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Surgery 2

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Question
Answer
Trauma PE: Head   Scalp lacerations, contusions. Skull fractures; rhinorrhea, otorrhea (CSF), hemotympanum, halo sx on bandage; visual acuity; pupil equality and reactivity. Facial fractures  
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Trauma PE: Neck   tracheal deviation; spinal tenderness or stepoffs (MAINTAIN MIDLINE IMMOBILIZATION DURING EXAM)  
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Trauma PE: Chest   clear and equal breath sounds, symmetric chest rise; rib and sternal fractures; clear heart sounds  
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Trauma PE: Abdomen   bowel sounds, distension, tenderness, contusions (e.g., seat-belts)  
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Trauma PE: Pelvis   instability on rocking; rectal exam (on everyone) for blood, sphincter tone, high-riding prostate; blood at urethral meatus  
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Trauma PE: Back   spinal tenderness or stepoffs; ecchymoses, lacerations (LOGROLL)  
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Trauma PE: Extremities   deformities, joint mobility, pulses, lacerations, contusions  
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Trauma PE: Neurologic   Glasgow Coma Scale (GCS); motor/sensory deficits  
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3 reasons to intubate a trauma pt   Impaired level of consciousness, a mechanically compromised airway, or ventilatory problems  
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True/False: Dx tension PTX can be made by chest X-ray.   False  
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Tension PTX: Sx:   tracheal deviation (away from side of PTX), increased JVD, decreased breath sounds, tympany to percussion, hypotension.  
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Tension PTX: Rx:   needle decompression followed by chest tube insertion  
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Beck’s Triad (reflecting cardiac tamponade)   Muffled HS, increased JVD, hypotension  
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GCS ≥13 =   mild brain injury  
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GCS of 9-12 =   moderate injury  
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GCS ≤8 =   severe injury  
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How can you evaluate the stable trauma patient with abdominal pain?   Observation w/ serial exam is an option only for stable pts w/ a reliable PE (no drugs or head injury)  
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Abdominal CT is used for:   stable pts w/ equivocal exams or with high-risk mechanisms.  
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Advantage of abdominal CT over DPL is:   ability to evaluate the retroperitoneum (aorta, IVC, pancreas, kidneys, and portions of duodenum and colon).  
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Ultrasound in trauma pt eval:   non-invasive but can be performed anywhere; can detect free intraperitoneal fluid as well as many solid organ injuries  
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Diagnostic Peritoneal Lavage (DPL) is for:   unexplained hypotension or for equivocal exam in a multiply injured pt. DPL can be performed anywhere & in less than 5 min  
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A positive DPL =   aspiration of gross blood or >100,000 rbc/ml on lab exam of lavage fluid. DPL is 98% sensitive for intraperitoneal bleeding.  
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Immediate exploratory laparotomy is indicated for:   most penetrating trauma or for the unstable patient with obvious evidence of abdominal injury on physical exam.  
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Unstable pts with pelvic fractures should undergo:   emergent external fixation  
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Closed head injury: CPP =   Cerebral perfusion pressure = MAP-ICP  
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Closed head injury: Rx:   Intubate, ICP monitoring, keep CPP >70 to prevent secondary injury; No steroids, Ventilate to keep CO2 30-35  
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3 types of shock most commonly seen in surgery:   Obstructive (cardiogenic), Hypovolemic, Distributive (neurogenic; septic; anaphylactic)  
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Hypovolemic Shock: <20%   Decreased pulse pressure; Ortho hypotension; Flat neck veins; increased Hct  
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Hypovolemic Shock: 20-40%   Thirst; Tachycardia; Oliguria; Mod hypotension  
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Hypovolemic Shock: >40%   MS changes; Severe hypotension; EKG-ischemic arrhythmias  
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Most significant cause of morbidity in pts w/ traumatic brain injuries:   DAI (diffuse axonal injury)  
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Closed head injury =   Intracranial hemorrhage  
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Closed head injury: Epidural   arterial bleed assoc w/ skull fx requiring immediate surg intervention; assoc w/ lucid interval following LOC  
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Closed head injury: Subdural   venous bleed btw cortex & dura requiring surg evacuation depending on severity  
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Closed head injury: Intracerebral   hemorrhage within the parenchyma, often associated with other injuries  
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Closed head injury: Subarachnoid   frequently missed on CT and rarely requiring immediate treatment  
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Hemothorax: Tx   if drains >1500cc blood, insert chest tube; if >200cc/hr: to OR for thoracotomy to r/o great vessel injury  
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Cardiac tamponade: Tx   OR or ED Thoracotomy (classic answer: pericardiocentesis) [ED thoracotomy: Subxyphoid, substernal notch, 45 degree angle, shoulder]  
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Intra-abdominal Injuries: must R/O:   hemoperitoneum  
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which GCS indicates the need for intubation   <8  
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