USMLE STEP 3 SURGERY Flashcards
First step in the management of trauma and change in mental status.
Establish airway
Best step in securing an airway when trauma patient has cervical spine injury?
Use flexible bronchoscope and orotracheal intubation with manual cervical immobilization.
2 ways to secure and airway when trauma patient has extensive facial trauma or bleeding into their airway/gurgling sounds.
cricothyroidotomy and percutaneous tracheostomy
First thing to do when oxygen saturation drops < 90
Obtain ABG
Try to find likely cause of hypoxia based on history
Normal PC02?
40
Normal Bicarb
24
First step in management of a patient in hypotensive shock?
Find and control the source of bleeding
Best way to identify hypovolemic shock
R atrial pressure, Pulmonary capillary wedge pressure, cardiac index and mixed venous saturation are all decreased. The only thing increased is systemic vascular resistance.
2 chest trauma conditions that manifest as distended neck veins and high CVP?
Pericardial tamponade and tension pneumothorax.
Dx & Next step in management:
enlarged heart on CXR, electrical alternans on EKG, pulsus paradoxus on vs,
Pericardial tamponade
Do pericardiocentesis and pericardial window if unsuccessful.
Dx and next step in management:
respiratory distress, tracheal deviation, absent breath sounds and hyperresonance to percussion.
Large bore needle or IV catheter into pleural space followed by a chest tube.
Where to insert an IV catheter or large bore needle when tension pneumothorax is the problem?
Second intercostal space
What should you never wait for in order to diagnose a tension pneumothorax?
CXR
The next step in management in a patient with abdominal trauma who is bleeding and hypotensive.
2 large bore IVs give fluids and blood type and screen foley cath IV abx prepare for immediate exploratory lap
First step in management in a patient in vasomotor shock (hypotension and tachycardia, warm and flushed). Bee sting or medication allergy etc
Vasoconstrictor and fluids
Never do this in a patient who presents with a penetrating wound with damage to internal organs.
Never remove the embedded object in the ER, Head to the OR
Next step in management: Asymptomatic robbery victim with a closed skull fracture and an overlying wound?
Clean and stitch laceration
Next step in management: Asymptomatic robbery victim with a comminuted or depressed skull fracture.
OR immediately
next step in management: a head trauma patient lost consciousness but has remained asymptomatic along with a no neurologic signs.
Not going home yet! CT head & neck without contrast, serial neuro exams
Next step in management: Trauma patient with racoon eyes, clear fluid leaking from nose and ear.
CT head and neck to see basal skull fracture.
Expect possible facial palsy 2-3 days later due to neuropraxia.
Dx and next step in management: Natasha Richardson falls in a colorado skii resort and suddenly looses consciousness but recovers and is lucid. CT head shows lens shaped/biconvex hematoma without a midline shift.
OR for emergency craniotomy
This is an arterial bleed from the middle meningeal artery, third branch of the maxillary artery which is from the external carotid artery.
Dx and next step in management: An elderly woman on coumadin falls, hits her head and is having gradual headaches, memory loss, personality changes, deme ntia, confusion and drowsiness. Her consciousness is fluctuating. CT head shows semilunar, crescent shaped hematoma with midline shift.
Subdural hematoma
To OR now for emergency craniotomy
Why order CT head without contrast to rule out head bleeds?
Blood and contrast look the same on CTs - so false positive
