question

penetrating trauma to the neck - zone 3

answer

zone 3 is angle of mandible and above -> triple endoscopy - direct laryngoscopy, bronchoscopy, and esophascopy at the time of initial evaluation.

question

penetrating trauma to the neck- zone 1

answer

zone 1 is at the cricoid cartilage and below. aortography is necessary.

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penetrating trauma to the neck - zone 2

answer

zone 2 is between the angle of the mandible and the cricoid cartilage. 2D doppler +/- exploratory surgery

question

anterior cord vs central cord syndrome

answer

anterior cord syndrome (burst fracture of vertebral bodies -> spinothalamic and motor tracts) Loss of motor function and loss of pain and temperature sensation on both sides distal to injury. DCML intact (vibration and pressure) . central cord syndrome (rear end collision -> forced hyperextension of neck) - paralysis and burning pain in the upper extremities with preservation of most function in lower exgtremities

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pulmonary contusion - Dx and Tx

answer

deteriorating blood gases, white out of the lung - Tx fluid restriction and diuretics , b/L chest tubes if ribs fractured.

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myocardial contusion

answer

EKG will detect it; troponins study ; management is prevention of arrythmias.

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traumatic rupture of the diaphragm

answer

bowel in the chest always on the left (liver is protective). Any suspicion calls for laparoscopy. surgery is via the abdominal cavity.

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traumatic rupture of the trachea or major bronchus

answer

subcutaneous emphysema in upper chest and lower neck or large air leak from a chest tube. Chest X-ray confirms the presence of air in the tissues, and fiberoptic bronchoscopy identifies the lesion and allows for intubation to secure an airway. surgical repair follows.

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traumatic rupture of the aorta

answer

the worst hidden injury. occurs at the section of the aorta where the ligamentum arteriosum attaches and occurs due to high decelleration injury. Death occurs by adventitial rupture of extravasated hematoma.

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air embolism

answer

presentation is a chest trauma patient who is intubated and on respirator or subclavian vein is opened to the air i.e. central line, supraclavicular lymph node biopsy. managment is cardiac massage in Left lateral decubitus. Trendelenburg position while performing procedures is a good preventitive measure.

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fat embolism

answer

patient with multiple trauma - several long bone fractures developing petechial rashes in axillae and neck ; fever, tachycardia, low platelet count who shows a full-blown pic of respiratory distress, hypoxemia, and b/L patchy infiltrates on chest X-ray . Respiratory therapy support.

question

gunshot wounds to the abdomen

answer

exploratory lap- below the nipple line is grounds for ex lap

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blunt trauma to the abdomen

answer

symptoms of internal hemorrhage i.e. low CVP, hypotension warrants exploratory laparotomy

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signs of internal bleeding in a patient with blunt trauma

answer

drop in blood pressure, fast thready pulse, low CVP, and low urinary output.

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Urethral injury - 1st step management

answer

retrograde urethrogram ( for any suspect urethral injury)

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Tx of pelvic hematomas

answer

Leave alone if not expanding

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Routine procedure for pelvic fractures

answer

Rectal exam, proctoscopy, bladder - retrograde cystourethrogram pelvic exam in women and urethrogram in males.

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Bladder injury management

answer

Retrograde cystourethrogram, followed by post void films. Surgical repair done and protected with suprapubic cystostomy.

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Pelvic fractures with uncontrolled bleeding

answer

Pelvic fixation to tamponade the source of the bleed, then have IR angiographic embolization of both internal iliac arteries.

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Potential complications of renal laceration from blunt trauma (ribs)

answer

Development of an AV fistula causing systolic congestive heart failure or Renal artery stenosis leading to renovascular hypertension

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High voltage electrical burns

answer

Myoglobinuria- renal failure -> fluids and osmotic diuretics other complications: posterior shoulder dislocations, compression fx to vertebral bodies, late development of cataracts, and demyelination.

question

Respiratory burns- inhalational injuries

answer

Burns and/or soot in or around the mouth indicate inhalational injury Dx made with fiberoptic bronchoscopy. Monitor blood gases with ABG (to determine if respirator needed) and monitor carbon monoxide levels.

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Eschar

answer

Circumferential burn - can lead to compartment syndrome by edema cutting off blood supply or oxygen supply if occurs on the chest. Perform escharotomy at bedside

question

Snakebite

answer

Severe local pain and swelling and discoloration- 1) type and crossmatch 2) coagulation studies 3) LFTs 4) renal function. Tx antivenin most common is CROFAB

question

Bee stings

answer

Anaphylaxis-Tx with epinephrine 1:1000 solution, few mL ; remove stingers without squeezing them

question

Black widow spiders and brown recluse

answer

Brown recluse- skin necrosis around bite site. dapsone with possible skin excision depending on extent of damage determined later... Black widow - nausea, vomitting and muscle cramps. IV calcium gluconate with muscle relaxants

question

testicular torsion

answer

severe testicular pain of sudden onset (no Hx of fever, pyuria, or recent mumps) ; testicles are high riding with horizontal lie. The cord is not tender. immediate surgical intervention to untwist, then orchiopexy (move the testicle into scrotum and fix it)

question

acute epididymitis

answer

young men , severe pain of testicles with sudden onset , fever, pyuria is present, and testicles are in the normal position. The cord is tender. Dx is with sonogram to ensure rule-out of testicular torsion. Tx with antibiotics

question

what are the three surgical emergencies of the urological tract?

answer

testicular torsion, acute epididymitis, and obstruction and concurrent infection of the urinary tract.

question

pyelonephritis

answer

chills, fever, nausea, and vomitting, flank pain. Dx based on IV pyelogram and sonogram Tx = Hospitalization and IV antibiotics based on cultures, and workup IVP

question

acute bacterial prostatitis

answer

seen in older men with chills, fever, dysuria and urinary frequency and an exquisitely tender prostate on rectal exam. Tx IV antibiotic. Risk of septic shock is high with repeated prostate massage.

question

workup for hematuria

answer

CT scan followed by cystoscopy (to rule out bladder cancer)

question

renal cell carcinoma

answer

May presents with hematuria, flank pain, flank mass, hypercalcemia, erythrocytosis, and elevated LFTs. Rarely all of them demonstrated simultaneously. CT scan gives the best diagnosis, Surgery is the only effective therapy

question

cancer of the bladder

answer

very close correlation with smoking. Dx: CT scan first , but cystoscopy is best test. Tx with Surgery and intravesicular BCG. Close followup necessary due to high rate of recurrence.

question

prostatic cancer

answer

surveillance stops at age 75. Dx is by sonogram guided transrectal needle biopsy

question

testicular cancer

answer

painless testicular mass. Dx is done after orchiectomy which is the treatment.

question

acute urinary retention

answer

huge palpable distended bladder 2ndary to benign prostatic hypertrophy. It can be precipitated by cold, antihistamines, and nasal drops and abundant fluid intake.

question

postoperative urinary retention

answer

involuntary release of small amounts of urine after an operation. A distended bladder is palpable on exam, which confirms overflow incontinence from bladder retention. An indwelling catheter is needed.

question

stress incontinence

answer

seen in middle-aged women who have had multiple pregnancies and vaginal deliveries. They leak small amounts of urine whenever abdominal pressure suddenly increases i.e. sneezing, laughing, getting out of chair or lifting a heavy object.

question

passage of ureteral stones

answer

colicky flank pain with radiation to the thigh and groin. CT scan will pickup most stones. pnesmall stones at ureterovesicular junction have 70% of passing spontaneously(Tx analgesics, copious fluid intake, and observation) whereas large stones require intervention Tx. corporeal shock wave lithotripsy, extraction, sonic probes, laser beams, and open surgery.

question

pneumaturia

answer

bubbles in the urine. pathogenesis involves fistulization between the bladder and the GI tract. etiology: diverticulitis followed by sigmoid cancer, then bladder cancer which is very rare)

question

impotence

answer

psychogenic - does not interfere with nocturnal emissions (stamp test) organic impotence 2nd to trauma - sudden onset in disease progression organic impotence 2nd to chronic disease - erection softer and softer over time Tx: viagra , vascular surgery, suction devices, and prosthetic implants(risky)

question

the one absolute contraindication to organ transplantation

answer

HIV positive status.

question

pathogenesis and prevention of hyperacute rejection

answer

vascular thrombosis occurs within minutes, preformed antibodies from the host against the organ. Prevented by ABO matching and lymphocytotoxic crossmatch

question

acute rejection

answer

occurs within the first 5 days within the first 3 months. can occur even on immunosuppression. Tx: first line is steroids bolus. then antithymocyte serum vs. antilymphocyte agents (OKT3)

question

chronic rejection pathogenesis and prevention

answer

years after transplantation causing gradual insidious loss of organ function. It is poorly understood and irreversible.

question

Stress incontinence etiopathogenesis

answer

Weakness in the pelvic floor muscles brought on by childbirth, surgery, or menopause. Men can get it through prostate surgery. SSx include leaking when coughing, sneezing, or heavy lifting. Tx is with a pessary

question

Urge incontinence

answer

aka overactive bladder, spastic bladder, detrusor overactivity--Urge to urinate arises suddenly so as to cause accidental urine leakage before person can make it to the bathroom. The volume of urine is inconsequential, nerves communicate the urge and the bladder cannot be inhibited. The bladder spasms and urine leaks out. This can be caused by nerve-damaging diseases such as diabetes, multiple sclerosis,Alzheimer's or bladder carcinoma. Tx is oxybutynin

question

Overflow incontinence

answer

The urge is absent but the urine leaks out anyways due to volume overflow. This can be due to tumors enlarging the prostate gland blocking normal flow of urine, diabetes, spinal cord injuries, and medications also can cause overflow incontinence. Dx with bethanechol Tx is with catheterization.

question

Functional urinary incontinence

answer

Not being able to make it to the restroom in time because of a physical disability I.e. Arthritis. The urogenital tract is normal.

question

Reflex incontinence

answer

A type of urge incontinence where you feel no need to urinate but urine is lost when the bladder spasms uncontrollably.

question

transient ischemic attacks

answer

most common site is in the internal carotid artery with high grade stenosis >70% ; Dx begins with ultrasound with doppler ; carotid endarterectomy indicated if lesion discovered explains the symptoms. stent can be alternative if filter successfully placed first.

question

subarachnoid bleeding from intracranial aneurysm

answer

most cases severe headache; some may present with meningeal irritation, nuchal rigidity. CT scan to find blood in the subarachnoid space followed with arteriogram to locate the aneurysm ; surgery option is clipping whereas endovascular coiling is the radiological alternative.

question

causalgia

answer

pain that develops after several months after a crushing injury. It is described as a burning agonizing pain that doesn't respond to the usual analgesics The extremity is cold, cyanotic, and moist. sympathetic block is diagnostic and sympathectomy is curative.

question

intussusception

answer

6-12 month old infants wth episodes of colicky abdominal pain that causes them to double up and squat. The pain lasts for 1 minute and then baby looks happy and normal until the next episode.

question

subclavian steal syndrome

answer

patient describes claudication of the arm - coldness tingling and muscle pain; visual symptoms and equilibrium problems, neurologic symptoms identifies subclavian steal (vascular symptoms alone would point to thoracic outlet syndrome) Dx: Duplex scanning showing reversal of flow ; Tx: bypass surgery.

question

most reliable physical finding of diagnosing compartment syndrome

answer

pain on extension of the limb

question

managing spleen rupture

answer

stable: serial hemoglobin and hematocrit levels q6h for 48 hrs unstable: exploratory laparotomy

question

the most common cause of massive upper GI bleeding

answer

erosive duodenal ulcer (gastroduodenal artery)

question

best test to confirm or exclude thoracic aortic dissection

answer

transesophageal echocardiogram.

question

when to give IV lines vs. control bleeding

answer

If you don't where bleeding is coming from then start large bore IV lines.

question

If trauma center is 2 miles away, do you start IV lines at ground zero?

answer

no. Need to get him into the ambulance and drive scoop and run. Two miles in two minutes is the motto.

question

rule of skull fractures

answer

leave it alone if closed wound and asymptomatic. The exception is if comminuted or depressed - debridement and possible craniotomy

question

mastoid ecchymosis with periorbital bruising and clear fluid leak from nose and ears - 1st step in management

answer

battle sign -> CT head and neck -> basal skull fracture , risk for lesion of the cervical spine as well.

question

Stab wound to the abdomen - hemodynamically stable with no peritoneal signs

answer

Perform digital exploration of the wound; If wound does not extend into the peritoneal space, no surgery is required. If unsure, then perform a CT scan of the abdomen.

question

Hypotension, tachycardia, and low CVP in a trauma patient with normal chest X-ray

answer

Perform CT scan if stable. If unstable, need to go to OR perform ultrasound or spleen.

question

Next step in management after spleen removal

answer

Administer pneumovax , Hib, and MCV vaccines

question

Bleeding from all orifices after massive transfusion

answer

Fresh frozen plasma and platelet packs , 10 units each

question

During open laparotomy, patient's core body temperature reaches below 34 degrees Celsius

answer

Stop operation, close the abdomen by packing all bleeding surfaces and make a temporary closure of the abdomen

question

Pelvic hematoma in a female patient after a trauma - next step in management.

answer

Determine if it's expanding. If not, then leave it alone and perform physical exam checking the rectum, vagina, and the bladder. Put in Foley catheter

question

Pelvic hematoma in a female patient after a trauma - hemodynamic parameters continue to deteriorate. U/S shows no intraabdominal bleeding.

answer

External pelvic fixation followed by IR-guided b/L embolization of internal iliac arteries

question

Blood in the Foley catheter in patient w/ Hx of trauma causing pelvic fracture - next step in management

answer

Retrograde cystourethrogram

question

Blood in the Foley catheter in patient with Hx of trauma causing rib fracture and abdominal contusions, but no pelvic fractures - next step in management

answer

CT scan of the abdomen - blood likely from injured kidney.

question

Shortness of breath and flank bruit in patient who had blunt trauma to the abdomen and hematuria six weeks prior - next step in management

answer

Arteriogram and surgical correction - this patient has an AV fistula and subsequent heart failure.

question

Gross hematuria after trauma

answer

Follow up with the hematuria, do not ignore.

question

Soot and burns in the oral and nasal passages in a patient - next step

answer

Give hyperbaric oxygen, intubation and possible mechanical ventilation; measure arterial blood gases, perform bronchoscopy to assess respiratory damage

question

Leathery anesthetic circumferential lesions in a 3rd degree burn victim

answer

Compulsive Doppler monitoring of peripheral pulses and capillary filling. Possible escharotomy at the first sign of compromised circulation. fasciotomy is the next step

question

Scalded skin - tender to touch with blisters - next step

answer

Silver sulfadiazine

question

Animal bite without capturing the culprit

answer

Empirical rabies immunoglobulin + rabies vaccine

question

Bear bites the face and the bear is captured

answer

Prophylaxis rabies due to risk to infection to the brain - bite was in proximity to the brain.

question

optimal position of the endotracheal tube when inserted

answer

2-6 cm above the carina

question

indication for Moh's micrographic surgery

answer

surgery for high risk areas that are cosmetically sensitive i.e. the face

question

indications for nissen fundoplication

answer

failed medical management of GERD or severe tissue damage to the lower esophagus with normal length esophagus and normal motility

question

indications for intubation

answer

1. significant respiratory distress or respiratory arrest 2. GCS <8 3. metabolic acidosis - inadequate hyperventilatory compensation 4. respiratory muscle fatigue 5. significant hypoxemia PaO2 50mmHg 6. expanding mass in the lateral neck

question

definitive diagnosis of cor pulmonale

answer

right heart catheterization demonstrating a pulmonary artery systolic blood pressure of >25 mmHg

question

tranexamic acid indications

answer

TXA is used for severe menstrual bleeding and postoperative blood loss . It does not reverse a supratherapeutic INR and it does not treat warfarin-associated hemorrhage.

question

contraindications to incision and drainage of an abscess

answer

if the abscess is deeply embedded in a tissue - the wall is too thick for a scalpel to reach the abscess i.e. breast abscess if the abscess is relatively small <5cm

question

next step after X-ray shows air underneath the diaphragm of a man who had a Hx of gastric ulcers

answer

IV antibiotics in prep for surgery (DO NOT DO BARIUM SWALLOW - that's for esophageal disorders)

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