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Surgery – Trauma and Ortho Essay Example

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question

Indications for intubation

answer

GCS =< 8 (comatose) Signs of non-patient AW (stridor) Expanding neck mass/hematoma severe inhalation injury

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When must you intubate with fiberoptic bronchoscope assistance ?

answer

Signs of subQ emphysema (means there

...

is a leak somewhere in the bronchial tree so you want to have good visualization while intubating)

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When is a cricothyroidotomy indicated?

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When you have poor visualization of the AW for intubation (ex. massive bleeding, facial trauma)

question

What are the zones of the neck. List some important associated structures

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answer

Zone 1 - Clavicle - cricoid -- apex of lungs, brachial plexus, thoracic duct, thymus Zone 2 - cricoid to mandible -- vagus, recurrent largyneal, phrenic Zone 3 - mandible to the base of the skull

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Structures in the carotid sheath

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common carotid, internal jugular, vagus

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Differential diagnosis for a pulsatile neck mass

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AV fistula, pseudoaneurysm, aneurysm

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What is a pseudoaneurysm

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full thickness artery injury that is temporarily contained by surrounding tissue

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What are some typical pex findings of an AV fistula in the neck

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pulsatile mass, bruits or thrills

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Which intrinsic muscle of the larynx is not innervated by the recurrent laryngeal nerve

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cricothyroid

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Indications for immediate surgical intervention in the setting of penetrating neck trauma

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Hard signs of bleeding: - Unstable, Shock, Hypotension - Active bleeding - Expanding or pulsatile neck mass - Crepitus - Bruits, thrills

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Patient is actively bleeding from the neck and cannot control the bleeding with direct pressure. You are waiting for the OR. What can you do?

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catheter with tamponade

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Patient was penetrating wound to the neck that has not penetrated the platysma. Next step.

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no workup indicated, no OR

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Patient has penetrating neck trauma, but no hard signs of bleeding. What is your next step?

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CTA

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CT head/neck shows clear signs of vascular or aerodigestive injury in the setting of penetrating neck trauma. What is your next step?

answer

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CT head/neck shows no

signs of injury in the setting of penetrating neck trauma. What is your next step?

answer

Observation

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CT head/neck shows some concern (but not definitive) signs of injury in the setting of penetrating neck trauma. The patient was stabbed at the level of the thyroid. What is your next step?

answer

This is a zone 2 injury Surgical exploration is indicated if vascular (good exposure is possible) Triple endoscopy if suspect aero-digestive involvement

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CT head/neck shows some concern (but not definitive) signs of injury in the setting of penetrating neck trauma. The patient was stabbed above the mandible? What is your next step?

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This is a zone 3 injury Catheter angiography (if suspect vascular) (don't have good exposure with open approach) Triple endoscopy if suspect aero-digestive involvement

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CT head/neck shows some concern (but not definitive) signs of injury in the setting of penetrating neck trauma. The patient was stabbed immediately above the clavicle? What is your next step?

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This is zone 1 Catheter angiography (if suspect vascular) (don't have good exposure with open approach) Triple endoscopy if suspect aero-digestive involvement (same as zone 3 management)

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Maximum amount of artery than can be removed and still allow for primary anastomosis

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2cm

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Patient post MVA. Has a focal neurological deficit that is not explained by head CT. What do you suspect and what a re your next steps?

answer

Suspect blunt carotid injury Next step - CTA neck Management - anticoagulation

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Management of pseudoaneurysm. What about AV fistula? Intimal injury?

answer

Pseudoaneurysm and AV fistula --> surgical repair Intimal injury (ex. blunt carotid artery) --> anticoagulation

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After a patient is intubated, there are no breath sounds on the L. What is the most likely cause and what is your next step?

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You have intubated the R main bronchus Next step --> pull back

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Inward movement of rib cage during inspiration

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Flail chest

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Patient dies suddenly from cardiac arrest after the removal of a central line. Other situations in which you might suspect

this

answer

Air emobolism May happen in a patient who is intubated and on a respirator due to chest trauma May happen any time the subclavian vein is opened to the air (supraclavicular LN biopsy, central line placement), CV surgery, lung trauma

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Management of air embolism

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Cardiac massage with the patient facing L side down

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Prevention of air emboli

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Trandelenburg during placement of lines into neck vasculature

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Management of hemothorax What are the indications for surgical management

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Needle thoracotomy If there is > 1.5 drainage from the tube after insertion of consistently

> 0.5 -1L/hr from the tube, you need surgical thoracotomy

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What are the six lethal injuries of thoracic trauma

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ABCs Airway - AW obstruction Breathing - Tension pneumo, open pneumo (sucking chest wound), flail chest Circulation - massive hemothorax, tamponade

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What are the six "hidden" injuries of thoracic trauma

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Blunt cardiac injury Aortic injury Pulmonary contusion Esophageal injury Tracheobronchial injury Diaphragmatic rupture

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What is an open pneumothorax? What is a classic physical exam finding

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Open chest wall injury - air enters the pleural cavity through the skin Air bubbling from a chest wound (sucking chest wound)

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Classic clinical presentation of cardiac tamponade

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Beck's triad: hypotension, jugular venous distension, muffled heart sounds (also look out for pulsus paradoxicus)

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Classic CXR finding for massive hemothorax

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unilateral white out

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CXR findings in blunt aortic injury

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mediastinal widening

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Tachycardia and new BBB after blunt thoracic trauma. What are you thinking

answer

class="flashcard__a_text">cardiac contusion

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What is the definition of decreased PP. Etiology? Ddx?

answer

< 30 Indicated decreased CO Ex. cardiac tamponade, shock (hypovolemic, cardiogenic)

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You have put in a central line. What is your next step?

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cxr

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In the trauma patient, what should be on your differential for distended jugular veins?

answer

tamponade and tension pneumo

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Etiology of air embolism. When should you suspect?

answer

fistula between bronchial tree and vein/artery Suspect when someone has a stab wound or GSW to near the hilum

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You suspect a patient has tamponade or pneumothorax. What should you avoid doing in either of these cases?

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avoid intubation or PEEP because can decrease cardiac filling in states in which there is already decreased CO

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Unilateral absent breath sounds. Stable vitals. Next step? What if the patient is unstable?

answer

cxr unstable - needle thoracocentesis

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Placement of needle thoracostomy vs tube thoracostomy

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needle: 2-3 rib, midclavicular tube: 4-5 rib, mid axillary

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Indications needle thoracostomy vs tube thoracostomy

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needle immediate decompression for tension pneumo tube - definitive management for tension pneumno, massive hemothorax

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Indications for surgical thoracotomy in the setting of massive hemothorax

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1.5 L of immediate drainage after tube thoracotomy Or >150 - 200mL/hr over 3 h

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Indications for ED thoracotomy

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penetrating trauma, unstable, pulseless < 15 minutes used to control bleeding, tamponade, clamp vessels, cardiac massage

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Management of cardiac tamponade

class="lbl">answer

Pericardiocentesis (for emergent management) If stable could do subxiphoid window to check if there is bleeding. If there is then you need to do median stenotomy Do NOT give pressors, do NOT intubate, do NOT give PEEP

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Patient has a small pneumothorax. They need surgery on their abdomen. What is your next step?

answer

chest tube (high risk when getting surgery)

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Management of sucking chest wound

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occlusive dressing and tube thoracotomy

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Patient has chest tube for pneumothorax, but is not improving. What should you suspect and what should you do?

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tracheobronchial disruption endotracheal tube, followed by brochscopy for diagnosis and repair with thoracotomy for definitive management

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Management of flail chest Which medication should you avoid

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Avoid opiates

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How long could it take for a pulmonary contusion to show up on CXR?

answer

48 hours

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Classic CXR and ECG findings in cardiac tamponade

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bottle shaped heart low voltage, electrical alternans

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Patient unstable, flat neck veins, widened mediastinum. What do you suspect? What is the next step in management?

class="flashcard__a">answer

Ao rupture OR

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Patient stable, flat neck veins, widened mediastinum. What do you suspect? What is the next step in management?

answer

Ao rupture CT (TEE or aortography if still unsure after that)

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Patient has severe retrosternal chest pain and crepitus neck. What do you suspect? How should you work it up?

answer

esophageal rupture water soluble contrast esophogram

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Patient has AMS, rash and respiratory distress. What do you suspect? What is the management.

answer

fat emobolism just supportive

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Presentation for traumatic rupture of the myocardium

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sudden death

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Initial steps in the evaluation of a patient with blunt thoracic trauma

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FAST, AP supine CXR, ECG * Only time you don't do this in the setting of blunt thoracic trauma is if it is a low risk injury and there are not a lot of signs of trauma --> then you can do PA and lateral CXR and/or ECG as necessary

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Patient admitted with blunt abdominal trauma. FAST, AP supine CXR and ECG are done. Managed appropriately. Still unstable. Next step?

answer

OR for thoracotomy

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Patient admitted with blunt abdominal trauma. FAST, AP supine

CXR and ECG are done. Managed appropriately. Stable now, Which additional tests might you consider

answer

CT angio or TEE for further evaluation

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Work up for blunt abdominal trauma

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Basically always do FAST and then CT Exceptions * If stable with AMS or stable and intoxicated --> do CT instead of FAST first * If FAST is done and patient is still unstable --> OR * Negative FAST and stable --> may consider serial abdominal exams

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Negative fast, stable, UA positive for blood s/p BAT. Next step

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CT (suspect kidney injury)

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Unstable + hematuria

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pyelopgraphy (it is faster than CT)

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Gross hematuria, difficulty urinating, blood at meatus. Next step

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Cystourethrogram

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Gross hematuria following BAT. What are you suspecting?

answer

Kidney or bladder injury

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How do you r/o kidney injury?

answer

CT abd/pelvis

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How do you r/o bladder injury?

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CT cystogram or retrograde cystogram

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What to suspect if BAT + lower rib fx + bleeding into abdomen

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Splenic (left) or liver laceration (right)

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Postoperative immunizations following spleen resection

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Encapsulated -Pneumococcus, HiB, Meningococcal

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Management of splenic injury if stable. Unstable?

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Stable - embolization Unstable - OR for splenectomy or repair

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Management of liver injury. If stable. Unstable?

answer

Stable - embolization Unstable - OR for packing

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What to suspect if BAT + shoulder pain

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diaphragmatic rupture

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In the OR perform the pringle maneuver and bleeding continues. What does this mean?

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Means that bleeding is not coming from the Hepatic artery or portal vein. Bleeding is coming from the hepatic vein most likely

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What to suspect if BAT + lower rib fx + hematuria

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kindey lacertion Confirm with CT with contrast

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What to watch out for if see handlebar sign

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pancreatic rupture

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What to consider if BAT + epigastric pain + retropreitoneal fluid on CT

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duodenal rupture

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Child with BAT (riding bicycle) now with postprandial vomiting, colicky abdominal pain early satiety. Negative FAST. What do you suspect

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Duodenal hematoma (Presents as bowel obstruction typically 24-36 h after BAT)

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Confirming Diagnosis of duodenal hematoma

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CT (after a negative FAST)

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Management of duodenal hematoma

answer

NG decompression, NPO, may require parenteral nutrition Usually resolves within 1-2 weeks Only surgery or percutaneous drainage if non-operative management fails

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2 weeks after BAT patient presents with N,V epigastric pain and palpable mass. What do you suspect

answer

Pancreatic pseudocyst

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When to perform a CT in the setting of penetrating abdominal trauma

answer

If stable, no signs of bleeding, but Hbg drops >3 or develop leukocytosis

question

Work up for penetrating abdominal trauma

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If unstable or peritonitis --> OR If stable and no peritonitis --> extended FAST and wound exploration, Q4h vitals, serial abdominal exams, q8h CBC

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Next step if have gunshot wound to the abdomen

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Ex Lap

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Next step if you see air under the diaphragm

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Ex Lap

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First step in the work up of suspected aortic injury

answer

CXR

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Next step if CXR with widened mediastinum and unstable patient

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OR for repair of suspected aortic injury

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Next step if CXR with widened mediastinum and stable patient

answer

question

Next step if CXR with widened mediastinum, stable patient, CT equivocal

answer

TEE or aortography

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Subdural hematoma - Presentation, imaging

answer

Crescent shaped Can be chronic (Old person) or acute (trauma)

question

Epidural hematoma - Presentation, imaging

answer

trauma --> lucid interval --> decompensation ipsilateral dialted, fixed pupil CL hemiparesis lens shaped lesion

question

Management of cranial hematomas

answer

ABCs, CT , C-spine precautions/evaluation Increased ICP prevention: head elevation, Definitive treatment (if persistent increased ICP, herniation)

question

Signs of increased ICP

answer

N/V, papilledema, HA, AMS

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Goal PaCO2 for management of increased ICP

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28-32 (hypervenilating)

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Management of penetrating head trauma

answer

Craniotomy

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Indications for craniotomy

answer

Persistent increased ICP, midline deviation, signs of herniation, penetrating head trauma

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Next step: head trauma, normal CT, neurologically intact

answer

D/C to home, family wakes them up frequently during the next 24 hours

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Signs of a basal skull fracture

answer

raccoon eyes, ecchymosis behind the ears rhinorrhea, otorrhea

question

Management of a basal skull fracture What should you NOT do

answer

Expectant management, C-Spine w/u do NOT do endotracheal intubation

question

Patient is admitted with a epidural hematoma Is in hypovolemic shock What should you do next?

answer

Look for another source or bleeding!

question

Long laparotomy with lots of fluids and blood given think...

answer

abdominal compartment syndrome

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Common bugs that cause Necrotizing Fasciitis

answer

strep pyogenes and clostridium

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Management of Nec Fasc

class="flashcard__img">

answer

IV PCN, I/D in the OR

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Management of malignant hyperthermia

answer

Dantrolene

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Shoulder pain after a seizure think... (or after an electrical burn)

answer

posterior shoulder dislocation

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Indications for ORIF clavicle fracture

answer

open, skin tenting, > 2cm shortening, neurovascular injury

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Arm held in external rotation ans numb over the deltoid

answer

anterior shoulder dislocation

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Images to obtain anterior vs posterior shoulder dislocation

answer

Anterior - AP and Lateral Posterior - axillary or scapular view

question

75 yo woman falls on an oustreched hand. Her wrist is dorsally displaced. Most likely diagnosis

answer

Colles Fracture

question

Management of colles fractures

answer

closed reduction and long arm cast

class="single__flashcard">

question

20 yo falls on an outstreched hand. Has pain in the anatomical snuff box. Xrays are negative. What do you suspect? What is the management?

answer

Scaphoid fracture (X-rays will be negative if the fx is non-displaced) Put on a thumb spica cast even if the x-ray is negative

question

20 yo falls on an outstreched hand. Has pain in the anatomical snuff box. X-ray shows a displaced scaphoid fracture. Management

answer

ORIF (there is a high rate of non-union)

question

Man punched a wall. Where is the fracture? Treatment

answer

4th or 5th metacarpal neck = boxer's fracture K-wires

class="lbl">question

Leg is shortened and externally rotated. What do you suspect

answer

hip fracture

question

Leg shortened, adducted and internally rotated. What do you suspect

answer

posterior dislocation of the hip

question

Herniated discs. Sx exacerbated by these activites

answer

Coughing, sneezing, defecating

question

Presentation of cauda equina

answer

Saddle anesthesia, poor anal sphincter tone, distended bladder

question

Back pain worse at night. Not relieved by rest.

What should be on differential

answer

cancer

question

Breast vs prostate bone mets

answer

Breast - lytic Prostate - blastic

question

What exams should you do in the setting of pelvic fracture?

answer

Rectal exam, proctoscopy, pelvic exam

question

Hypotensive and pelvic fracture. What should you do next?

answer

FAST

question

Pelvic fracture + high riding prostate and blood at the meatus. What do you do next?

What should you do if it is negative?

answer

retrograde urethrogram (NO FOLEY) If it is negative do retrograde cystogram

question

What is the presentation of urethral injury

answer

Usually follows pelvic fracture Blood at meatus, high riding prostate Not able to void Scrotal hematoma

question

You do a retrograde urethrogram and see extraperitoneal fluid. What do you do next?

answer

Bed rest and foley catheter

question

You do a retrograde urethrogram and see intraperitoneal fluid. What do you do next?

answer

Ex lap and surgical repair (protect with suprapubic cystostomy)

question

Patient with blunt abdominal trauma has hematuria. CXR shows they have multiple broken ribs. FAST is done. What is the next test?

answer

CT to evaluate for kidney injury

question

Rare complication of renal injury

answer

AV shunts --> CHF

question

Management of scrotal hematoma

answer

Watchful waiting (unless testicle is ruptured) W/u with a sonogram

question

Work up for penetrating wounds of the extremities

answer

Clean If not near a vessel --> just tetanus

ppx If near vessel --> Dopplers or CT anguo If pt sx (decreased pulses, expanding hematoma, pulsatile bleeding--> go directly to OR!

question

Potential complications of crush injuries

answer

hyperkalemia, myoglonemia, myoglobinuria, renal failure, compartment syndrome

question

What is a first degree burn?

answer

Only epidermis

question

Describe first degree burns

answer

red, blanching, NO blisters only penetrate the epidermis

question

What is a second degree burn

answer

Epidermis and some dermis

question

Two types of second degree burns

answer

Superficial Partial Thickness Deep Partial Thickness

question

Superficial Partial Thickness vs Deep Partial Thickness burns

answer

Both - have Blisters Superficial - red and painful Deep - white, weeping and PAINLESS

question

What is a third degree burn

answer

all of epidermis and dermis

question

Describe 3rd degree burns

class="flashcard__a">answer

Full thickness Non blanching, PAINLESS, thick, leathery

question

When do you start to consider excision and skin grafting for burns

answer

second (usually deep) and third degree burns

question

Initial management of all burn types

answer

ABCs (low threshold for intubation in the setting of inhalation injury) 2 large bore IV needles foley rule of 9s resuscitation wound closure rehab H2 blockers (ppx for Cushing Ulcers) No indication for empiric abx

question

What is the rule of 9s

answer

9% for each body part Head, each arm, 4 quadrants in torso (2 front and 2 back, front of legs, back of legs

question

When should a patient go to a burn center?

answer

2nd or 3rd degree burns + --- > 20% TBSA in all patients --- > 10% if 50yo --- involving hands, feet, perineum, genitalia, skin over joints Electrical or chemical burns Inhalation injury Significant preexisting medical conditions

question

Fluid management in burn victims

answer

%BSA * kg * (2-6) Give half within the first 8 hours

question

Which type of fluids do you use initially in burn victims

answer

question

When do you start

rehab for burns? What are you trying to prevent?

answer

on day 1 trying to prevent contractures

question

Patient presents with singed nose hairs, wheezing and soot in their mouth. What should you consider strongly as your next step

answer

intubation!

question

What confirms the diagnosis of inhalation injury

answer

fiberoptic bronchoscopy

question

Patient escaped from burning building. Has HA and dizziness. Normal pulse ox. What should you do next?

answer

ABG to check carboxyhemoglobin (suspect CO poisoning) (PaO2 will be normal, but SaO2 will be decreased)

question

Management of CO poisoning

answer

100% o2 consider hyperbaric o2

question

How do you diagnose a burn wound infection?

answer

Clinical Presentation (fevers, tachycardia) Punch biopsy > 10^5 bacteria/g Histopathology

question

Initial management of electrical burns

answer

stop the electric source EKG!

question

Initial management of chemical burns

answer

douse them in water

question

DC current (lightening) puts pt at risk of ... What about AC current (wall socket)

answer

Lightening --> Asystole DC --> V fib

question

Long term complication of electrical injury

answer

Cataracts

question

Circumferential burn management

answer

escharotomy

question

Route of abx administration in the setting of burns

answer

must be topical Do not give PO or IV

question

Topical ointments that can be given for burns that do not penetrate the eschar. What are their adverse effects?

answer

Silver nitrate --> hyponatremia and hypokalemia, brown staining or skin, rare methemoglobinemia Silver sulfadiazine --> neutropenia, thrombocytopenia Neither of these cover Pseudomonas

question

Topical ointment that does penetrate the eschar. Adverse effect

answer

sulfamylon/mafenide acetate --> painful DOES cover pseudomonas

question

Presentation of brown-sequard. Typical scenario

answer

Hemisection - Paralysis and loss of proprioception on the side of the lesion - Loss of temperature and pain on the opposite side

question

Presentation of anterior cord syndrome. Typical scenario

answer

Loss of pain, temp and paralysis Preserved vibratory sense and proprioception Typically seen in burst fx of vertebral bodies

question

Bitten by wild dog, it is not available. Next step

answer

Rabies vaccine and immunoglobin

question

Presentation of black widow spider bite Antidote

answer

N/V Severe muscle cramps Antidote: Ca gluconate

question

Presentation of brown recluse spider bites Management

answer

skin ulcer with necrotic center and surrounding halo of erythema Dapsone Surgical excision may be needed, but WAIT until a week later when the damage is fully evident

question

Management of human bites

answer

I+D in the OR

question

Screening test for cervical trauma

answer

Lateral Xray

question

Patient has lost sensation over the distal medial thigh and leg. Which nerve is this and what else would they have deficits in

answer

Femoral nerve (medial leg is supplied by the saphenous branch) Decreased knee extension, hip flexion (innervated the anterior compartment of the thigh)

question

Tibial nerve provides sensory innervation to ...

answer

The entire leg EXCEPT the medial part

(which is the saphenous branch of the femoral nerve) and the plantar foot

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