Trauma/Critical Care Flashcards
What’s the difference between a shunt vs. Dead space?
Shunt: (+) blood flow / (-) aeration
Dead space: (-) blood flow / (+) aeration
What is the PaO2 that defines failure to oxygenate?
What PaCO2 defines failure to ventilate?
PaO2 < 60
PaCO2 > 55
Mechanical ventilation safe lung strategy
Tidal volume less than what?
Plateau pressure less than?
Permissive hypercapnia up to how much?
Tidal volume <6cc/kg
Plateau pressure <30mmHg
Permissive hypercapnia up to pH7.2
What’s the difference between ALI vs. ARDS?
ALI: PaO2 to FiO2 ratio <300
ARDS: PaO2 to FiO2 ratio <200
What do NSAIDs do for renal afferent/efferent vasculature?
What does hypotension do for renal perfusion?
NSAIDs: inhibit afferent vasodilation (afferent constriction)
Hypotension: afferent constriction, efferent dilation
What’s the lifespan of RBC’s?
Lifespan of platelets?
Lifespan of wbcs?
RBC’s: 120 days
Platelets: 8-9 days
Wbcs: 1-2 days
What are the five grades of pancreatic trauma? How do you treat them?
[T/F] grade III pancreatic injury can be managed non-operatively
I: minor contusion
II: major contusion without ductal injury
- non-op
III: distal transection
- distal panc
IV: proximal transection
- drain + post-op ERCP
For grades III and IV non-op management has higher complication rate. so they need an exploration if discovered on imaging
V: massive disruption of the pancreatic head
- DRAIN DRAIN DRAIN
What’s the grading system for blunt injuries to the duodenum?
I: hematoma or laceration without perforation
II: disruption <50% circumference
III: disruption 50-75% circumference
IV: >75% circumference involving the ampulla/distal CBD
- primary repair
V: massive disruption of the duodenopancreatic complex or duodenal devascularization
Blunt trauma, rib fx non-op vs rib fixation
- narcotic requirement
- cost
- ventilator days
- pneumonia
- mortality
Who should be considered for rib fixation, when is the optimal timing?
No difference in narcotic requirement Rib fixation is more expensive Rib fixation reduces ventilator days Rib fixation reduces pneumonia rate No difference in mortality
People who can’t be weaned off of ventilator. Maximum benefit within 3-5 days
If Pringle slows down the bleeding, what does it mean? Where is the injury?
What might you consider for repair if Pringle works?
It means IVC and hepatic veins are probably fine.
Consider hepatic artery ligation
What complication may occur if you ligate the hepatic artery?
Abscess or a biloma
Surgical airway in a 13 yr old. What do you do?
Cricothyroidotomy for kids 12 or older.
For kids younger than 12 -> 12, 14, 16 gauge needle airway
Neck stab wound. Carotid artery injury found during exploration. What do you do in general?
What to do if the defect >2cm? Use prosthesis?
What about a high carotid injury- how do you expose?
Generally primary repair. Prolene
2>cm use saphenous vein graft. Prosthesis is avoided generally for long term patency
High carotid- divide the digastrics, subluxation of the mandible
Neck stab wound. Esophageal injury. How do you repair it?
What if it’s hard to locate the injury?
What if it’s been more than 24 hrs?
NG tube. Can use methylene blue to identify hole. Close in two layers, absorbable suture
> 24hrs then esophagostomy, feeding tube, tissue buttress
Neck stab wound. Tracheal injury. What do you do?
What if a tracheostomy is needed? Through the same hole?
Repair with interrupted absorbable sutures muscle buttress
Never through the same hole
Neck stab wound. Vertebral artery injury. What do you do?
IR embolize
Neck stab wound. Big vein injury. IJ. Use a graft to repair? Why or why not
Graft will thrombose. Just ligate the vein
Odontoid fx types. I, II, III
Which one tends to be painful?
Which type may have airway compromise due to swelling?
Painful: type I
Airway: type II
Cardiac tamponade pathophys.
What are the two pressures at war here? What’s the endpoint?
How many phases?
Cardiac output starts to get affected when?
Initial signs of shock becomes evident in what phase?
Intrapericardial pressure vs. ventricular DIASTOLIC filling pressure. Endpoint is when these two pressures become the same. Phase 3
3 phases
Cardiac output is maintained during phase I with tachycardia & increased SVR. Phase II cardiac output goes down.
Signs of shock at phase II
ED thoracotomy
- which intercostal space?
- how many joules to defribrillate after EDT? How many Joules to externally defib?
- to Foley or not to Foley?
5th intercostal space
15-30J to internally defib. 100-200J for external defib
Don’t Foley because it can tear the defect, make it bigger
Resuscitation goals for
Plt
INR
Fibrinogen
T
Plt > 100k
INR < 1.2
Fibrinogen > 100
T > 37 (98.6)
Define pancreatic leak
What’s considered a minor fistula vs. high output.
Drain amylase > serum x3
Minor fistula < 200cc/day
High output > 700cc/day
Boundary of posterior neck triangle
Sternocleido anteriorly
Trapezius posteriorly
Clavicle at the base
Neck stab wound. Totally stable, no crepitus, no dysphagia, no dysphonia. Small 2cm sound. Non-op management. Still do CTA? Chest XR? Barium swallow?
Yes to all. Every neck wound if non-op, get everything
What are some differences between superficial second degree burn vs. Deep second degree burn?
Superficial second degree
Wet
Pink
Deep second degree:
Dry
More pale than pink
When doing a nephrectomy, what are the tributary vessels to renal vein? Do you divide the vein first or the artery first?
Gonadals, lunbars, adrenals.
Divide these three to mobilize the renal vein. You need to mobilize the vein in order to obtain control of the renal artery.
Divide the artery first then divide the renal vein to prevent renal congestion
Mild, moderate, severe traumatic brain injury: what is the diagnosis based on?
What is the most prevalent type?
What % of moderate TBI will develop into severe TBI?
What is the mortality rate of severe TBI?
What % of mild TBI will have an identifiable lesion on CTH?
Who needs ICU?
GCS 13-15: mild TBI
GCS 9-12: moderate TBI
GCS <8: severe
Mild is the most prevalent (80%)
12% of moderate TBI becomes severe
20% mortality rate for severe TBI
10-30% of mild will have CTH lesion
All moderate to severe TBI needs ICU. GCS <12
Externally rotated leg. Abducted.
What dislocation? What associated injury?
Anterior disloc
Femoral vein thrombosis
Internally rotated leg, adducted
What dislocation? What associated injury?
Posterior dislocation. Sciatic nerve inj
Distal radius fracture. What nerve?
Median nerve
Mid humerus fx. What nerve!
Radial
Supracondylar humerus fx. What injury?
Distal humerus fx
Brachial artery
Volksmann ischemic contracture
Anterior shoulder dislocation. What injury?
Axillary nerve
Spenic lac grade. % surface area hematoma & cm?
What’s the failure rate for conservative management?
Grade I: <10% hematoma, <1cm deep lac
5%
Grade II: 10-50% hematoma, 1-3cm deep lac
10%
Grade III: >50% hematoma, >3cm deep
20%
Grade IV: laceration involving hilum, major devascularization
33%
Grade V: shattered spleen
75%
Most common bacterial organisms in human bite? What’s the first line treatment?
Which bites more likely to cause tenosynovitis? Dog? Cat? Human?
First line treatment for animal bites?
Staph aureus, strep. Cephalosporin
Cat bites: tenosynovitis
Animal bites: augmentin (amox-clav)
What are the different phases of empyema?
What % of empyema are culture positive?
When/how many days is an operation needed?
Acute(7d), subacute, chronic
20-30% not culture (+)
After 7d
Post ruq stab wound biloma.
- what volume from the drain suggests you should operate?
- most are intra- extrahepatic bike duct injury?
- persistent drainage >50cc/day -> what’s the diagnosis? What’s the treatment
- > 300/day operate
- most are to intrahepatic ducts
- biliary fistulas. Usually resolve without treatment
What is the complication rate for chest tube?
Is bigger chest tube 36-40Fr better than smaller chest tube for hemothorax?
What’s the Hounsfield unit for hemothorax?
If hemothorax is < ____ cc then chest tube shouldn’t be placed
Abx for traumatic chest tube?
25%.
Tube size apparently doesn’t matter.
Hounsfield unit 35-70
300cc
No abx
What is Rivaroxaban?
What’s the reversal agent?
Does dialysis work?
Xarelto
Factor Xa inhibitor
Andexanet Alfa
Dialysis doesn’t work because it highly binds to proteins
Dabigatran. What is it?
How do you reverse?
Pradaxa
Direct thrombin inhibitor
Dialysis or idarucizumab (monoclonal antibody)
What are the components of the Berlin definition of ARDS? What are the mortality rates based on mild moderate severe ards?
PaO2/FiO2 200-300 mild aka ALI ~25% mortality
PaO2/FiO2 100-200 moderate ~32% mortality
PaO2/FiO2 <100 severe ~45% mortality
Need to have PEEP @ 5
Hypoxia must occur 7 days after the insult
Caloric requirement for critically ill?
Protein requirement for critically ill?
25-30kcal/day
1.5-2g/kg/day
What is the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition diagnostic criteria for malnutrition?
Involuntary loss of >10% body weight in 6 months
Or
5% body weight loss in 1 month
Up to how many tracheal rings in length can be repaired primarily?
Best way to gain access to distal tracheal injury?
Up to 5 or 6 tracheal ring length
Right posterolateral thoracotomy provides the best access to the distal intrathoracic trachea
What incision for proximal control of right subclavian artery?
Median sternotomy
What incision for proximal control of left subclavian artery?
what about for exposure of an injury 1cm distal to left subclavian takeoff?
Anterior thoracotomy in the third intercostal space
for aortic injury distal to subclavian takeoff -> Left posterolateral thoracotomy
When to use infraclavicular vs. Supraclavicular incisions for subclavian artery injury?
Infraclav: distal control of the subclavian artery
Supraclav: for repair of the vessel
Mechanical ventilation safe lung strategy
Tidal volume less than what?
Plateau pressure less than?
Permissive hypercapnia up to how much?
Tidal volume < 6mL/kg
Plateau pressure < 30mmHg
Permissive hypercapnia up to pH 7.2
What’s the difference between ALI vs. ARDS?
ALI: PaO2 to FiO2 ratio <300
ARDS: PaO2 to FiO2 ratio <200
Where is calcium absorbed?
How is it absorbed? Active or passive?
Duodenum & jejunum
It binds to calbindin which then transfers it to the basal membrane. Then it actively gets pumped in.
Active transport in the duodenum
Passive transport in jejunum > ileum
Indication for therapeutic hypothermia (TH)
What T?
When should you stop?
pts who fail to awaken after cardiac arrest
T 32-34C (89.6-93.2F) for 12-24 hrs after ROSC
Hypotension + hgb decrease by 3
1 cause of exudative pleural effusion?
What % of pneumonia have associated effusion? What % of those effusions will develop into empyeme?
What are the stages of empyema?
What type of organism is most common in empyema?
1 is malignancy
Up to 50% of pneumonia have effusion. Only ~5% of them will develop into empyema
Stage I: EXUDATIVE stage. Fluid is thin, lights, low wbc count, low LDH
Stage II: FIBRIN PURULENT stage. Fluid becomes infected. LDH and WBC increase. Glucose and pH drop. Lung is often unable to expand
Stage III: ORGANIZING stage. Think pleural peel created by migrating fibroblasts -> DECORT
Used to be strep pneumo, now anaerobes.
What are the components of vital capacity?
Inspiratory reserve volume + tidal volume + expiratory reserve volume
Inspiratory capacity = inspiratory reserve volume + tidal volume
What is inspiratory capacity?
Tidal volume + inspiratory reserve volume
What is FRC?
Functional residual capacity = expiratory reserve volume + residual volume
Total lung volume - inspiratory capacity
Total lung volume - inspiratory reserve volume - tidal volume
Inspiratory capacity = inspiratory reserve volume + tidal volume
4 components of total lung capacity?
Inspiratory reserve volume + tidal volume + expiratory capacity + residual volume
Respiratory quotient of pure carb metabolism
1
Respiratory quotient of pure protein metabolism
0.8
Respiratory quotient of pure fat metabolism
0.7
What does RQ > 1 mean vs. RQ < 1?
> 1 means overfeeding glucose/fat
<1 means ketogenesis
Free water deficit equation
(pt sodium - ideal Na) / ideal Na x total body water in L
Total body water = pt weight in kg x gender factor (0.5 for women, 0.6 for men)
Normal ICP?
7-15 mmHg
When to transfuse platelets for
- hospitalized adult pt to reduce spontaneous bleeding
- surgery
- for central line
- hospitalized adult pt to reduce spontaneous bleeding: < 10 x10^9
- surgery: < 50 x 10^9
- for central line: < 20 x 10^9
What’s p Delta in compartment check?
What’s the threshold for fasciotomy?
DBP - compartment pressure
< 20-30 mmHg usually indicates fasciotomy
top 3 Most common hospital acquired infection?
#1: hospital acquired pneumonia 25-48% #2: surgical site infxn 24% #3: UTI 14%
Most common fungal pulmonary infection? Treatment.
Histoplasmosis, itraconazole
What is apixaban
mechanism?
How do you reverse?
kidne or liver clearance?
Eliquis. Factor Xa inhibitor
idarucizumab (praxbind)
dialysis
Pcc
liver clearance
What to do with carotid injuries depending on size?
What about very high carotid injury? How to expose
Jugular injury?
<2 cm: primary repair
>2 cm: vein patch (saphenous graft)
High: subluxate the mandible or divide the digastrics
Just ligate the veins
For ogilvie’s how much neostigmine do you give? Over how long?
2.5mg over 3 minutes
Should see effect within 10 minutes
When is resuscitative thoracotomy indicated for penetrating vs blunt traumas?
Penetrating: thoracic trauma who are hemodynamically unstable on arrival to the ED despite resuscitation
Or in patients who have been pulseless and receiving CPR for less than 15 minutes
Blunt: pts who lose vital signs in transit or in the ED + no obvious non-survivable injury
Or in patients with cardiac tamponade rapidly diagnosed by ultrasound with no obvious non-survivable injury
What are the grades of frostbite?
Grade I: superficial, numbness, firm plaque (1-2 weeks to heal)
Grade II: clear or milky blisters (2-4 wks to heal) - drain these
Grade III: bloody blisters. Black eschars (1-3 months) - may aspirate but leave intact. do not debride
Grade IV: black mummified skin. Involves bone
Medially rotated leg vs externally rotated leg. gotta watch out for injury to what structure for each scenario?
Internal rotation: posterior dislocation. Sciatic nerve
External rotation: anterior dislocation.
What makes a DPL positive?
~10mL of gross blood, bile, food
> 100,000 RBC
> 500 WBC
What are the lab value indications for damage control laparotomy for trauma?
PH < 7.2
Base deficit > 15
Temp < 35
What is the key difference between cerebral salt wasting and SIADH and their treatment?
What about diabetes insipidus?
CSW: volume depleted -> replete volume, replete sodium
SIADH: normal volume -> water restrict, demeclocycline
Insipidus: high serum sodium -> DDAVP, diuretics
CSW: excess secretion of sodium and water
SIADH: too much ADH. too much free water absorption
Insipidus: no ADH. Excess secretion of free water
Through which receptor does donutamine cause vasodilators effects?
B2 agonist.
Primarily B1 agonist -> inotrope
Ionotropic agent of choice in cardiogenic shock?
When would you use dopamine?
Dobutamine.
Dopamine only if pt develops hypotension with dobutamine
When do you do crani for SDH? what size and how many mm midline shift?
Shift > 5mm
Thickness > 10mm
Or change in gcs > 2 points
What does the abdominal compartment syndrome do to ICP and why?
Increases ICP because increased thoracic P prevents venous outflow out of the brain
1 wk after CABG diffuse ST elevation. What is the diagnosis and treatment? When would you cath?
Post-pericariotomy syndrome. NSAID
cath would be indicated if there’s a new area of ischemia. That wouldn’t show up with diffuse ST elevation
Leading cause of death in pts with replaced aortic valves?
Survival difference between mechanical vs biologic aortic valves?
Reoperation rate higher in which?
Which one needs lifelong anticoagulation?
Heart failure. No longer endocarditis
No survival difference
Bioprosthetic requires more reoperation
Mechanical valve: lifelong AC
T/F: PEG and open G-tubes have similar morbidity/mortality
True apparently
Empiric treatment for VAP?
vanc and zosyn
Or any combo that covers gram (-) and MRSA
Median survival of hepatorenal syndrome type I vs. II
What is the only treatment for hepatorenal syndrome?
what electrolyte abnormality?
Type I: 2 weeks
Type II: 6 months
Liver txp is the only rx
hypokalemia, hyponatremia
What is the propofol infusion syndrome?
Metabolic acidosis, kidney failure, heart failure, rhabdo (elevated cpk)
Stop the propofol
Oxygen extraction ratio is usually around what?
Oxygen extraction ratio is highest where?
Increase or decrease with hypothermia?
0.3 because mixed venouse O2 is normally around 70%
Coronary circulation and brain
Increase with hypothermia. In hypothermia tissue must maintain oxygenation with limited O2 delivery therefore extraction increases
What aortic valve area is an indication for surgical aortic valve replacement?
What’s an indication for balloon valvuloplasty?
Area < 1 cm2
Balloon if unable to tolerate surgery
1 cause of mortality from refeeding syndrome is what?
In refeeding syndrome metabolism shifts from what to what? Protein? Carb? Fat?
Cardiac due to hypophosphatemia, NOT respiratory
Metabolism shifts from fat to carb. Insulin surge causes extracellular potassium, phosphate, and Mg to move into the intracellular compartment
Anaphylaxis results in tachycardia or bradycardia?
Initially tachycardia but turns bradycardia. So can be both
What is polymorphic v-tach and what’s the treatment
It’s torsade. Magnesium
Indications to operate in mitral valve endocarditis?
Persistent sepsis New onset heartblock Valve dehiscence Systemic embolism Fungal or multi drug resistant organisms
What is the most common organism associated with ventilator associated pneumonia?
Staph in VAP tends to be methicillin sensitive or resistant?
Pseudomonas
More than 1/2 of staph in VAP are MRSA
What’s the mechanism of action of IABP?
what does it do to preload and afterload?
Decreases preload AND afterload
Works by increasing aortic diastolic pressure. Increases peak diastolic pressure improving coronary perfusion
For liver failure + encephalopathy should the feeds have more aromatic amino acid or less? What about branched chain amino acids?
What are the BCAA’s?
Liver failure has excess of aromatic amino acid so less is better. Needs more branched chain amino acids
Valine leucine isoleucine
Cerebral perfusion pressure should be kept between what values?
50-70mmHg
CPP = MAP - ICP
7yo. What size ET tube?
7/4 + 4 = 5-6Fr
Or size of the pinky finger
Intubating a trauma pt now. Urgent. Why would ketamine not be a good choice?
Versed
There could be a head injury
Versed drops bp
What is the normal blood pressure for a 7yo?
80 + age x2 = 94
What is the dose of etomidate/succinylcholine for RSI?
Etomidate: 0.3mg/kg
Succinylchokine: 1-2mg/kg
What is the LOaVES protocol?
Lidocaine (1-2mg/kg) Oxygenate (100% non-rebreather) Vecuronium (0.01mg/kg) atropine (0.01mg/kg) kids can get bradycardic Etomidate (0.3mg/kg) Succinylcholine (1-2mg/kg)
Where is the narrowest point of the airway in adults vs children?
Adults: vocal cords
Children: cricoid. It’s below the cricoid
Other than the tachycardia and narrowed pulse pressure what do you see in class 2 hemorrhagic shock?
Delayed cap refill
What is the total blood volume in kids?
How much do they have to lose to become hypotensive?
How much blood do you start transfusing kids with?
80cc/kg
24cc/kg. 30% of the total blood volume
10cc/kg x1 for blood. 20cc/kg for fluid bolus
Three things you can do to quickly lower the ICP
1) raise the head of bed
2) mannitol (0.5g/kg) bolus
3) hyperventilate (CO2 between 35-40)
Let’s say you’re doing a trauma lap. There’s nothing else but you find duodenal hematoma. What do you do? Leave it alone?
Open the serosa evacuate the hematoma, close
What is the most common cause of spontaneous spleen rupture in the US?
Worldwide?
hematologic malignancy > Mononucleosis
Malaria
Most common reason to do a partial splenectomy?
Gaucher’s disease
Genetic disease
Fat buildup in spleen, etc
How do you expose the lower abdomen during trauma?
Catell brasch. Not mattox. Mattox is for suprarenal aorta.
Mobilize the right colon and kocherize. Take the root of the mesentery (goes from left upper quadrant to right lower quadrant) and lift it. All bowel goes to the left shoulder
You’re doing a catell brasch. You see the iliacs at the bottom. Seeing what at the top tells you you’re done with catell brasch?
Third portion of duodenum
Gsw to lower abdomen. Aortic bifurcation injury. What do you do if no contamination, stable
What if poop all over the place?
Aorta bifem.
Poop -> ligate proximal ligate distal, open abdomen. Live to fight another day. Then do ax-fem, fem-fem
Bullet goes through at the bifurcation of IVC. what to do?
Ligate infrarenal ivc with impunity.
When you ligate infrarenal ivc for trauma, what’s a caveat? Location of ligation
As close to the renals as possible. Otherwise you get dvts
Bullet goes through suprarenal Ivc. What to do?
Take a 40fr. Chest tube. Sew it proximal, sew it distal. New Vena cava for the next day.
Repair: saphenous vein. Cut longitudinally, wrap it around a 40Fr chest tube, sew it. Slide the chest tube out. It’s a new Vena cava
Bullet goes through celiac trunk. What do you do?
<2% bowel death rate from celiac ligation.
Get plenty of collaterals from the SMA.
Three branches of celiac: left gastric, splenic, common hepatic
Bullet goes through SMA. No veins available. Tons of contamination.
90% incidence of bowel death. Can’t resect.
Take internal iliac artery and use it
How much small bowel do you need to avoid short bowel syndrome? If you have a colon vs if you dont
If you have colon: 75 - 100cm.
If you don’t: 150cm
Bullet goes through SMV. can you ligate it?
Can you ligate portal vein?
Yes but 30% there will be bowel compromise. You have to do second look operation the next day.
Yes. Ligate portal vein but also needs second look
Bullet goes through CBD. What do you do?
If <50% then primary repair over a T-tube
If >50% don’t out the two ends together. Rny hepaticoJ. Retrocolic
Bullet goes through head of the pancreas. What do you do?
1) do a ductogram. Small purse string in the dome of the GB. Give 30-40cc of contrast. Give 4mg of morphine. It clenches the ampulla. You’ll see the pancreatic duct.
If duct is not involved, drain. Done
If (+) extract drain and stent. Duodenotomy, squeeze the gb to identify the ampulla, out a pediatric feeding tube inside
What do you use to close duodenal injuries and why?
80% injury to duodenum. Able to close but it’s going to be too narrow. What to do?
No vicryl because of pancreatic enzymes. Use permanent suture like prolene, 2 layers
> 50% injury -> pyloric exclusion, drain the duodenum.
Earliest signs of uncal herniation?
Anisocoria (unequal pupil size), ptosis, impaired extraocular movements.
Otherwise normal motor
A transected nerve put back together. How fast does it grow back daily?
1-2 mm/day
1inch/month
What kind of tracheal injuries can be managed nonoperatively other than hemodynamically stable ones?
Size? % circumference involved?
<4cm, <1/3 circumference, well opposed edges
Post-TURP. 154/109, HR54, serum Na: 110, K: 5.4
What to do?
Give lasix to remove excess fluid, hypertonic saline
Due to using large amounts of hypotonic irrigation during the procedure
What is the Wells criteria?
Used to estimate the probability of acute PE
Immobilization >3 days
Surgery within the past 4 weeks
Malignancy within the last 6 months
HR > 100
Past diagnosis of DVT
Hemoptysis
Clinical signs and symptoms of DVT
Risk factors for development of multiorgan failure (MOF) within 72 hrs of injury vs after 72 hrs?
MOF happening in <72 hrs:
- injury severity score > 24
- SBP < 90
MOF happening after >72 hrs:
- Base deficit > 8 within first 12 hrs of injury
- age > 55
Lactate, 6u blood: within and after 72hrs
What are the prerequisites before apnea test can be performed?
Euvolemia PaCO2 35-45 T > 96 SBP > 100 (pressors okay) PaO2 > 200
What deficiency causes macrocytic anemia with elevated methylmalonic acid and normal homocysteine?
B12. Methylmalonic acid level is normal even if folic acid is low
Normal methylmalonic acid + high homocysteine: folic acid
What dificiency causes macrocytic anemia with normal methylmalonic acid and high homocysteine?
Folic acid. You need folic acid for homocysteine to get metabolized. So no folic acid -> homocysteine builds up
High methylmalonic acid + normal homocysteine anemia: B12
What are the other names for vitamin B1 and B2?
What do their deficiencies cause?
B1: thiamine. Causes beriberi
B2: riboflavin. Causes iron deficiency anemia
Describe the stages of Tylenol toxicity
Stage I: symptoms within 24 hrs. Malaise, nausea, vomiting
Stage II: 24-72 hrs. RUQ pain, N/V. Elevated AST/ALT/INR/Tbili
Stage III: 72-96 hrs. Encephalopathy and jaundice
Stage IV: Resolution of GI symptoms
T/F: for trauma lap and open abdomen, 3% saline reduces time to fascial closure
True apparently
T/F: perc trach is safe without bronch
T/F: perc trach is contraindicated in pts with recent anterior cervical fusion
True. Originally bronch was used but safe without it
False. Safe in pts who had cervical fusion
For sepsis what is the initial amount of crystalloid that needs to be given per kg?
30cc/kg in the first 3 hrs
3L for 100kg person over 3 hrs
T/F: massive transfusion protocol improves 30d mortality
What does 1:1:1 actually mean?
F. It improves the 24hr survival
6u pRBC, 6u FFP, 6 pack of plts
What is the new definition of sepsis?
Definition of septic shock?
What about severe sepsis?
SOFA score of at least 2
1 pt: altered mentation
1 pt: RR > 22
1 pt: SBP < 100
Septic shock: persistent hypotension requiring pressors to keep MAP >65 and lactate > 2 despite volume resuscitation
Severe or complicated sepsis are no longer used
For hypovolemia, does capillary permeability increase or decrease?
Hypovolemia -> capillary permeability decreases to maintain hydrostatic pressure
What is the grading system for rectal injury?
I: contusion or hematoma/partial thickness laceration II: laceration < 50% circumference III: laceration > 50% circumference IV: full thickness laceration V: devascularized segment
Rectal trauma grade III and above need what?
Resection, end colostomy
PPI’s in intubate ICU pts. Do they:
- protective against stress ulcers?
- increase nosocomial pneumonia rate?
Not GI protective
They do increase pneumonia rate
Can you give epinephrine through interosseous?
Yes
Critically ill patients may require (more/less) heparin than normal people. Why?
More than normal
They tend to have increased levels of acute phase proteins which bind heparin. This is treated with escalating doses of heparin
What are the components of cryo?
- fibrinogen
- vWF
- factor 8
- factor 13
- fibrinectin
Sternal fracture. Ekg shows new LBBB. Why does this person need an echo?
You don’t know exactly how much and what kind of damage was done to the heart. He could have a wall rupture or something. Echo allows you to see what structural damage was done
Cardiac index below what after CABG indicates aortic balloon pump?
<2.2 L/min/m²
Normal CI is between 2.5-4.5L/min/m²
1 cause of jugular vein suppurative thrombiphlebitis
Pharyngitis
ED thoracotomy
T/F: incision should start just to the right of the sternum and should proceed in the seventh or eighth intercostal space to the left midaxillary line
False. 5th intercostal space
Swan ganz.
A sharp rise in pressure followed by a rapid decrease in pressure with a gradual increase in pressure between waves, coinciding with the QRS complex on ekg.
Where the fuck is your catheter
A small pressure increase (c wave) followed by a small decrease in pressure (x descent) beginning after the QRS complex. Where is your catheter?
Right ventricle
Wedged pressure begins after the QRS complex
Swan ganz.
A small pressure in tease (c wave) followed by a small decrease in pressure (x descent), coinciding with p wave. Where is your catheter?
a rapid increase and decrease (dicrotic notch), followed by another rapid increase and decrease in pressure coinciding with T wave. Where is your catheter?
Right atrium
Pulmonary artery
What is wrong with this statement?
- the subclavian vein originates medial to the first rib
- one of the external landmarks for the site where the vein passes between the first rib and the clavicle is the medial edge of the sternocleidomastoid muscle where it inserts into the clavicle.
- subclavian vein originates lateral to the first rib
- it’s the lateral edge of the SCM
Spinal dysreflexia
What T level?
What happens to BP, HR,
Spinal cord injury at or above T6
Hypertension
Bradycardia
Diaphoresis
Kinda like cushing’s reflex I guess but no brain inj
air embolism. what position?
head down, right side up
left lateral decubitus and trendelenburg
fat embolism. treatment?
supportive care
The broselow tape can be used for kids under what age, under what weight?
Do you have to take gender into account?
Arm span?
12 and under.
Under 36 kg (80lb)
Gender doesn’t matter
Arm span doesn’t matter
In pregnancy, they physiologically [hyper/hypo]-ventilate. So the normal PaCO2 in pregnant women ranges are [ ? ]
Increases minute ventilation in pregnancy/hyperventilate.
Normal PaCO2: 25-30
PaCO2 of 36 in a pregnant woman can actually mean impending respiratory failure
Up to heart rate of what can be normal in pregnancy?
HR may increase by 15-20 during pregnancy
Even HR 115 can be normal
How is blood pressure affected in pregnancy?
Tend to be hypotensive. 5-15mmHg lower. Both systolic and diastolic
Central cord syndrome
Motor loss in b/l upper > Lower
Anterior cord syndrome
Complete loss of motor, pain, temperature below the injury.
Intact proprioception and vibration
Indications for ICP monitoring in a trauma pt with a normal CT
1) post-resuscitation GCS 8 or less
2) age > 40
3) any history of hypotension
4) abnormal posturing
Supracondylar humerus fracture. What contracture? From what injured structure?
Volkmann ischemic contracture. Brachial artery injury
Anterior shoulder dislocation. What structure iniured
Axillary nerve
Distal radius fx. What structure is injured?
Median nerve compression
Cerebral salt wasting vs SIADH vs DI
Volume status? Sodium load? Urine output? Treatment?
CSW: hypovolemia / hyponatremia / increases urine output
Mechanism: excess salt and water excretion
Treatment: fluid resuscitation and sodium repletion
SIADH: normal/hypervolemia / hyponatremia / normal urine output
Mechanism: too much ADH. Gain free water
Treatment: volume restriction then demeclocycline (ADH antagonist)
DI: Hypovolemia / hypernatremia / increases urine output
Mechanism: no ADH/resistance to ADH. Lose free water
Treatment: 45% saline, DDAVP
Bullet goes through I’ma. Treatment? Second look?
Ligate IMA with impunity. No need for second look
SVR [increases/decreases] with increasing age
SVR increases with age
What happens to SVR on septic pt?
Cardiac index? CVP?
Decreases SVR
Increases cardiac index
Decreased CVP
indication for stress ulcer prophylaxis in the ICU (6)
traumatic brain/spinal cord injury ventilation > 48hr (not 24) INR > 1.5 plt < 50k severe burn > 35% surface area high dose steroids 250mg hydrocortisone
What accounts the most for transfusion related mortality over the world?
what % of pts with TRALI require intubation?
what is the mortality rate?
TRALI
70-90% will not respond to O2 and need intubation
mortality ~5%
TRALI occurs within what timeframe after transfuion
once it occurs, how long does TRALI last?
mechanism?
within 6 hours
lasts for about 72 hrs
DONOR antibodies attack stuff in the host body
chest tube should be inserted at what angle from the chest wall?
what is the complication rate for chest tube
chest tube is not indicated for hemothorax less than what volume?
less than 30 degree angle from the chest wall
True. do the digital exam
25% complication rate
not indicated for volume < 300cc
hemothorax is housefeld unit what on CT?
abx for trauma chest tubes?
35-70
no prophylactic abx for traumatic chest tubes
what does flexible bronchoscopy do to: - airway resistance - PaO2 - PaCO2 - end-expiratory lung volumes - tidal volume what happens to PaO2/FiO2 after bronchoalveolar lavage?
- airway resistance: higher
- PaO2: lower
- PaCO2: higher
- end-expiratory lung volumes: lower
- decreases tidal volume
- PaO2/FiO2 can be decreased for more than an hr
LMWH vs. UFH for TBI patients
- VTE rate?
- mortality rate?
- rate of HIT?
For patients with traumatic brain injury, use of low molecular weight heparin for VTE prophylaxis results in LOWER ODDS RATIO OF VTE and LOWER MORATLITY compared with unfractionated heparin
LOWER HIT (10x more with UFH)
therapeutic hypothermia. target temperature and duration after a cardiac arrest?
33-36C, 24 hrs
question describes a young football player with concussion. HDS, GCS14. dc home or observe?
observe first in the ed for several hours. up to 24 hr obs can be indicated
if develops vomiting, headache, seizure then CTH
pneumomediastinum after trauma is pretty common and benign. what kind of pneumomediastinum should raise your alert a bit though?
posterior pneumomediastinum or pneumo throughout the whole mediastinum should trigger contrast/endoscopy studies to rule out esophageal injury
GSW to buttock. EUA shows rectal injury. regardless of where the injury is, what do you do first?
how do you decide to repair the injury or not?
proximal diverting colostomy first
If an extraperitoneal rectal injury is located much closer to the anal opening, primary repair may be considered if the injury can be fully evaluated and closed. 8-10cm from dentate line is a bit too proximal for repair
A 25-year-old man sustains a left zone II neck stab wound. He is hemodynamically normal without hard signs of an aerodigestive or vascular injury. He has dysphagia. What is the most appropriate next step in management?
a) CTA of the neck
b) esophagram
c) EGD
d) angiography
e) neck exploration
a) CTA
CTA of the neck is not sensitive enough to completely rule out esophageal injury; however, it is preferred as the initial diagnostic study because it has the ability to further evaluate the potential for tracheal, esophageal, and vascular injury. When the CTA of the neck is suggestive of esophageal injury, the patient requires additional testing, especially in the setting of dysphagia or odynophagia. Further workup should include contrast esophagram or flexible esophagoscopy
pregnancy and trauma. left lateral decubitus or right lateral decubitus?
left lateral decubitus to decompress the IVC
right lateral decubitus actually has an opposite effect
Which of the following is most predictive of failure of nonoperative management for blunt splenic trauma?
A. Hemodynamic normality on admission B. Grade IV splenic injury C. Hemoperitoneum D. Age younger than 40 years E. Arterial contrast blush on CT scan
Risk factors with strong evidence for failure of nonoperative management include
- age older than 40
- grade III or higher injury
- injury severity scores of at least 25.
No evidence for failure of nonoperative management exits for hemodynamic status on admission, emergency department mean blood pressure, hemoglobin, hematocrit level, or heart rate.
Blunt injury to aorta with contained rupture 1 cm distal to the left subclavian artery. what incision?
left posterolateral thoracotomy
T/F: Glasgow coma scale is a sensitive test for concussion injuries
false. GCS doesn’t guarantee no concussion
true
true
After splenectomy, what % of autotransplantation is needed to not get vaccine?
After first vaccine, do they need redosing? Which kinds how many years after splenectomy?
Needs at least 50%
Yes redose 23-pneumococcal, meningococcal 4-6 years after.
What incision for proximal control of left common carotid artery?
Median sternotomy
how to expose the infrarenal aorta?
how to expose the suprarenal aorta?
how to expose the IVC at the level of renal veins?
transect what structure to gain access to distal IVC, common iliac vein?
infrarenal aorta: Reflection of the transverse mesocolon cephalad, with incision of the retroperitoneum
suprarenal aorta: Mattox manuever
IVC: catell brasch
transect right iliac artery
