trauma/critical care/other

Question 1

Classic Stem: 72 year old man with several years of dysphagia, now c/o regurgitating undigested food. What do you want to do?

Answer 1

Zenker’s Diverticulum

Question 2

Classic Stem: 28 year old woman who is a floor nurse, complains of weakness, dizziness and headaches at the end of her shifts. One night she feels so bad, her coworkers take her to the ER where a fingerstick reveals a glucose of 30. She now presents to your office, after resolution of the acute problem.

Answer 2

Insulinoma v Munchausens.

Question 3

Air embolus: What do you do?

Answer 3

Intubate the patient;
Place patient in trendelenberg with left lateral decubitus.
Get (or complete) a central line.
Aspirate the air from RV.

Question 4

A 73-year-old male is 2 years status post CABP and 4 years status post abdominal aortic aneurysm surgery. He presents with new onset of massive hematochezia. BP-90/40, P-120/min

Answer 4

aortoenteric fistula
Can temporize with a vascular stent.
Start broad spectrum antibiotics
For the patients undergoing open repair there are the following options: (1) axillary–bifemoral bypass before graft excision and fistula repair, (2) axillary– bifemoral bypass after graft excision and fistula repair, and (3) primary aortic repair without extraanatomic bypass

Question 5

What are some long-term complications of an undrained pseudocyst?

Answer 5

Pain, biliary/duodenal obstruction, infection, hemorrhage into cyst either from erosion into stomach or splenic vein, splenic vein thrombosis with development of gastric hypertension

Question 6

Chronic Pancreatitis: If the patient is a suitable operative candidate and has a “chain of lakes” ductal anatomy, what procedure is appropriate?

Answer 6

Puestow procedure. Know how to describe. In particular, you do not anastomose mucosa of intestine to mucosa of duct. You need to extract pancreatic stones and duct should be opened well into head of pancreas.

Question 7

How can you localize an intraductal pappiloma on physical exam?

Answer 7

Try to ascertain which areolar quadrant is involved by circumferentially milking breast. There is no breast mass and you cannot localize the duct. Get mammogram/ultrasound

Question 8

How do you do a rapid sequence intubation?

Answer 8

Bag mask and preoxygenate; initial positioning.
20 Etomidate (.3mg/kg) for induction
150 Succinylcholine 2mg/kg) IV push
Use a miller blade to elevate the glottis and visualize the cords.
Visualize 7.5 ETT passing thru the cords.
Confirm placement by end tidal CO2 and auscultation.

Question 9

What are side effects of etomidate

Answer 9

Fast LOC
no hypotension
high cortisol

Question 10

what are effect and side effects of succinylcholine?

Answer 10

rapid paralysis; wears off in 8 mins

contraindicated with hyperkalemia, burns or neuromuscular disease.

Question 11

Why no versed for induction for rapid sequence intubation?

Answer 11

too slow

Question 12

What is alternative to succinylcholine for rapid sequence intubation?

Answer 12

Rocuronium (1mg/kg)

Safe in hyperkalemia/burns but causes paralysis for 30+ mins so don’t use in difficult airways.

Question 13

What formula for pediatric Endotrachial tubes?

Answer 13

Uncuffed ETT (mm ID) =(age in years/4) + 4 
Cuffed ETT (mm ID) = (age in years/4) + 3

Question 14

How do you do presacral drainage in Pelvic/rectal trauma?

Answer 14

3 cm curvilinear incision b/w coccyx and rectum
Posterior dissection carried up to level of injury
Distal rectal washout
2 liters of GU irrigant following an anal stretch

Question 15

What are indications for a fasciotomy

Answer 15

Decompression for:
Strong clinical suspicion
Compartment pressure > 40 mmHg
Compartment pressure within 30 mmHg of diastolic
BP
Bivalve any cast

Question 16

Describe Leg fasciotomy

Answer 16

In leg:
Two incisions
First incision from knee to ankle and centered
between anterior and lateral compartments
Divide fascia 1 cm above and below intermuscular
septum to free anterior and lateral compartments
respectively
Careful to avoid superficial peroneal nerve in
lateral compartment
Second incision also from knee to ankle and is
2 cm posterior to posteromedial border of
tibia

Question 17

Operative repair of a hepatic vein injury?

Answer 17

Hepatic vein injury—Pringle maneuver, Rummel
tourniquet around infrahepatic (suprarenal)
IVC, median sternotomy, open pericardium,
Rummel tourniquet around intrapericardial
IVC, +/− atriocaval shunt

Can also send to IR packed if packing controlls hemorrhage

Question 18

Classifications of pelvic fracture?

Answer 18

Anterior-posterior compression
Lateral compression
Vertical shear
Combined vector injury

Question 19

Tests for stable penetrating neck injury

Answer 19

Laryngoscopy/Bronchoscopy—to assess for airway
injuries
Lateral C-spine—SQ emphysema, tracheal deviation
CXR—widened or pneumo-mediastinum, pneumothorax,
hemothorax, tracheal deviation
Gastrografin swallow—assess esophageal injuries
Angiography—All Zone I and Zone III injuries

Question 20

Operations for Zone I neck injury:

Answer 20

ONLY IF UNSTABLE PATIENT

(i) sternotomy to obtain proximal control for
everything except injury to left of left
midclavicular line (then left anterolateral thoracotomy)
(ii) right subclavian
median sternotomy
(iii) inominant artery
median sternotomy
(iv) left subclavian
trap door incision

Question 21

Operation for Zone II neck injury:

Answer 21

(4) Zone II
(a) explore anything that penetrates the platysma
(b) prep earlobe to umbilicus and upper thigh for
possible SVG harvest
(c) anterior SCM incision
(i) esophageal injuries
If < 24 h, repair injury in 2 layers if early
If > 24 h, T-tube drainage to create controlled
fistula or Esophagostomy
(ii) tracheal injuries
Repair primarily with 3’0 vicryl
Tracheostomy if severe injury
(iii) thoracic duct
Injury may occur in Zone I or II
Ligation acceptable
(iv) jugular vein
Repair if possible
Can ligate unilaterally only
Watch for air embolism
(v) carotid injury—
Repair even if comatose as this may be
secondary to drugs or shock
Ligate if unstable or other life-threatening
injuries
Ligate sup. thyroid and repair carotid end to
end for small defects, interpose SVG for
defects longer than 2 cm
Can reach high carotid artery by:
anterior subluxation of mandible
division of omohyoid/digastric
using Fogarty balloon to control proximal
bleeding

Question 22

When do you do ED thoracotomy?

Answer 22

Penetrating trauma with actual or impending cardiac
arrest or “Signs of life” in the field and lost
en route to ED

Question 23

how do you do ED thoracotomy?

Answer 23

Done through sixth intercostal space, left anterolateral
incision
Rib spreader, hold lung superiorly with sponge
stick or assistant’s hand
Open pericardium anterior to phrenic nerve
Clamp descending aorta jut above diaphragm
(feel for NGT)
Not for blunt trauma or when lost “signs of life”
and > 10 minutes resuscitation en route

Question 24

When to take to OR for thoracotomy?

Answer 24

CT output > 1000 cc initially
CT output > 200 cc for 4 consecutive hours
Large air leak with hypoxemia (on side of injury)
Esophageal injury (right thoracotomy unless distal
third esophagus)
Left subclavian and descending aortic injury

Question 25

When to do median sternotomy?

Answer 25

Left supraclavicular stab wound
Suspicion of great vessel injury (pulmonary hilum)
Suspicion of injury to right inominant artery (can’t
reach this through anterolateral thoracotomy)
Tracheal injury
Allows access to ascending aorta, inominant, proximal
right subclavian, right carotid

Question 26

When to do pericardial window?

Answer 26

Stable pt with transmediastinal GSW

Dilated neck veins/high CVP and pt in shock