEM interpretation

A

clotting time low - give FFP or PCC
MCF (max clot firmness) low - get FIBTEM
FIBTEM MCF low - fibrinogen
FIBTEM MCF nl - plt
LI30 - give TXA

262
Q

TEG interpretation

A

R time to make clot - give FFP
K time to make 20mm clot - give cryo
A angle to make strong clot - cryo
Max amp size of clot - plt
LY30 to lyse - TXA if high

263
Q

Bladder injury?

A

Esp in PELVIC fx.

dx = CT cystogram or retrograde cystopgraphy
Intra: OR
Extra: Foley if uncomplicated

264
Q

How to suture bladder injuries

A

2 layers, watertight absorbable suture with Foley x 10-14 days prior to removal

265
Q

Ureteral injury management?

A

Mid-ureteral: if <2cm spatulate, primary anastomosis with double J stent with FINE ABSORBABLE suture. if> 2cm tie off +PCNT, later can do UU or ileal conduit

Distal: re-implant +/- psoas hitch If tension.

266
Q

Urethral injury signs?

A

Scrotal/perineal hematoma, high riding prostate, blood at meatus. Can’t pass a foley

267
Q

Urethral injury suspected? Diagnostic of choice?

A

RUG. RETROGRADE URETHROGRAM.

268
Q

Hard signs of vascular injury?

A

Pulsatile bleeding.
Expanding hematoma.
Absent pulses.
Bruit/thrill.

269
Q

Soft signs of vascular injury

A

Nonexpanding hematoma.
Decreased pulses ABI < 0.9.
Proximity to nv structures.

270
Q

Popliteal artery/vein injury

A

Consider fasciotomy after repair.

271
Q

Cuffed vs uncuffed ETT pediatrics?

A

CUFFED tube (except in infants)

272
Q

ETT size peds?

A

Pinky nail bed width or

Age/4 + 4 = ET tube size

273
Q

intubation considerations for peds

A

narrow, short, anterior airway
use a straight blade with upward angulation

274
Q

Pediatric resuscitative fluid dosing?

A

20 cc/kg bolus for crystalloid
10 cc/kg bolus for blood

275
Q

Handlebar injury ass’d injury?

A

Duodenal hematoma

if able, just NGT decompression bowel rest & parenteral nutrition, repeat contrast study in 5-7 days
OR in 10-14 days if no improvement

276
Q

When to suspect popliteal artery injury?

A

Posterior knee dislocation

277
Q

Large differential between peak and plateau (insp pause) pressure?

A

Large airway obstruction
or Bronchospasm

278
Q

inspiratory pause?

A

alveolar pressure

279
Q

expiratory pause

A

total PEE (pressure in airways when there is no airflow)

280
Q

Berlin criteria for ARDS

A

Mild P:F 200-300
Mod 100-200
Severe <100

281
Q

Indications for diverting colostomy in trauma?

A

Complex perineal wound
Big rectal wall hematoma on rigid proctoscopy (GSW)

282
Q

If both peak and plateau pressures are high?

A

Alveolar lung disease (ARDS)

283
Q

SIMV vs ACVC

A

Both RR and Tv are set.

In SIMV: Spontaneous breaths ABOVE set rate are not fully supported but delivered breaths are synchronized (typically more comfortable)

284
Q

Extubation criteria

A

50% or less
PEEP < 10
RSBI (Rapid shallow RR/TV) < 100 (BEST PREDICTOR)
NIF > 20 (good predictor to fail if < 20)

285
Q

Acuity of ARDS?

A

1 wk from insult

286
Q

ARDSNET

A

Vt 4-6 cc/kg

287
Q

Permissive hypercapnia in ARDS?

A

pH > 7.20 as long as good oxygenation

288
Q

ARDS tx plateau pressure

A

keep it low < 30 cm H2O

289
Q

APRV mode?

Airway pressure release ventilation

A

Long inhalation, short exhalation

Set Phigh and Plow, Thigh, Tlow (time) … want long Thigh and short Tlow

Spontaneous breaths

290
Q

Prospective RCTs proved what benefits ARDS?

A

Proning and paralysis.

291
Q

Severe sepsis definition

A

SIRS + source + EOD*

292
Q

Sepsis based on SOFA

A

If SOFA increases by 2+ or a score of 2+

293
Q

SOFA score based on:

A

GCS
MAP
P:F
PO tolerance
Cr
plt
BG

294
Q

What lab to send for fungal infection?

A

1,3 beta D glucan assay

295
Q

What lab to send for invasive candidiasis?

A

Mannan antigen
+
Anti-mannan antibody

296
Q

Timing in sepsis management?

A

3 hrs - Cx, Abx, fluids
6 hrs - pressors

297
Q

Dopamine receptors

kidney, squeeze, press.

A

LOW:
DA (kidneys)

MEDIUM:
B1

HIGH:
alpha

298
Q

Norepinephrine receptors

A

alpha > B1

299
Q

Epinephrine receptors

A

alpha, B1

300
Q

Phenylephrine receptors

A

alpha ONLY

301
Q

Vasopressin receptors

A

V1-R

302
Q

Dobutamine receptors

A

B1, B2
(cardiac output and some vasodilatory…)

303
Q

Milrinone receptors

A

Phosophodiesterase inhibitor

Increase CO, cAMP… inotrope, vasodilatory

304
Q

Uncommon PE EKG Finding

A

S1Q3T3

305
Q

Cardiac output calculation?

A

CO = HR X SV

306
Q

Cardiac index calculation?

A

CI = CO/BSA (body surface area)

307
Q

Swan reading in HEMORRHAGIC SHOCK

A

Low CO, high SVR, LOW** filling pressures (CVP, PWP)

308
Q

Swan reading in SEPTIC SHOCK

A

HIGH* CO (may be low in late severe), LOW* SVR, low/normal CVP and PWP (filling pressures)

309
Q

Swan reading in CARDIOGENIC SHOCK

A

Low CO, high SVR, HIGH** filling pressures

310
Q

Oxygen delivery calculation

A

Oxygen delivery = CO x [Hgb x O2 sat x 1.34 + (PaO2 x 0.003)]

311
Q

Oxygen consumption calculation

A

Consumption = CO x (Arterial - venous O2 differences)

312
Q

Extraction ratio calculation

A

O2 consumption / O2 delivery

313
Q

AMPLE secondary survey questiosn?

A

Allergies
Medications
Past illnesses/preg
Last meal
Events leading up to injury

314
Q

lumbar vessels orientation to renals?

A

Lumbar veins enter posterior L renal vein

315
Q

Right gonadal into IVC?

A

Anteriorly

316
Q

Right adrenal into IVC?

A

Laterally

317
Q

Exposure to unk status? Needle stick

A
  1. wait for results of blood.
  2. if HBV titer high, good.
  3. if unvax/unk, give PEP HBV: HBIG and vaccination
  4. give PEP HIV: 3 drug
318
Q

Traumatic bronchus injury?

A

If blunt:
MC distal trachea within 2 cm of carina >
Right main bronch

Chest CT confirms with pneumomediastinum.

Vent has continuous air leak.

319
Q

cauda equina syndrome injury?

A

compression of lumbar plexus:

spinal roots (L3-S1) = motor loss, flaccid, loss DTR

spinal roots (S2-S4) = perineal sensory loss and bowel/bladder/sexual dysfunction, no rectal tone

320
Q

IVC injury - ligation indication?

A

attempt anastomosis
4-0 / 5-0 prolene transverseley

better than time consuming patch or graft or shunt.

if ligating, wrap legs after and elevate

321
Q

forearm compartment fasciotomy?

A

3 compartments: superficial flexor compartment, deep flexor compartment, and extensor compartment.

fasciotomy: dorsal incision + volar incision

322
Q

when to repair facial N injury

A

if lateral to lateral canthus, need to surgically repaired within 72 hours…
reapproximate epineural layer or use interposition graft.

if medial, can fix nonop

323
Q

direct defibrillation energy?

A

15 to 30 J only (as compared to 200J biphasic, 350J monophasic)

324
Q

blunt solid organ injury return to work?

A

grade of injury + 2 wks

325
Q

frostnip

A

frostnip: brief exposure - ice crystals on surface of skin only, with pain and the numbness/pallor

tx with rewarming - no long term damage

326
Q

frostbite: 4 degrees

A
  1. first degree.
    superficial. numbness, edema with firm plaque
    - heals spontaneously 1-4 wks
  2. second degree.
    partial thickness with milky-white blister, healing skin is atrophic
    2-4 wks to heal
  3. third degree.
    full thickness hemorrhagic blister. eschar resulting in limb/tissue loss
    1-3 mos to heal
  4. fourth degree.
    all the way to bone
    mummified. black.
327
Q

tx frostbite

A
  1. core temp normothermic first
  2. remove jewelry
  3. rapid rewarming fo tissue in 37-39 water until tissue pliable to touch
  4. assess for drainage/debridement
  5. remove blisters (harmful prostaglandins) via needle aspiration
    but leave hemorrhagic blisters intact
    - no abx warranted
328
Q

external landmarks for subclavian line

A

junction between medial and middle thirds of clavicle
and
the lateral edge of the SCM where it inserts into clavicle

329
Q

where does the SCV originate?

A

medial border of the anterior scalene muscle

330
Q

HF subsets

A

HFrEF <40%
HFmrEF (midrange/borderline) 41-49%
HFpEF 50+%

331
Q

highest mortality rate for sepsis?

A
  1. respiratory
  2. abdomial
  3. UTI
332
Q

VAP empiric coverage?

A

IV Vanc/Zosyn

333
Q

IM epi for anaphylaxis, positioning?

A

lay flat to prevent empty heart syndrome

334
Q

MC CAP and VAP?

A

CAP: S. pneumo
VAP: Pseudomonas

335
Q

or after ctb?

A

1500 initial
or 200 x 4 hrs

336
Q

shock index suggestive of shock

A

HR/SBP > 1
think hemorrhagic

337
Q

eastern vs western trauma for resuscitative thoracotomy

A

WESTERN; <10min blunt, pulseless, no signs || <15min penetrating

EASTERN: penetrating thoracic: RT if signs of life; conditional without
penetrating extrathoracic RT conditional pulseless
blunt extrathoracic RT conditional pulseless with signs ONLY

338
Q

esophageal injjury repair goals

A

control
debride
drain widely
abx
buttress
distal feeding

339
Q

thoracentesis landmark

A

1-2 IC spaces above highest extent of the effusion if seated upright

340
Q

auscultatory triangle

A

thinnest portion of musclular chest wall; 5-6th midaxillary line

341
Q

what temp to stop CPR as you rewarm?

A

90F

342
Q

what to explore if anterior stomach injury

A

posterior stomach

343
Q

what to explore if posterior stomach injury

A

pancreas

344
Q

aast stomach injury grades

A

I: contusion/hematoma
II: lac <2cm in GEJ or pylorus, <5cm proximal 1/3, <10cm distal 2/3
III: >
IV: tissue loss/devasc < 2/3 stomach
V: >

345
Q

aast duo injury grades

A

I: hematoma x 1 or partial thickness lac
II: hematoma x 2, or lac < 50% circumf
III: lac D2 50-75%, D1/3/4 50+%
IV: lac >75% D2 involving ampulla
V: devasc of duodenopancreatic complex

346
Q

tx duo injury with GOO

A

NGT x 5-7 days
CT with PO contrast prior to PO intake
+/- TPN

347
Q

tx duo injury

A

grade I-III: Heinecke Mikulicz
IV/V: DD or RNY DJ

348
Q

aast small bowel injury

A

I; hematoma, partial lac
II: lac < 50%
III: 50+%
IV: transection
V: transection with tissue loss or devascularized segment

349
Q

bucket handle injury tx

A

resection

350
Q

rectal injury tx

A

intra: resection
extra: fecal diversion with colostomy (loop or end)
do not irrigate/presacral drainage as definitive mgmt)

351
Q

repewat scan post splnic angioembolization?

A

consider for psa or delayed bleed

352
Q

mc opsi

A

s. pneumo

353
Q

MC location for blunt liver injury?

A

posterior right lobe

354
Q

presentation of hepatic arterial to biliary fistula

A

days to weeks after initial injury… hematemesis

dx with CTA and embolize

355
Q

hepatic necrosis mgmt

A

only necrosectomy/resection if causing pain or PO intolerance

356
Q

aast renal injury grading

A

I: subcap hematoma w/o lac or contusion
II: nonexpanding hematoma perirenal, lac <1cm deep
III: lac > 1 cm deep without CD injury
IV: lac involving CD or hilar vascular injury with contained hemorrhage
V: shattered kidney OR avulsion with devascularizatino

357
Q

aast liver grading

A

I: hematoma subcap < 10%, lac <1cm deep
II: hematoma subcap 10-50% or parench <10 cm, lac 1-3 cm deep, < 10 cm long
III: hematoma subcap >50% or parench >10 cm (can all be expanding), lac > 3 cm deep
IV: laceration disrupting 25-75% lobe of 1-3 segments within 1 lobe
V: >75% lobe or >3 segments within 1 lobe or juxtahepatic venous injury - retrohepatic cava or central hepatic veins
VI: hepatic avulsion

358
Q

geriatric trauma inpatient (ICU) admission criteria? EAST

A

major trauma to any system with ISS >3
base deficit <-6av

359
Q

avoid succinylcholine in who?

A

burn
hyperK
crush injuries
Muscular dystrophy
significant spinal cord trauma
malignant hyperthermia

360
Q

MVC with lumbar chance fracture and seat belt sign?

A

high suspicion for HOLLOW viscus injury
maybe pancreatic injury

361
Q

mortality sepsis

A

10%

362
Q

mortality septic shock

A

40-50%

363
Q

sepsis guidelines timing

A

1hr Abx after Cx
3 hr fluid 30cc/kg if lactate > 4
6 hr start pressor PRN

364
Q

sepsis steroid use

A

IV hydrocorti 200 mg/day

365
Q

respiratory failure types

A

1: hypoxemic
2: hypercapnic

366
Q

oxygenation affected by (mech vent)

A

FiO2, PEEP, mean airway pressure

367
Q

ventilation affected by

A

RR and Vt

368
Q

PE tx heparin

A

bolus = 60-70 U/kg (max 5000)
+ gtt for PTT 60-80

369
Q

PE tx

A
  1. AC
  2. thrombolytics (systemic) if HD instability, RH strain on TTE
  3. IR embolectomy/catheter directed thrombolysis
  4. Trendelenberg procedure if thrombolysis contraindication
370
Q

coag goals before IR perc chole tube

A

INR 1.5
plt 50 K

371
Q

mangled extremity score to amputate?

A

greater than 7

372
Q

superficial peroneal (fibular) N injury in fasciotomy?

A

N trvels in lateral compartment, exits fascia 10-12 cm superior to lateral malleolus

373
Q

superifical peroneal N injury sx

A

difficult foot eversion
tingling to dorsal foot

374
Q

hounsfield units to consider blood

A

> 35

375
Q

pedicle flap to aorta/ivc repair

A

patch omentum

376
Q

see bleeding lac after pringle

A

suture ligation of vessels and omental packing

377
Q

total spinal anesthesia

A

excessive cephalad spread of local anesthetic… large volume into intrathecal space (direct for C/S) or in dural puncture after epidural….

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