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FRCS > Trauma/Emergency > Flashcards

Trauma/Emergency Flashcards

1
Q

How should anticoagulants be managed with UGIB?

A

Continue aspirin
Stop clopidogrel etc until haemostasis unless stents (40% risk of death/MI within 1 year), aim restart 5-7 days)
Stop warfarin/doacs

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2
Q

What medical treatments are required in the post operative period after perf DU repair?

A

Broad spectrum antibiotics covering gram+ve, gram-ve and anaerobes - e.g. Co-amoxiclav and gent

Collect fluid samples

Consider antifungals if immunocompromised, old or comorbid (Azoles if not previously exposed, if previously exposed then give echinocandins)

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3
Q

What is the most common complication of peptic ulcer disease?

A

Bleeding - 0.02-0.06% annual incidence, 30d mortality of 8.6%
Perforation less common but higher mortality

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4
Q

How are ERCP perforations classified?

A

Stapfer classification

1) Hole lateral/medial wall - endoscope mania
2) periampullary (sphincterotomy related)
3) Distal ductal
4) retroperitoneal air (guide wire)

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5
Q

What is an appropriate cerebral perfusion pressure (MAP-ICP) in adults and children?

A

70 in adults, 40-70 in children

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6
Q

What threshold should be used for CT in suspected appendicitis?

A

> 40 (WSES Jerusalem guidelines 2020)

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7
Q

What is the indication for vATS with traumatic pneumothorax?

A

Persistent air leak at 3 days

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8
Q

Which organ is most frequently injured by blunt trauma?

A

Spleen

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9
Q

How can entero-cutaneous fistulae be classified?

A

Output -

High >500ml in 24 hours
Moderate 200-500ml in 24 hours
Low - <200ml in 24 hours

Organ

Type 1 - Oesophageal/gastroduodenal
Type 2 - Small bowel
Type 3 - Colonic
Type 4 - enteroatmospheric

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10
Q

Which main vessel cannot be accessed easily through a midline sternotomy?

A

Proximal left subclavian (anterolateral thoracotomy at 3rd IC space)

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11
Q

Where does the brachial artery begin?

A

Lower border of Teres Major

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12
Q

What is the AAST splenic trauma classification?

A

1 - <1cm or <10%
2 - 1-3cm depth lac or 10-50% surface SCH
3 - >3cm lac or SC haematoma >50% or IC haematoma >5cm
4 - >25% devascularised
5 - shattered spleen/devascularised hilum

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13
Q

For patients with non-variceal UGI bleed, what adjunctive medical treatments should be used?

A

Prokinetics (erythromycin) and PPI infusion IV for 72 hours then 6-8 weeks -halves rebreeding risk.

If platelets <50 then infusion
Transfusion trigger of 70

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14
Q

What is the AAST liver trauma classification?

A

1: Lac <1cm depth or sc haematoma<10%
2: Lac 1-3 depth <10cm or sc haematoma 10-50%
3: Lac >3cm depth or SC >50% or IC haematoma >10cm
4: Disruption of 25-75% hepatic lobe
5: Disruption of >75% hepatic lobe
6: Hepatic Avulsion

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15
Q

How quickly will IV iron achieve results?

A

About 3 weeks

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16
Q

What are the mechanisms of injury with gunshot?

A
  • Laceration/cutting
  • Cavitation
  • Direct energy transfer on impact
  • Fragementation
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17
Q

What proportion of abdominal stab wounds do not penetrate the peritoneum

A

1/3

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18
Q

How is pancreatitis graded on CT?

A

Balthazar severity index

- Grade 1-4 + necrosis <30,30-50,>50

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19
Q

What are the Atlanta criteria for severity of pancreatitis?

A

Mild - interstitial oedematous, no failure, resolves in 1 week (80-85%)
Moderate - transient organ failure, local complications
Severe - persistent organ failure

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20
Q

What are risk factors for PUD?

A 
NSAIDS (inhibit PDE synthesis)
Smoking (inhibits HCO3- increases acid)
H.Pylori
Bariatric marginal ulcer
FAsting
Drugs
Zollinger-Elliison
Steroids
Alcohol
Bevacizumab
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21
Q

What is the most superficial structure in the popliteal fossa?

A

The tibial nerve. Starts laterally and passes medially

The artery is deepest

Encountered first in a medial exploration proximally then after the vein distally

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22
Q

What is the incidence of staple line bleed after colorectal surgery?

A

1-2%

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23
Q

If gallstones and alcohol are excluded as causes of pancreatitis, what other causes need to be investigated?

A

1 - metabolic (hypercalcaemia, hyperlipidaemia)
2 - prescription drugs
3 - microlithiasis
4 - hereditary causes PRSS1 mutation (AD)
5 - Autoimmune (IgG4)
6 - malignancy
7 - Anatomical abnormalities

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24
Q

If the CFA is inaccessible through haematoma how may proximal control be obtained?

A

Through dividing the inguinal ligament or posterior inguinal canal

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25
Q

How should patients with Cirrhosis be surveilled for varices?

A

OGD at diagnosis

  • No varices –> rescope 2-3 years
  • G1 varices –> rescope 1 year
  • G2/G3 varices or red signs –> Propranolol or VBL
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26
Q

What single preendoscopy treatment has been shown to improve outcome in patients with variceal bleeds?

A

IV antibiotics

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27
Q

What are the classical signs of appendicitis?

A

Rosvings sign
Obturator sign - RLQ pain with int/ext rot right hip
Psoas sign - RLQ pain with extension of right hip

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28
Q

Which organ is most often damaged by penetrating stab wounds?

A

Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)

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29
Q

When is the recommended timing of OGD for UGI bleed?

A

Within 24 hours (unless unstable or variceal)

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30
Q

What are Cullen’s, Grey-Turner and Fox’s signs?

A

Retroperitoneal bleeding –> bruising around:

Cullens - umbilicus
Grey-Turner - flank
Fox - inguinal ligament

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31
Q

How is the brachial artery accessed?

A

Supine, arm abducted, incision in groove between biceps and triceps

Incise deep fascia, avoiding basilic vein at lower aspect

First aspect encountered is median nerve (starts lateral and passes anteriorly)

Distally - S shaped incision across ACF, with brachial artery bifurcation immdeidately deep to biceps tendon

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32
Q

What are the indications for clamshell thoracotomy?

A

Penetrating trauma with cardiocirculatory arrest, <15min of CPR

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33
Q

What technical aspects of appendicectomy are evidence based?

A

WSES Jerusalem guidelines

  • Suction only in complicated disease
  • no difference in mesoappendix control
  • stump control loop or suture
  • no drains
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34
Q

Which artery is the classical cause of a traumatic extradural haemorrhage?

A

Middle meningeal

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35
Q

What scoring systems are useful in appendicitis?

A

Acute appendicitis score in women
Appendicitis inflammatory response score in men

Most important factor is location/severity of pain

If low risk - <1% risk of advanced appendicitis

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36
Q

How do you perform a four compartment fasciotomy?

A

Anterior incision - for anterior and lateral compartments - 2 finger breadths lateral and below tibial tuberosity to two finger breadths proximal to lateral malleolus - then 2 x fascial incisions

Posterior incision - 2 finger-breadths posterior to medial border of tibia and 2 FB distal to head to 2FB sup to medial malleolus, then sup fascia opened and deep entered by taking gastrocneumeus/soleus down

Risk - Anterior - superficial peroneal
Posterior - long saphenous vein

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37
Q

What cranial nerve is most frequently involved after head injury and raised ICP?

A

3rd nerve - occulomotor - caused dilated pupils with poor light response
Often associated with 4,5 and 6th nerve palsies

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38
Q

Which organisms are involved in Post splenectomy sepsis?

A

Encapsulated organisms - Neisseria meningitides, Haemophilis Influenzae and Streptococcus Pneumoniae

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39
Q

When should a cholangiogram be performed after insertion of a cholecystostomy?

A

4 weeks

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40
Q

Where will an embolus most frequently lodge in mesenteric ischaemia?

A

SMA distal to origin of middle colic and pacnreaticoduodenal

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41
Q

How should WON and pseudocysts be managed?

A

Best is probably cystogastrostomy, with lumen apposing metal stent (LAMS) for WON

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42
Q

What proportion of pancreatic ductal disruptions are caused by penetrating injury?

A

70%

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43
Q

What is the most frequent biochemical abnormality seen in burns patients?

A

Hypernatraemia

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44
Q

How often is free air seen in a perf DU?

A

30-85% of cases

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45
Q

What is the trauma triad?

A

Hypothermia
Metabolic acidosis
Coagulopathy

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46
Q

When should OGD be performed with caustic ingestion?

A

<24 hours - risk of perforation maximal about 3 days

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47
Q

What is the management of choice for endoscopic oesophageal perforation?

A

Endoscopic closure and SEMS

SEMS>Surgery - WSES guidelines
Minimum of 2-4 weeks

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48
Q

What is the most prognostic criteria for pancreatitis?

A

Presence of SIRS - 2/4 of

T>38/<36, HR>90, RR>20, WCC<4/>12

At 48hrs >admission

CRP >150
Urea >20

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49
Q

What proportion of patients with an oesophageal FB obstruction will have underlying disease?

A

25% (Schatzki ring, eosinophilic oesophagi’s, achalsia, tumours)

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50
Q

What predictors of outcome are available for Perf DU?

A

NELA

Boey, PULP, ASA, Hypoalbuminaemia

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51
Q

What scores can be used to predict UGI bleeding risk pre OGD

A

Glagow-Blatchford - if ≤1 then very low chance of requiring intervention
if ≥7 very high risk

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52
Q

When should splenectomy be considered in variceal disease?

A

Gastric varices with splenic vein thrombosis or left side portal hypertension

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53
Q

When should enteral nutrition be instituted for patients with pancreatitis?

A

Within 48-72 hours. There is no difference between OG/NG if tolerated

(NICE)

Decreases sepsis, organ failure, surgery and mortality when compared to TPN (Frontline gastroenterology 2018)

Bakker RCT - no difference in Oral or NG feeding. Tolerated in 69% of severe

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54
Q

In major perineal wounds (E.g. devolving), what abdominal procedure is often required

A

End colostomy

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55
Q

What are the defining characteristics of the 4 stages of shock?

A

Stage 1: <750ml/15%
Stage 2:750-1500ml 15-30%
Stage 3:1500-2000ml 30-40%
Stage4: >2000ml, >40%

Stage 1 Normal
Stage 2 Tachypnoea, HR100-120, reduced UO
Stage 3 HR120-140, BP reduced, poor UO, confused
Stage 4 HR>140, v.low UO

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56
Q

What treatment should patients identified to have a Forest 2c lesion receive?

A

Medical only for 2c/3 (i.e. haematin on ulcer or clean based ulcer)

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57
Q

What are risk factors for failure of non-operative management in splenic trauma?

A

Age >55
High ISS
Moderate to severe splenic injury

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58
Q

How should patients with delayed presentation of traumatic diaphragmatic hernia be managed?

A

VATS/Thoracotomy

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59
Q

In whom with splenic injuries should angioembolisation be mandatory according to the WSES?

A

Stable patients with AAST 4/5 disease

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60
Q

What is the velocity of a high velocity gunshot wound?

A

> 300m/s

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61
Q

How would you fix a large perforated ulcer?

A
  • suspicion of gastric malignancy - 10-16% of gastric perforations
  • if Gastric/D1 - resection/reconstruction
  • if ampullary - pyloric exclusion, gastric decompression and external biliary diversion
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62
Q

What are the most common organisms of infection after human bites?

A

Strep > Staph

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63
Q

What proportion of patients with oesophageal caustic injuries develop cancer?

A

7-15% adenocarcinoma (x 1000 risk)

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64
Q

What are indications for emergency OGD (<6hours) after FB ingestion?

A

Sharp (35% perforation)
Batteries
Complete obstruction

65
Q

What are the hard signs of major vascular injury in the neck?

A

Rapidly expanding or pulsatile haematoma
visible exsanguination
thrill or bruit
dense neurological deficit

Presence of any –> theatre

66
Q

When might non-operative management be appropriate for perf DU?

A
  • demonstrated sealed on water soluble contrast study
  • <70 and less comorbid

need - NBM, IVI< NGT, PPI+/-octreotide, Abx

67
Q

What is the initial investigation for patients with caustic oesophageal injuries?

A

Contrast CT > OGD (absence of post contrast wall enhancement)

CT classification
1 - mucosal oedema
2a - mucosal/submucosal oedema - target appearance
2b - rim of external enhancement, necrotic muocsa
3 - necrotic (Absence of PCWE)

68
Q

What proportion of blunt renal injuries can be managed conservatively?

A

Up to 90%, even with urine extravasation.

If required consider endo-ureterologic and percutaneous drainage (if stable)

69
Q

When is the benefit of TXA seen in a trauma setting?

A

If given within 3 hours

70
Q

What are the zones of the retroperitoneum?

A

Zone 1 - midline from hiatus to bifurcation
Zone 2- lateral kidneys to bifurcation
Zone 3 - bifurcation to pelvis

Zone 1 all need exploring (also divided supra/inframesocolic - supra/infrarenal control)
Zone 2/3 explore penetrating if expanding. Can be observed blunt and not expanding

71
Q

What adjunctive therapies can be used for food boluses?

A

Buscopan and fizzy drinks

72
Q

How is the popliteal artery accessed through a medial approach?

A

Proximal - Incision between vastus medialis and sartorius. Incise deep fascia posterior to femur and palpate artery immediately behind bone - artery is medial here

Distal - separate incision 1cm behind tibia from medial femoral condyle, through the deep fascia avoiding the vein which is medial to the artery here

73
Q

What are the components of the GCS?

A

Eyes 1-4 None, Pain, Voice, Spontaneous
Motor 1-6 None, Extension, Flexion, Withdraws from pain, Purposeful to painful stimulus, Commands
Voice 1-5 None, Incomprehensivble, Inappropriate with discernible words, Confused, Oriented

74
Q

How should patients presenting with bleeding oesophageal varices be managed?

A

Standard then VBL
+Antibiotics, terlipressin/somatostain/octreotide
Secondary prophylaxis after D5 with VBL+NSBB

If Childs B with bleeding or Childs C –> TIPSS

75
Q

What are the types of Peptic Ulcer?

A 
Johnson criteria
1 - lesser curve
2 - gastric and duodenal (acid hyper secretion)
3 - prepyloric (Acid hyper secretion)
4 - GOJ 
5 - drug induced, anywhere
76
Q

How do you access the infrarenal aorta?

A

Kocher Maneuver to access retroperitoneum and dissect proximally to renal veins

77
Q

For patients managed non operatively for perforated appendicitis how should they be followed up?

A

<40 - nothing unless symptomatic

>40 3-17% risk of cancer –> colonoscopy and CT

78
Q

What monitoring should patients with chronic pancreatitis undergo?

A

Exocrine function and malnutrition every 12 months, 2 yearly DEXA

(NICE)

79
Q

How are liver injuries graded by the WSES?

A

Minor (AAST 1-2 stable)
Moderate (AAST 3 stable)
Severe (AAST 4-5 stable or 1-6 unstable)

80
Q

How often is Mackler’s triad seen in Boerhaaves?

A

15%

81
Q

How do you access the suprarenal aorta?

A

Open the gastrohepatic ligament and palpate the aorta against the vetebrae

82
Q

Which organ is most often damaged by gunshot?

A

Small bowel (50%)
Colon (30%)
Liver (20%)

83
Q

Are acid or alkali caustic injuries worse?

A

Acid –> Coagulation necrosis - protects against further damage
Alkali –> Liquifactive necrosis, saponification and cell death with threat to airway, more likely stricture

84
Q

Where are areas of likely impaction in the oesophagus?

A

1) Cricopharyngeus
2) Aortic arch/tracheal bifurcation
3) Diaphragm

85
Q

What are the aetiologies of oesophageal perforations?

A

60% OGD
15% Boerhaave
Other - trauma, malignancy, FB, caustics

86
Q

What are the classification systems for splenic trauma?

A

AAST (1-5)
1 - sub capsular haematoma <10%, capsular tear <1cm depth
2 - sub capsular haematoma 10-50%, intraparenchymal <5cm, 1-3cm lac
3 - haematoma sub capsular >50%, ruptured haematoma, intraparenchymal haematoma >5cm or >3cm laceration
4 - devascularisation of >25% of spleen
5 - shattered spleen, hilar disruption

and WSES (1-4)

1- AAST 1-2, stable (NOM)
2- AAST 3 , stable (consider angio)
3 - AAST 4-5, stable (all angio)
4 - AAST 1-5, unstable - Operative managment

87
Q

Which vessel injury carries the highest rate of limb loss?

A

Popliteal

88
Q

What is the Forest Classification?

A 
Endoscopic description of UGI bleeding findings 
1-3
1- bleeding
2-pathology likely to bleed
3 - pathology
89
Q

What is the mortality of patients with acute pancreatitis?

A

15-20% as inpatient

90
Q

What is the rate of recurrence in the short term following gallstone pancreatitis?

A

18% recurrence in 6 weeks.

If have ERCP, still 10%

91
Q

In which patients with oesophageal perforation can non-operative management be adopted?

A

Altorjay criteria

  • Early
  • Well
  • Cervical or contained perforation
  • No pre-existing pathology
  • Can be surveilled

Also Pittsburgh classification

92
Q

What is the Zargar classification of oesophageal caustic injury?

A 
0 Normal
1  superficial mucosal edema
2a superficial ulceration, erosion
2b deep ulceration, erosion
3a focal necrosis
3b extensive necrosis
4 perforation

For grade 2b - 80% chance of strictures in future
Grade 1-2a usually recover quickly
Grade 3+ need surgery

93
Q

Which vein is most at risk when dissecting out the PFA?

A

Lateral femoral circumflex vein

94
Q

How should patients with infected pancreatic necrosis be managed?

A

Endoscopic if possible > Percutaneous

NICE

95
Q

What pressure should a Sengstaken Blakemore tube be inflated to on insertion?

A

35-40mmHg then deflate to 25

Traction weight of 0.5-1kg after this

96
Q

How should patients with gastric variceal bleeding be managed?

A

Cyanoacrylate injection or thrombin
+Antibiotics, terlipressin/somatostain/octreotide

Secondary prophylaxis after d5 with cyanoacrylate injection. Consider NSBB or thrombin

97
Q

How should a colonic laceration be repaired?

A

In general with a primary closure

98
Q

What is the incidence of microscopic abnormalities in a macroscopically normal appendix?

A

25-35%

99
Q

How can oesophageal strictures be graded

A

Archand classification

Grade 1 Short non circumferential
Grade 2 Short circumferential elastic, 
Grade 3 <1cm circumferential, fibrotic
Grade 4a >1cm, easily dilated
Grade 4b - deep fibrotic progressive
100
Q

What is the most common cause of diaphragmatic injury?

A

Blunt trauma causing large radial tears (laceration –> smaller tears)
More common on left
Initial CXR normal in 50% of cases
Treatment with surgery

101
Q

What is the incidence of recurrence of appendicitis treated with antibiotics?

A

26.4% at 1 year and 39.1% at 5 years (APPAC trial)

Of IV antibiotics - 8% initial failure

102
Q

What is the major mechanism of pancreatic injury?

A

Deceleration injury

103
Q

For patients managed non operatively for perforated appendicitis how should they be followed up?

A

<40 - nothing unless symptomatic

>40 3-17% risk of cancer –> colonoscopy and CT

104
Q

What are the principles of surgery for oesophageal perforation (6)?

A 
Exposure
Debridement (mucosa>muscularis)
Closure (2 layer - 25% breakdown +/- T-tube)
Buttress
Drainage
Nutrition
105
Q

When do strictures occur following caustic ingestion?

A

Within 4 months - usually should be attempted within 3-6 weeks here few (<3) and short <5cm

106
Q

How would you gain access and to and control of the femoral artery?

A
  • Longitudinal incision from midinguinal point down

- Through fascia lata to identify CFA, SFA and PFA, then sling and clamp

107
Q

What are the defining characteristics of a massive haemorrhage?

A

Loss of 50% Circulating volume in 3 hours
Loss of 100% Circulating volume in 24 hours
Loss of >150ml/min
Transfusion of 4 units in 4 hours with bleeding
Transfusion of 10 units in 24 hours

108
Q

What is the most reliable imaging where pancreatic injury is suspected?

A

MRCP >CT for ductal injuries

109
Q

How is haemodynamic instability defined in adults?

A

1) SBP <90 with skin vasoconstriction, confusion, dyspnoea or:

2) SBP>90 but
- requiring vasopressors
- requiring bolus infusions
- BE ≥-5
- PRC requirement of >4 in 8 hours

WSES 2020

110
Q

What threshold should be used for CT in suspected appendicitis?

A

> 40 (WSES Jerusalem guidelines 2020)

111
Q

When should stable patients with liver trauma undergo angioembolisation?

A

Positive blush, early aneurysm irrespective of injury severity (perhaps not in children)

112
Q

Which is the most frequently injured peripheral artery?

A

Brachial

113
Q

When should a patients be taken back to theatre for a relook after having bowel stapled off inside?

A

24-48hrs

114
Q

What is the Cushings reflex?

A

Hypertension and Bradycardia caused by raised ICP (Munroe Kellie doctrine)

115
Q

How should patients with pancreatitis be fluid resuscitated?

A

Goal directed, with CSL at 5-10ml/kg/hr (APA guidelines)

Aim for HR< 120, MAP65-85, UO>0.5-1

116
Q

What endoscopic interventions are suggested for UGI bleed?

A

If Forest 1a/1b/2a (i.e. vessel spurtin/oozing/visible) –> dual modality endoscopic

117
Q

What is a normal intra abdominal pressure?

A

5-7mmHg in critically ill

118
Q

What is the Catell Brasch manoeuvre?

A

Medial visceral rotation from the right

119
Q

What is the most common cause of mortality in patients with chronic pancreatitis?

A

Cardiovascular

120
Q

What complications are associated with chronic pancreatitis?

A
  • Pancreatic duct obstruction (?surgery or ESWL)
  • Pseudocysts (drain if symptomatic or duct disruption)
  • Ascites
  • Type 3c diabetes

(NICE)

121
Q

How is the axillary artery best accessed?

A

Supine, arm abducted. Transverse incision inferior to clavicle through pectoralis major.

Exposure and division of clavipectoral fascia to identify axillary vein.

May need to divide thoracoacromial artery (superficial branch)

122
Q

What evidence is there for laparoscopy in perf DU?

A

WSES guidelines recommend if stable then attempt laparoscopy.
Meta-analysis by Cirocchi - less pain, less wound infections

123
Q

When would you endoscope following treatment of perf PUD?

A

for gastric at 6 weeks

124
Q

How is abdominal compartment syndrome defined?

A

Pressure >20mmHg with new organ dysfunction

125
Q

What is the WSES Splenic trauma classification

A

Minor WSES 1 - AAST 1-2 stable
Moderate WSES 2 - AAST 3 stable
Moderate WSES 3 - AAST 4-5 stable
Severe WSES 4 AAST 1-5 unstable

126
Q

Which bacteria typically cause cellulitis?

A

Streptococcus pyogenes and staphylococcus aureus

127
Q

What antibiotic prophylaxis is required after splenectomy?

A

Probably 250mg BD Amox.

Consider septrin if allergic

128
Q

How would you fix a small perforated ulcer?

A

If <2cm, no evidence to support omental patch over suture closure alone (WSES 2020), however the additional risk appears small so its probably sensible

Single drain at suture site

129
Q

What are the risk factors for non operative management of splenic injuries?

A

Age >55
High injury severity score
AAST IV-V injuries

130
Q

What treatments should be instituted for a diagnosis of abdominal compartment syndrome?

A

Gastric decompression
Muscle relaxation/sedation
Drain collection
Consider fluid restriction/diuretics

If fails –> Laparotomy

131
Q

What are the Atlanta criteria for fluid collections in pancreatitis?

A

<4 weeks - acute fluid collection or acute necrotic collection
>4 weeks - pseudocyst or walled off necrosis

A diagnosis of infection can be made from presence of gas on CT.

132
Q

What blood products should be given in a major haemorrhage situation?

A

PRC, FFP and Platelets in a 1:1:1 ratio

Remember TXA (CRASH study)

133
Q

What is the Mattox maneuver?

A

Complete left medial visceral rotation to access aorta

134
Q

In patients with splenic injuries how long should bed rest be recommended for?

A

72 hours

135
Q

How does the AAST grade renal injuries?

A

1 - Subcapsular/no parenchymal/haematuria
2 - <1cm parenchymal injury
3- >1cm parenchyma injury without damage to collecting system or urinary extravasation
4 - parenchymal injury extending through cortext, medulla and collecting system or main vessel injury with contained haemorrhage
5 - shattered kidney or avulsion of hilum

136
Q

In delayed ureteral injury presentation with complete transection, how should these patients be managed?

A

Nephrostomy and delayed reimplantation

137
Q

How should intraperitoneal bladder rupture be managed?

A

Operative repair

138
Q

What is the management of choice for anterior urethral injuries?

A

Endoscopic realignment - if fails –> surgery

139
Q

How should bleeding from the main renal vein be managed?

A

If not self limiting this is an indication for surgery

140
Q

How should bleeding from the main renal vein be managed?

A

If not self limiting this is an indication for surgery

141
Q

What is the success rate of conservative management of SBO?

A

70%

Bologna guidelines 2017

142
Q

What is the benefit of laparoscopy in the surgical management of SBO?

A

Reduced LoS (LASSO trial 2019)

143
Q

What is the recurrence rate of adhesive SBO after surgery for similar?

A

19-53% (Bologna guidelines)

144
Q

How may adhesions be classified?

A

Zuhkle classification
Grade 0 - none/insignificant
Grade 1 - Fimly adhesions dissected bluntly
Grade 2- mostly blunt and some sharp
Grade 3 - sharp dissection only with clear vascularisation
Grade 4 - dense adhesions with no planes and difficult to avoid damage

145
Q

What is the Peritoneal adhesion index?

A

Grade of adhesions from 0-3 (similar to Zuhkle without the intermediate grade 2 from filmy to strong)

In 10 regions

therefore 0-30

146
Q

What is the benefits of non-operative management of adhesive SBO?

A

Hajbandeh meta-analysis 2017
operation –> higher risk of mortality and complications

no difference in LoS or reintervention

147
Q

What types of anti-adhesive can be used?

A

For open surgery
- seprafilm (carboxymethylcellulose)

For lap
-adept (icodextrin) liquid

148
Q

How is WSCS useful in SBO?

A

Bologna guidelines 2017

  • if no contrast in colon at >24 hours, cons mx likely to fail
  • reduces need for surgery (OR 0.6)
  • reduces LoS, time to resolution, no effect on complications
149
Q

How should SBO be managed in pregnancy?

A

High rate of failure of cons mx (94%)

Risk of foetal loss of 17%

150
Q

When should laparoscopy be attempted in sBO?

A

If surgery indicated and:

  • sufficient expertise
  • ≤ 2laparotomies in history
  • expecting single band

Bologna guidelines 2017

151
Q

How is appendicitis graded by the AAST?

A 
1 - acutely inflamed
2 - gangrenous intact
3 - perforated local contamination
4 - perforated with phlegm or abscess
5 - perforated with generalised peritonitis
152
Q

What are the Zone for insertion of a Reboa?

A

1: Descending thoracic aorta above renal
2: Infradiaphragmatic Juxtarenal
3: Infrarenal to bifurcation

153
Q

What is the key mediator of acute traumatic coagulopathy?

A

APC

154
Q

How is the ISS score calculated?

A

The square of the 3 highest AIS scores
Maximum of 75
>16 is major trauma

155
Q

What percentage of blunt trauma in the UK is caused by falls and MVCs?

A

50% and 30%

156
Q

What percentage of cardiac index is produced by internal and external chest compressions?

A

Internal 40%

External 20%

157
Q

How can traumatic brain injury be graded by GCS?

A

≤8 Severe
9-12 Moderate
13-15 Mild

158
Q

When can rivaroxaban be restarted following removal of epidural?

A

6 hours

FRCS (13 decks)

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