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Trauma MRCS e
| Question | Answer |
|---|---|
| A 76 year old woman with a body weight of 50 kg is undergoing an excision of a lipoma from her forehead. It is the first time the senior house officer has performed the procedure. He administers 30ml of 2% lignocaine to the area. | The procedure is complicated by bleeding and discomfort of pt, a further 10ml of the same anaesthetic is then administered. Over the following 5 minutes the pt complain of tinnitus and becomes drowsy. which drug administered? A: intralipid 20% |
| Local anaesthetic toxicity treatment? | Intralipid |
| Local anaesthetic toxicity results from: | 1) accidental intravascular injection (rapid onset of symptoms-usually correct dose), or 2) from excessive dosage (slower onset) |
| MOA of local anaesthetics on how it causes toxicity SYMPTOM: Local anaesthetic agents not only exert a membrane stabilising effect on peripheral nerves but will also act on excitable membranes within the CNS and Heart. ...... | The inhibitory neurones in the CNS are suppressed before the central ones. As a result the early symptoms will typically be those of circumoral paraesthesia and tinnitus, followed by falling GCS and eventually coma. |
| MANAGEMENT OF LOCAL ANAESTHETIC TOXICITY | Stop injecting the anaesthetic agent. High flow 100% oxygen via face mask. Cardiovascular monitoring. Administer lipid emulsion (Intralipid 20%) at 1.5ml/Kg over 1 minute as a bolus. Consider lipid emulsion infusion, at 0.25ml/ Kg/ minute |
| safe dose of local anaesthetics? | 10ml of lignocaine 1% contains 100mg of drug, this would constitute 70% of the maximum safe dose in a 50 kg patient. Up to 7mg / kg can be administered if adrenaline is added to the solution |
| dose of lignocaine | Agent/ Dose plain/ Dose with adrenaline: :::::Lignocaine/ 3mg/Kg 7mg/Kg |
| dose of bupivacaine | Agent/ Dose plain/ Dose with adrenaline: :::::Bupivicane 2mg/Kg 2mg/Kg |
| dose of prilocaine | Agent/ Dose plain/ Dose with adrenaline: :::::Prilocaine 6mg/Kg 9mg/Kg |
| A patient is brought to the ER following a MVA. He is unconscious and has a deep scalp laceration. HR is 120/min, bp is 80/40 mmHg, and RR is 35/min. 2 L of Hartmans solution rapid administration, no change in V/S, mechanism of patient's hypotension: | A. Epidural haematoma B. Sub dural haematoma C. Intra parenchymal brain haemorrhage D. Base of skull fracture E. None of the above :answer hypotension and tachycardia should not be uncritically attributed to the head injury, could be other organ |
| When cardiovascular collapse occurs as a result of rising intracranial pressure, it is generally accompanied by: | hypertension, bradycardia, and respiratory depression. |
| what is Extradural haematoma | Bleeding into the space between the dura mater and the skull ( cause::: results from acceleration-deceleration trauma or a blow to the side of the head) |
| majority of extradural haematomas occur in the temporal region why? | skull fractures cause a rupture of the middle meningeal artery. |
| feature of extradural hematoma | Raised intracranial pressure and some patients may exhibit a lucid interval |
| subdural hematoma common location around ..... lobes? | Most commonly occur around the frontal and parietal lobes. subdural type: May be either acute or chronic |
| risk factor for subdural hematoma | Risk factors include old age and alcoholism |
| Subarachnoid haemorrhage cause? | Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury |
| primary brain injury may be: | primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury). |
| when will Secondary brain injury occur??????????????? occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. | The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. CUSHINGS REFLEX (hypertension and bradycardia) often occurs late and is usually a pre terminal event |
| Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of...... REQUIRED | IV mannitol/ frusemide may be required. |
| Diffuse cerebral oedema..... REQUIRED | may require decompressive craniotomy. |
| Definitive treatment of extradural hematoma | Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap. |
| Depressed skull fractures that are open require what treatment? | formal surgical reduction and debridement/////closed injuries may be managed non operatively if there is minimal displacement. |
| ICP monitoring and GCS association | ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan |
| hyponatraemia in Head injury d/t | Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. |
| cerebral perfusion pressure in adult and children | Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children. |
| Pupil size ////Light response ::::: Unilaterally dilated ///Sluggish or fixed>>>> Intrepretation | 3rd nerve compression secondary to tentorial herniation |
| Pupil size ////Light response ::::: bilaterally dilated ///Sluggish or fixed>>>> Intrepretation | -Poor CNS perfusion -Bilateral 3rd nerve palsy |
| Pupil size ////Light response ::::: unilaterally dilated or equal///cross reactive (Marcus Gunn)>>>> Intrepretation | Optic nerve injury |
| Pupil size ////Light response ::::: bilaterally constricted /// may be difficult to assess>>>> Intrepretation | Opiates Pontine lesions Metabolic encephalopathy |
| Pupil size ////Light response ::::: unilaterally constricted ///preserved>>>> Intrepretation | Sympathetic pathway disruption |
| Features of an addisonian crisis: (there is a long MCQ question) | Features of an addisonian crisis: Hyponatraemia, Hyperkalaemia, Hypoglycaemia |
| Addisonian crisis: Causes: | Causes: Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism). Adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia). Steroid withdrawal |
| treatment of addisonian crisis | Hydrocortisone 100 mg IM or IV. 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic. Continue hydrocortisone 6 hourly until the patient is stable. Oral replacement after 24 hours and be reduced to maintenance over 3-4 days |
| A 32 year old man closed unstable spiral tibial fracture s/p intramedullary nail . On return to the ward have increasing pain in the limb and o/e the limb is swollen and tender with pain on passive stretching of the toes. Diagnosis? | Compartment syndrome |
| The two main fractures having compartment syndrome complication: | supracondylar fractures and tibial shaft injuries. |
| sign and symptom of compartment syndrome: | pain (on active and passive movement), palor, paraesthesia, pulselessness, |
| diagnosis of compartment syndrome: | Diagnosis: Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic. |
| treatment of compartment syndrome | This is essentially prompt and extensive fasciotomies |
| .............may occur following fasciotomy and treatment of it is.......... | Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids. |
| Death of muscle groups may occur within .....hours if compartment syndrome not treated | Death of muscle groups may occur within 4-6 hours |
| A 28 year old man is involved in a road traffic accident and sustains a flail chest injury. On arrival in the ER he is hypotensive. O/E he has an elevated jugular venous pulse and auscultation of the heart reveals quiet heard sounds. diagnosis | Cardiac tamponade |
| The presence of a cardiac tamponade is suggested by.... | Becks Triad |
| Becks Triad: | Hypotension. Muffled heart sounds. Raised JVP. |
| Tension pneumothorax MCC | mechanical ventilation in patient with pleural injury |
| hyper-resonant percussion note is more likely in ...... | tension pneumothorax |
| What happens in Flail chest | Chest wall disconnects from thoracic cage |
| association of flial chest and management | Multiple rib fractures (at least two fractures per rib in at least two ribs). Associated with pulmonary contusion. Abnormal chest motion. Avoid over hydration and fluid overload |
| pneumothorax MCC | lung laceration with air leakage. |
| Traumatic pneumothorax management | chest drain |
| ...........should not be done before chest drain application in traumatic pneumothorax | mechanical ventilation |
| Haemothorax cause | laceration of lung, intercostal vessel or internal mammary artery |
| treatment of hemothorax that are large? | Haemothoraces large enough to appear on CXR are treated with large bore chest drain |
| indication of surgical exploration in hemothrorax? | Surgical exploration is warranted if >1500ml blood drained immediately |
| cardiac temponade might even occur with ...... ml of blood | 100ml |
| pulsus paradox seen in | cardiac temponade |
| most common potential lethal chest injury | pulmonary contusion |
| management of pulmonary contusion | Early intubation within an hour if significant hypoxia |
| Blunt cardiac injury: Usually occurs secondary to | chest wall injury |
| ECG finiding of chest wall injury minic.... | ECG may show features of myocardial infarction. |
| Sequelae of chest wall injury | Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities |
| aortic disruption occurs due to .... | decelearation injury |
| finding in aortic disruption | Contained haematoma. Widened mediastinum |
| Diaphragm disruption occurs due to : | Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears). More common on left side. |
| confirmation of diaphragm disruption | Insert gastric tube, which will pass into the thoracic cavity |
| feature of mediastinal traversing wound | Entrance wound in one haemothorax and exit wound/foreign body in opposite haemothorax. |
| Mediastinal haematoma or pleural cap suggests ..... | great vessel injury. Mortality is 20% |
| A 52 year old male type 2 diabetic is admitted to the vascular ward for a femoral popliteal bypass. He suddenly develops expressive dysphasia and marked right sided weakness. CT head scan which shows a 60% left middle cerebral artery territory infarct. | There are no beds on the stroke unit. Overnight the patient becomes unresponsive and a CT head confirms no bleed. What is the next best management option? ANS: ASPIRIN |
| Indications for hemicraniectomy include: | Age under 60 years. Clinical deficit in middle cerebral artery territory. Decreased consciousness. >50% territory infarct |
| Primary intracerebral haemorrhage (PICH, c. 10%):Presents with | Primary intracerebral haemorrhage (PICH, c. 10%):Presents with headache, vomiting, loss of consciousness |
| Total anterior circulation infarcts (TACI, c. 15%): Involves..... AND clinical features include........ | Involves middle and anterior cerebral arteries: Hemiparesis/hemisensory loss, Homonymous hemianopia, Higher cognitive dysfunction e.g. Dysphasia |
| Partial anterior circulation infarcts (PACI, c. 25%): Involves..... AND clinical features include........ | smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery. Higher cognitive dysfunction or two of the three TACI features |
| Lacunar infarcts (LACI, c. 25%) Involves ..........AND clinical features include........ | Lacunar infarcts (LACI, c. 25%) Involves perforating arteries around the internal capsule, thalamus and basal ganglia. Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia |
| Posterior circulation infarcts (POCI, c. 25%) involves.........AND clinical features include........ | Posterior circulation infarcts (POCI, c. 25%): Vertebrobasilar arteries: Presents with features of brainstem damage. Ataxia, disorders of gaze and vision, cranial nerve lesions |
| Lateral medullary syndrome (posterior inferior cerebellar artery) involves..........AND clinical features include........ | Lateral medullary syndrome (posterior inferior cerebellar artery): Wallenberg's syndrome. Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's. Contralateral: limb sensory loss |
| Weber's syndrome:involves..........AND clinical features include........ | Weber's syndrome: Ipsilateral III palsy. Contralateral weakness |
| Anterior cerebral artery Involvement in stroke: C/F///////////////. causes............ syndrome | Anterior cerebral artery: Contralateral hemiparesis and sensory loss, lower extremity > upper. Disconnection syndrome |
| Middle cerebral artery Involvement in stroke: clinical feature.......... | Middle cerebral artery: Contralateral hemiparesis and sensory loss, upper extremity > lower. Contralateral hemianopia. Aphasia (Wernicke's). Gaze abnormalities |
| Posterior cerebral artery Involvement in stroke: C/F | Posterior cerebral artery: Contralateral hemianopia with macular sparing. Disconnection syndrome |
| Lacunar Involvement in stroke: C/F | Lacunar: Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia |
| Lateral medulla (posterior inferior cerebellar artery): Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy | Lateral medulla (posterior inferior cerebellar artery): Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy |
| Horner's neurological: clinical feature | Horner's: Contralateral: limb sensory loss |
| Pontine: hemorrhage clinical feature | Pontine: VI nerve: horizontal gaze palsy. VII nerve. Contralateral hemiparesis |
| A 24 y/m is involved in a rta in which he collides with the wall of a tunnel in a head on car crash, speed 85mph. He is wearing a seatbelt and the airbags have deployed. When rescuers arrive he is lucid and conscious and then dies suddenly. DIAG? | Aortic transection |
| Aortic transections typically occur distal to ..... | Aortic transections typically occur distal to the ligamentum arteriosum |
| x ray feature of aortic transection if can be done | widened mediastinum |
| A 30y/f is involved in rta (head on collision> 60mph). She has been haemodynamically stable throughout with only minimal tachycardia. O/E she has marked abdominal tenderness and a large amount of intra abdominal fluid on CT scan. DIAG? | Duodeno-jejunal flexure disruption |
| A 17 year old boy is involved in a motorcycle accident in which he is thrown from his motorcycle. On admission he has distended neck veins and a weak pulse. The trachea is central. DIAG? | Haemopericardium (most likely a cardiac tamponade produced by haemopericardium) >>>>Diagnosis is suggested by muffled heart sounds, paradoxical pulse and jugular vein distension. |
| A 14Y/M is admitted to acute surgical unit with appendicitis. (fit and normally well) metoclopramide given and patient starts acting strange. O/E he is agitated, has a clenched jaw and his eyes are deviated upwards. What is the most likely diagnosis? | Oculogyric crisis (This is a classic description of an oculogyric crisis, a form of extrapyramidal disorder) |
| Oculogyric crisis precipitated by: | This is precipitated by antipsychotics (haloperidol) and metoclopramide in susceptible individuals with a genetic predisposition to this. ((((((alsoPhenothiazines. Haloperidol. Metoclopramide. Postencephalitic Parkinson's disease))))) |
| treatment of oculogyric crisis | procyclidine IM. |
| Oculogyric crisis is due to ......... | An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions |
| features of oculogyric crisis | Features: Restlessness, agitation. Involuntary upward deviation of the eyes |
| A 6 year old boy pulls over a kettle and suffers superficial partial thickness burns to his legs. Which of the following will not occur? | Damage to sweat glands |
| Partial thickness burns are divided into: | Partial thickness burns are divided into superficial and deep burns |
| Superficial partial thickness burns will typically heal by | reepithelialization |
| deep burns will heal by | scarring |
| superficial partial thickness skin layers affected | Epidermis and part of papillary dermis affected (pale, dry) |
| Deep partial thickness skin layers affected | Epidermis, whole papillary dermis affected (Mottled red colour) |
| Full thickness skin layers affected | Whole skin layer and subcutaneous tissue affected (Dry, leathery hard wound) |
| Depth of burn assessment done by: | Bleeding on needle prick. Sensation. Appearance. Blanching to pressure |
| how is Percentage burn estimation done? | Lund Browder chart: most accurate even in children Wallace rule of nines Palmar surface: surface area palm = 0.8% burn |
| >15% body surface area burns in adults needs ............... | urgent burn fluid resuscitation |
| Transfer to burn centre if: | Need burn shock resuscitation. Face/hands/genitals affected. Deep partial thickness or full thickness burns. Significant electrical/chemical burns |
| Escharotomy indicated in: Indicated in circumferential full thickness burns to the torso or limbs..... | Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved) |
| You are called to the acute surgical unit. A patient who has short gut syndrome has developed a broad complex tachycardia. You suspect a diagnosis of ventricular tachycardia. What is the most likely precipitant? | Hypomagnesaemia |
| ................is broad-complex tachycardia originating from a ventricular ectopic focus. | Ventricular tachycardia (VT)is broad-complex tachycardia originating from a ventricular ectopic focus. |
| ...........has the potential to precipitate ventricular fibrillation | VT |
| TYPES OF ventricular tachycardia | two main types of VT: monomorphic VT: most commonly caused by myocardial infarction.////////// Polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. |
| A subtype of polymorphic VT is.........which is precipitated by prolongation of the QT interval. | torsades de pointes |
| ...... is commonly caused by myocardial infarction | monomorphic VT |
| Congenital cause of prolonged QT interval | Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel). Romano-Ward syndrome (no deafness) |
| Drugs causing of prolonged QT interval | Drugs: amiodarone, sotalol, class 1a antiarrhythmic drugs. Tricyclic antidepressants, fluoxetine. Chloroquine. Terfenadine*. Erythromycin |
| disease causing of prolonged QT interval | electrolyte: hypocalcaemia, hypokalaemia, Hypomagnesaemia. Acute myocardial infarction. Myocarditis. Hypothermia. Subarachnoid haemorrhage |
| 13. Based on the current guidelines, which option regarding management of head injuries is false? | A. Opiates should be avoided B. Consider intubation if the GCS is <8 or = 8 C. Immediate CT head if there is > 1 episode of vomiting D. Half hourly GCS assessment until GCS is 15 E. Contact neurosurgeons if suspected penetrating injury Ans: A |
| Pain should be controlled, with.......preferably BECAUSE | OPIATES/////// as this avoids distress and hypertension post injury. |
| Acc to NICE guidelines: If GCS <8 or = to 8, | t/t stabilise the airway. Treat pain with low dose IV opiates (if safe). Full spine immobilisation until assessment if: GCS < 15. Neck pain/tenderness. Paraesthesia extremities. Focal neurological deficit. Suspected c-spine injury. |
| if c spine injury is suspected to do? | Suspected c-spine injury. If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if: Intubated. GCS <13. Normal x-ray but continued concerns regarding c-spine injury |
| Acc to NICE gurideline: Immediate CT head (within 1h) if: | GCS < 13 on admission. GCS < 15 2h after admission. Suspected open or depressed skull fracture. Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear). Vomiting > 1 episode. coagulopathy .post traumatic vomit |
| contact neurosurgeon | Persistent GCS < 8 or = 8. Unexplained confusion > 4h. Reduced GCS after admission. Progressive neurological signs. Incomplete recovery post seizure. Penetrating injury. Cerebrospinal leak. |
Created by:
sarthaknepal1