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Forget Nots > Trauma/Critical Care > Flashcards

Trauma/Critical Care Flashcards

1
Q

What’s the difference between a shunt vs. Dead space?

A

Shunt: (+) blood flow / (-) aeration

Dead space: (-) blood flow / (+) aeration

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2
Q

What is the PaO2 that defines failure to oxygenate?

What PaCO2 defines failure to ventilate?

A

PaO2 < 60

PaCO2 > 55

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3
Q

Mechanical ventilation safe lung strategy
Tidal volume less than what?
Plateau pressure less than?
Permissive hypercapnia up to how much?

A

Tidal volume <6cc/kg
Plateau pressure <30mmHg
Permissive hypercapnia up to pH7.2

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4
Q

What’s the difference between ALI vs. ARDS?

A

ALI: PaO2 to FiO2 ratio <300
ARDS: PaO2 to FiO2 ratio <200

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5
Q

What do NSAIDs do for renal afferent/efferent vasculature?

What does hypotension do for renal perfusion?

A

NSAIDs: inhibit afferent vasodilation (afferent constriction)

Hypotension: afferent constriction, efferent dilation

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6
Q

What’s the lifespan of RBC’s?

Lifespan of platelets?

Lifespan of wbcs?

A

RBC’s: 120 days
Platelets: 8-9 days
Wbcs: 1-2 days

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7
Q

What are the five grades of pancreatic trauma? How do you treat them?

[T/F] grade III pancreatic injury can be managed non-operatively

A

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

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8
Q

What’s the grading system for blunt injuries to the duodenum?

A

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

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9
Q

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?

A 
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

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10
Q

If Pringle slows down the bleeding, what does it mean? Where is the injury?

What might you consider for repair if Pringle works?

A

It means IVC and hepatic veins are probably fine.

Consider hepatic artery ligation

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11
Q

What complication may occur if you ligate the hepatic artery?

A

Abscess or a biloma

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12
Q

Surgical airway in a 13 yr old. What do you do?

A

Cricothyroidotomy for kids 12 or older.

For kids younger than 12 -> 12, 14, 16 gauge needle airway

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13
Q

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?

A

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

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14
Q

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?

A

NG tube. Can use methylene blue to identify hole. Close in two layers, absorbable suture

> 24hrs then esophagostomy, feeding tube, tissue buttress

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15
Q

Neck stab wound. Tracheal injury. What do you do?

What if a tracheostomy is needed? Through the same hole?

A

Repair with interrupted absorbable sutures muscle buttress

Never through the same hole

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16
Q

Neck stab wound. Vertebral artery injury. What do you do?

A

IR embolize

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17
Q

Neck stab wound. Big vein injury. IJ. Use a graft to repair? Why or why not

A

Graft will thrombose. Just ligate the vein

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18
Q

Odontoid fx types. I, II, III

Which one tends to be painful?

Which type may have airway compromise due to swelling?

A

Painful: type I

Airway: type II

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19
Q

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?

A

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

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20
Q

ED thoracotomy

  • which intercostal space?
  • how many joules to defribrillate after EDT? How many Joules to externally defib?
  • to Foley or not to Foley?
A

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

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21
Q

Resuscitation goals for

Plt
INR
Fibrinogen
T

A

Plt > 100k
INR < 1.2
Fibrinogen > 100
T > 37 (98.6)

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22
Q

Define pancreatic leak

What’s considered a minor fistula vs. high output.

A

Drain amylase > serum x3

Minor fistula < 200cc/day
High output > 700cc/day

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23
Q

Boundary of posterior neck triangle

A

Sternocleido anteriorly
Trapezius posteriorly
Clavicle at the base

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24
Q

Neck stab wound. Totally stable, no crepitus, no dysphagia, no dysphonia. Small 2cm sound. Non-op management. Still do CTA? Chest XR? Barium swallow?

A

Yes to all. Every neck wound if non-op, get everything

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25
Q

What are some differences between superficial second degree burn vs. Deep second degree burn?

A

Superficial second degree
Wet
Pink

Deep second degree:
Dry
More pale than pink

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26
Q

When doing a nephrectomy, what are the tributary vessels to renal vein? Do you divide the vein first or the artery first?

A

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

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27
Q

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?

A

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

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28
Q

Externally rotated leg. Abducted.

What dislocation? What associated injury?

A

Anterior disloc

Femoral vein thrombosis

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29
Q

Internally rotated leg, adducted

What dislocation? What associated injury?

A

Posterior dislocation. Sciatic nerve inj

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30
Q

Distal radius fracture. What nerve?

A

Median nerve

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31
Q

Mid humerus fx. What nerve!

A

Radial

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32
Q

Supracondylar humerus fx. What injury?

A

Distal humerus fx

Brachial artery

Volksmann ischemic contracture

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33
Q

Anterior shoulder dislocation. What injury?

A

Axillary nerve

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34
Q

Spenic lac grade. % surface area hematoma & cm?

What’s the failure rate for conservative management?

A

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%

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35
Q

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?

A

Staph aureus, strep. Cephalosporin

Cat bites: tenosynovitis

Animal bites: augmentin (amox-clav)

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36
Q

What are the different phases of empyema?

What % of empyema are culture positive?

When/how many days is an operation needed?

A

Acute(7d), subacute, chronic

20-30% not culture (+)

After 7d

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37
Q

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
A
  • > 300/day operate
  • most are to intrahepatic ducts
  • biliary fistulas. Usually resolve without treatment
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38
Q

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?

A

25%.

Tube size apparently doesn’t matter.

Hounsfield unit 35-70

300cc

No abx

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39
Q

What is Rivaroxaban?

What’s the reversal agent?

Does dialysis work?

A

Xarelto

Factor Xa inhibitor

Andexanet Alfa

Dialysis doesn’t work because it highly binds to proteins

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40
Q

Dabigatran. What is it?

How do you reverse?

A

Pradaxa

Direct thrombin inhibitor

Dialysis or idarucizumab (monoclonal antibody)

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41
Q

What are the components of the Berlin definition of ARDS? What are the mortality rates based on mild moderate severe ards?

A

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

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42
Q

Caloric requirement for critically ill?

Protein requirement for critically ill?

A

25-30kcal/day

1.5-2g/kg/day

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43
Q

What is the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition diagnostic criteria for malnutrition?

A

Involuntary loss of >10% body weight in 6 months

Or

5% body weight loss in 1 month

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44
Q

Up to how many tracheal rings in length can be repaired primarily?

Best way to gain access to distal tracheal injury?

A

Up to 5 or 6 tracheal ring length

Right posterolateral thoracotomy provides the best access to the distal intrathoracic trachea

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45
Q

What incision for proximal control of right subclavian artery?

A

Median sternotomy

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46
Q

What incision for proximal control of left subclavian artery?

what about for exposure of an injury 1cm distal to left subclavian takeoff?

A

Anterior thoracotomy in the third intercostal space

for aortic injury distal to subclavian takeoff -> Left posterolateral thoracotomy

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47
Q

When to use infraclavicular vs. Supraclavicular incisions for subclavian artery injury?

A

Infraclav: distal control of the subclavian artery

Supraclav: for repair of the vessel

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48
Q

Mechanical ventilation safe lung strategy
Tidal volume less than what?
Plateau pressure less than?
Permissive hypercapnia up to how much?

A

Tidal volume < 6mL/kg
Plateau pressure < 30mmHg
Permissive hypercapnia up to pH 7.2

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49
Q

What’s the difference between ALI vs. ARDS?

A

ALI: PaO2 to FiO2 ratio <300
ARDS: PaO2 to FiO2 ratio <200

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50
Q

Where is calcium absorbed?

How is it absorbed? Active or passive?

A

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

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51
Q

Indication for therapeutic hypothermia (TH)

What T?

When should you stop?

A

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

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52
Q

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?

A

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.

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53
Q

What are the components of vital capacity?

A

Inspiratory reserve volume + tidal volume + expiratory reserve volume

Inspiratory capacity = inspiratory reserve volume + tidal volume

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54
Q

What is inspiratory capacity?

A

Tidal volume + inspiratory reserve volume

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55
Q

What is FRC?

A

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

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56
Q

4 components of total lung capacity?

A

Inspiratory reserve volume + tidal volume + expiratory capacity + residual volume

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57
Q

Respiratory quotient of pure carb metabolism

A

1

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58
Q

Respiratory quotient of pure protein metabolism

A

0.8

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59
Q

Respiratory quotient of pure fat metabolism

A

0.7

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60
Q

What does RQ > 1 mean vs. RQ < 1?

A

> 1 means overfeeding glucose/fat

<1 means ketogenesis

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61
Q

Free water deficit equation

A

(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)

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62
Q

Normal ICP?

A

7-15 mmHg

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63
Q

When to transfuse platelets for

  • hospitalized adult pt to reduce spontaneous bleeding
  • surgery
  • for central line
A
  • hospitalized adult pt to reduce spontaneous bleeding: < 10 x10^9
  • surgery: < 50 x 10^9
  • for central line: < 20 x 10^9
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64
Q

What’s p Delta in compartment check?

What’s the threshold for fasciotomy?

A

DBP - compartment pressure

< 20-30 mmHg usually indicates fasciotomy

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65
Q

top 3 Most common hospital acquired infection?

A 
#1: hospital acquired pneumonia 25-48%
#2: surgical site infxn 24%
#3: UTI 14%
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66
Q

Most common fungal pulmonary infection? Treatment.

A

Histoplasmosis, itraconazole

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67
Q

What is apixaban

mechanism?
How do you reverse?
kidne or liver clearance?

A

Eliquis. Factor Xa inhibitor

idarucizumab (praxbind)
dialysis
Pcc

liver clearance

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68
Q

What to do with carotid injuries depending on size?

What about very high carotid injury? How to expose

Jugular injury?

A

<2 cm: primary repair
>2 cm: vein patch (saphenous graft)

High: subluxate the mandible or divide the digastrics

Just ligate the veins

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69
Q

For ogilvie’s how much neostigmine do you give? Over how long?

A

2.5mg over 3 minutes

Should see effect within 10 minutes

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70
Q

When is resuscitative thoracotomy indicated for penetrating vs blunt traumas?

A

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

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71
Q

What are the grades of frostbite?

A

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

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72
Q

Medially rotated leg vs externally rotated leg. gotta watch out for injury to what structure for each scenario?

A

Internal rotation: posterior dislocation. Sciatic nerve

External rotation: anterior dislocation.

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73
Q

What makes a DPL positive?

A

~10mL of gross blood, bile, food

> 100,000 RBC

> 500 WBC

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74
Q

What are the lab value indications for damage control laparotomy for trauma?

A

PH < 7.2
Base deficit > 15
Temp < 35

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75
Q

What is the key difference between cerebral salt wasting and SIADH and their treatment?

What about diabetes insipidus?

A

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

76
Q

Through which receptor does donutamine cause vasodilators effects?

A

B2 agonist.

Primarily B1 agonist -> inotrope

77
Q

Ionotropic agent of choice in cardiogenic shock?

When would you use dopamine?

A

Dobutamine.

Dopamine only if pt develops hypotension with dobutamine

78
Q

When do you do crani for SDH? what size and how many mm midline shift?

A

Shift > 5mm
Thickness > 10mm

Or change in gcs > 2 points

79
Q

What does the abdominal compartment syndrome do to ICP and why?

A

Increases ICP because increased thoracic P prevents venous outflow out of the brain

80
Q

1 wk after CABG diffuse ST elevation. What is the diagnosis and treatment? When would you cath?

A

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

81
Q

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?

A

Heart failure. No longer endocarditis

No survival difference

Bioprosthetic requires more reoperation

Mechanical valve: lifelong AC

82
Q

T/F: PEG and open G-tubes have similar morbidity/mortality

A

True apparently

83
Q

Empiric treatment for VAP?

A

vanc and zosyn

Or any combo that covers gram (-) and MRSA

84
Q

Median survival of hepatorenal syndrome type I vs. II

What is the only treatment for hepatorenal syndrome?

what electrolyte abnormality?

A

Type I: 2 weeks
Type II: 6 months

Liver txp is the only rx

hypokalemia, hyponatremia

85
Q

What is the propofol infusion syndrome?

A

Metabolic acidosis, kidney failure, heart failure, rhabdo (elevated cpk)

Stop the propofol

86
Q

Oxygen extraction ratio is usually around what?

Oxygen extraction ratio is highest where?

Increase or decrease with hypothermia?

A

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

87
Q

What aortic valve area is an indication for surgical aortic valve replacement?

What’s an indication for balloon valvuloplasty?

A

Area < 1 cm2

Balloon if unable to tolerate surgery

88
Q

1 cause of mortality from refeeding syndrome is what?

In refeeding syndrome metabolism shifts from what to what? Protein? Carb? Fat?

A

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

89
Q

Anaphylaxis results in tachycardia or bradycardia?

A

Initially tachycardia but turns bradycardia. So can be both

90
Q

What is polymorphic v-tach and what’s the treatment

A

It’s torsade. Magnesium

91
Q

Indications to operate in mitral valve endocarditis?

A 
Persistent sepsis
New onset heartblock
Valve dehiscence
Systemic embolism
Fungal or multi drug resistant organisms
92
Q

What is the most common organism associated with ventilator associated pneumonia?

Staph in VAP tends to be methicillin sensitive or resistant?

A

Pseudomonas

More than 1/2 of staph in VAP are MRSA

93
Q

What’s the mechanism of action of IABP?

what does it do to preload and afterload?

A

Decreases preload AND afterload

Works by increasing aortic diastolic pressure. Increases peak diastolic pressure improving coronary perfusion

94
Q

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?

A

Liver failure has excess of aromatic amino acid so less is better. Needs more branched chain amino acids

Valine leucine isoleucine

95
Q

Cerebral perfusion pressure should be kept between what values?

A

50-70mmHg

CPP = MAP - ICP

96
Q

7yo. What size ET tube?

A

7/4 + 4 = 5-6Fr

Or size of the pinky finger

97
Q

Intubating a trauma pt now. Urgent. Why would ketamine not be a good choice?

Versed

A

There could be a head injury

Versed drops bp

98
Q

What is the normal blood pressure for a 7yo?

A

80 + age x2 = 94

99
Q

What is the dose of etomidate/succinylcholine for RSI?

A

Etomidate: 0.3mg/kg

Succinylchokine: 1-2mg/kg

100
Q

What is the LOaVES protocol?

A 
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)
101
Q

Where is the narrowest point of the airway in adults vs children?

A

Adults: vocal cords
Children: cricoid. It’s below the cricoid

102
Q

Other than the tachycardia and narrowed pulse pressure what do you see in class 2 hemorrhagic shock?

A

Delayed cap refill

103
Q

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?

A

80cc/kg

24cc/kg. 30% of the total blood volume

10cc/kg x1 for blood. 20cc/kg for fluid bolus

104
Q

Three things you can do to quickly lower the ICP

A

1) raise the head of bed
2) mannitol (0.5g/kg) bolus
3) hyperventilate (CO2 between 35-40)

105
Q

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?

A

Open the serosa evacuate the hematoma, close

106
Q

What is the most common cause of spontaneous spleen rupture in the US?

Worldwide?

A

hematologic malignancy > Mononucleosis

Malaria

107
Q

Most common reason to do a partial splenectomy?

A

Gaucher’s disease

Genetic disease

Fat buildup in spleen, etc

108
Q

How do you expose the lower abdomen during trauma?

A

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

109
Q

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?

A

Third portion of duodenum

110
Q

Gsw to lower abdomen. Aortic bifurcation injury. What do you do if no contamination, stable

What if poop all over the place?

A

Aorta bifem.

Poop -> ligate proximal ligate distal, open abdomen. Live to fight another day. Then do ax-fem, fem-fem

111
Q

Bullet goes through at the bifurcation of IVC. what to do?

A

Ligate infrarenal ivc with impunity.

112
Q

When you ligate infrarenal ivc for trauma, what’s a caveat? Location of ligation

A

As close to the renals as possible. Otherwise you get dvts

113
Q

Bullet goes through suprarenal Ivc. What to do?

A

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

114
Q

Bullet goes through celiac trunk. What do you do?

A

<2% bowel death rate from celiac ligation.

Get plenty of collaterals from the SMA.

Three branches of celiac: left gastric, splenic, common hepatic

115
Q

Bullet goes through SMA. No veins available. Tons of contamination.

A

90% incidence of bowel death. Can’t resect.

Take internal iliac artery and use it

116
Q

How much small bowel do you need to avoid short bowel syndrome? If you have a colon vs if you dont

A

If you have colon: 75 - 100cm.

If you don’t: 150cm

117
Q

Bullet goes through SMV. can you ligate it?

Can you ligate portal vein?

A

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

118
Q

Bullet goes through CBD. What do you do?

A

If <50% then primary repair over a T-tube

If >50% don’t out the two ends together. Rny hepaticoJ. Retrocolic

119
Q

Bullet goes through head of the pancreas. What do you do?

A

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

120
Q

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?

A

No vicryl because of pancreatic enzymes. Use permanent suture like prolene, 2 layers

> 50% injury -> pyloric exclusion, drain the duodenum.

121
Q

Earliest signs of uncal herniation?

A

Anisocoria (unequal pupil size), ptosis, impaired extraocular movements.

Otherwise normal motor

122
Q

A transected nerve put back together. How fast does it grow back daily?

A

1-2 mm/day

1inch/month

123
Q

What kind of tracheal injuries can be managed nonoperatively other than hemodynamically stable ones?

Size? % circumference involved?

A

<4cm, <1/3 circumference, well opposed edges

124
Q

Post-TURP. 154/109, HR54, serum Na: 110, K: 5.4

What to do?

A

Give lasix to remove excess fluid, hypertonic saline

Due to using large amounts of hypotonic irrigation during the procedure

125
Q

What is the Wells criteria?

A

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

126
Q

Risk factors for development of multiorgan failure (MOF) within 72 hrs of injury vs after 72 hrs?

A

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

127
Q

What are the prerequisites before apnea test can be performed?

A 
Euvolemia
PaCO2 35-45
T > 96
SBP > 100 (pressors okay)
PaO2 > 200
128
Q

What deficiency causes macrocytic anemia with elevated methylmalonic acid and normal homocysteine?

A

B12. Methylmalonic acid level is normal even if folic acid is low

Normal methylmalonic acid + high homocysteine: folic acid

129
Q

What dificiency causes macrocytic anemia with normal methylmalonic acid and high homocysteine?

A

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

130
Q

What are the other names for vitamin B1 and B2?

What do their deficiencies cause?

A

B1: thiamine. Causes beriberi
B2: riboflavin. Causes iron deficiency anemia

131
Q

Describe the stages of Tylenol toxicity

A

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

132
Q

T/F: for trauma lap and open abdomen, 3% saline reduces time to fascial closure

A

True apparently

133
Q

T/F: perc trach is safe without bronch

T/F: perc trach is contraindicated in pts with recent anterior cervical fusion

A

True. Originally bronch was used but safe without it

False. Safe in pts who had cervical fusion

134
Q

For sepsis what is the initial amount of crystalloid that needs to be given per kg?

A

30cc/kg in the first 3 hrs

3L for 100kg person over 3 hrs

135
Q

T/F: massive transfusion protocol improves 30d mortality

What does 1:1:1 actually mean?

A

F. It improves the 24hr survival

6u pRBC, 6u FFP, 6 pack of plts

136
Q

What is the new definition of sepsis?

Definition of septic shock?

What about severe sepsis?

A

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

137
Q

For hypovolemia, does capillary permeability increase or decrease?

A

Hypovolemia -> capillary permeability decreases to maintain hydrostatic pressure

138
Q

What is the grading system for rectal injury?

A 
I: contusion or hematoma/partial thickness laceration
II: laceration < 50% circumference
III: laceration > 50% circumference
IV: full thickness laceration
V: devascularized segment
139
Q

Rectal trauma grade III and above need what?

A

Resection, end colostomy

140
Q

PPI’s in intubate ICU pts. Do they:

  • protective against stress ulcers?
  • increase nosocomial pneumonia rate?
A

Not GI protective

They do increase pneumonia rate

141
Q

Can you give epinephrine through interosseous?

A

Yes

142
Q

Critically ill patients may require (more/less) heparin than normal people. Why?

A

More than normal

They tend to have increased levels of acute phase proteins which bind heparin. This is treated with escalating doses of heparin

143
Q

What are the components of cryo?

A
  • fibrinogen
  • vWF
  • factor 8
  • factor 13
  • fibrinectin
144
Q

Sternal fracture. Ekg shows new LBBB. Why does this person need an echo?

A

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

145
Q

Cardiac index below what after CABG indicates aortic balloon pump?

A

<2.2 L/min/m²

Normal CI is between 2.5-4.5L/min/m²

146
Q

1 cause of jugular vein suppurative thrombiphlebitis

A

Pharyngitis

147
Q

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

A

False. 5th intercostal space

148
Q

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?

A

Right ventricle

Wedged pressure begins after the QRS complex

149
Q

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?

A

Right atrium

Pulmonary artery

150
Q

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.
A
  • subclavian vein originates lateral to the first rib

- it’s the lateral edge of the SCM

151
Q

Spinal dysreflexia

What T level?

What happens to BP, HR,

A

Spinal cord injury at or above T6

Hypertension
Bradycardia
Diaphoresis

Kinda like cushing’s reflex I guess but no brain inj

152
Q

air embolism. what position?

A

head down, right side up

left lateral decubitus and trendelenburg

153
Q

fat embolism. treatment?

A

supportive care

154
Q

The broselow tape can be used for kids under what age, under what weight?

Do you have to take gender into account?

Arm span?

A

12 and under.
Under 36 kg (80lb)

Gender doesn’t matter

Arm span doesn’t matter

155
Q

In pregnancy, they physiologically [hyper/hypo]-ventilate. So the normal PaCO2 in pregnant women ranges are [ ? ]

A

Increases minute ventilation in pregnancy/hyperventilate.

Normal PaCO2: 25-30

PaCO2 of 36 in a pregnant woman can actually mean impending respiratory failure

156
Q

Up to heart rate of what can be normal in pregnancy?

A

HR may increase by 15-20 during pregnancy

Even HR 115 can be normal

157
Q

How is blood pressure affected in pregnancy?

A

Tend to be hypotensive. 5-15mmHg lower. Both systolic and diastolic

158
Q

Central cord syndrome

A

Motor loss in b/l upper > Lower

159
Q

Anterior cord syndrome

A

Complete loss of motor, pain, temperature below the injury.

Intact proprioception and vibration

160
Q

Indications for ICP monitoring in a trauma pt with a normal CT

A

1) post-resuscitation GCS 8 or less

2) age > 40
3) any history of hypotension
4) abnormal posturing

161
Q

Supracondylar humerus fracture. What contracture? From what injured structure?

A

Volkmann ischemic contracture. Brachial artery injury

162
Q

Anterior shoulder dislocation. What structure iniured

A

Axillary nerve

163
Q

Distal radius fx. What structure is injured?

A

Median nerve compression

164
Q

Cerebral salt wasting vs SIADH vs DI

Volume status? Sodium load? Urine output? Treatment?

A

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

165
Q

Bullet goes through I’ma. Treatment? Second look?

A

Ligate IMA with impunity. No need for second look

166
Q

SVR [increases/decreases] with increasing age

A

SVR increases with age

167
Q

What happens to SVR on septic pt?

Cardiac index? CVP?

A

Decreases SVR

Increases cardiac index

Decreased CVP

168
Q

indication for stress ulcer prophylaxis in the ICU (6)

A 
traumatic brain/spinal cord injury
ventilation > 48hr (not 24)
INR > 1.5
plt < 50k
severe burn > 35% surface area
high dose steroids 250mg hydrocortisone
169
Q

What accounts the most for transfusion related mortality over the world?

what % of pts with TRALI require intubation?

what is the mortality rate?

A

TRALI

70-90% will not respond to O2 and need intubation

mortality ~5%

170
Q

TRALI occurs within what timeframe after transfuion

once it occurs, how long does TRALI last?

mechanism?

A

within 6 hours

lasts for about 72 hrs

DONOR antibodies attack stuff in the host body

171
Q

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?

A

less than 30 degree angle from the chest wall

True. do the digital exam

25% complication rate

not indicated for volume < 300cc

172
Q

hemothorax is housefeld unit what on CT?

abx for trauma chest tubes?

A

35-70

no prophylactic abx for traumatic chest tubes

173
Q 
what does flexible bronchoscopy do to:
- airway resistance
- PaO2
- PaCO2
- end-expiratory lung volumes
- tidal volume
what happens to PaO2/FiO2 after bronchoalveolar lavage?
A
  • 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
174
Q

LMWH vs. UFH for TBI patients

  • VTE rate?
  • mortality rate?
  • rate of HIT?
A

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)

175
Q

therapeutic hypothermia. target temperature and duration after a cardiac arrest?

A

33-36C, 24 hrs

176
Q

question describes a young football player with concussion. HDS, GCS14. dc home or observe?

A

observe first in the ed for several hours. up to 24 hr obs can be indicated

if develops vomiting, headache, seizure then CTH

177
Q

pneumomediastinum after trauma is pretty common and benign. what kind of pneumomediastinum should raise your alert a bit though?

A

posterior pneumomediastinum or pneumo throughout the whole mediastinum should trigger contrast/endoscopy studies to rule out esophageal injury

178
Q

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?

A

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

179
Q

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

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

180
Q

pregnancy and trauma. left lateral decubitus or right lateral decubitus?

A

left lateral decubitus to decompress the IVC

right lateral decubitus actually has an opposite effect

181
Q

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
A

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.

182
Q

Blunt injury to aorta with contained rupture 1 cm distal to the left subclavian artery. what incision?

A

left posterolateral thoracotomy

183
Q

T/F: Glasgow coma scale is a sensitive test for concussion injuries

A

false. GCS doesn’t guarantee no concussion

184
Q
A

true

true

185
Q

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?

A

Needs at least 50%

Yes redose 23-pneumococcal, meningococcal 4-6 years after.

186
Q

What incision for proximal control of left common carotid artery?

A

Median sternotomy

187
Q

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?

A

infrarenal aorta: Reflection of the transverse mesocolon cephalad, with incision of the retroperitoneum

suprarenal aorta: Mattox manuever

IVC: catell brasch

transect right iliac artery

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