Surgery 2
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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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Created by:
Abarnard
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