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USMLE2 Surgery 1
Trauma
| Question | Answer |
|---|---|
| after a trauma, pt speaking in normal voice, but then soon loses ability to speak | Consider expanding hematoma or emphysema in the neck |
| what should you do if pt after trauma is breathing in noisy or gurgly way? | intubate |
| intubation first or dealing with cervical spine injury? | intubation first |
| how do you establish an airway when there is maxillofacial injuries? | cricothyroidotomy or percutaneous tracheostomy |
| shock with low CVP after trauma | low intravascular vol --> possible bleeding --> can lead to shock |
| shock with high CVP after trauma to chest | consider pericardial tamponade or tension PTX |
| What kind of shock is blood loss? | Hypovolemic |
| What kind of shock is third spacing? What is an example? | Hypovolemic. E.g. pancreatitis. |
| What kind of shock is vomiting? | Hypovolemic |
| What kind of shock is caused by tension PTX? | Cardiogenic |
| What kind of shock is SIRS? | Septic |
| What kind of shock is PE? | Cardiogenic |
| What kind of shock is anaphylaxis? | Neurogenic |
| What kind of shock is Pericardial Tamponade? | Cardiogenic |
| What kind of shock is spinal injury? | Neurogenic |
| SVR, CO, and CVP in hypovolemic shock | SVR high, CO low, CVP low |
| What is the main problem in hypovolemic shock? | intravascular volume depletion |
| What is the main problem in cardiogenic shock? | inadequate forward blood flow |
| What is the main problem in septic shock? | loss of vascular tone --> inadequate volume |
| What is the main problem in neurogenic shock? | loss of vascular tone --> inadequate volume |
| SVR, CO, and CVP in cardiogenic shock | SVR high (response to low CO), CO low, CVP high |
| SVR, CO, and CVP in neurogenic shock | SVR very very low, CO low, CVP low |
| SVR, CO, and CVP in septic shock | SVR low, CO high, CVP anything |
| Three types of distributive shock | anaphylactic, neurogenic, septic |
| SIRS criteria | Criteria for SIRS ( >= 2 or more of the following): a) Fever > 38 C or hypothermia < 36 C, b) Respiratory rate > 20/min, PaCO2 < 32 mm Hg, or mechanical ventilation, c) Heart rate > 90/min, d) WBC > 12,000 mm3 or < 4,000 mm3, or >10% band forms |
| Physiologic goals in management of septic shock | MAP > 65 mm Hg, CVP > 8 mm Hg (may need higher if ventilated), UOP > 0.5 mL/kg/hour |
| Trauma is urban setting | stop bleeding, then IVF. |
| Trauma in non-urban setting | 1. IVF, 2. pRBC --> UOP >0.5 and CVP doesn't exceed 15 |
| Rules for getting IV access | 1. 2 16g PIV --> 2. either percutaneous fem vein cath or saph vein cut-down in adult. If <4yo, intraosseus cannulation of proximal tibia |
| How to dx cardiac tamponade? | clinical (if Q, then choose US to dx). |
| How to tx linear skull fracture? | if closed and no overlying wound, leave it alone. Only need to close if open fracture |
| What kind of skull fractures need to be treated in the OR? | Comminuted or depressed |
| Who gets a CT in head trauma? How to manage after the CT? | Anyone who becomes unconcious. After CT, if neurologically intact, can go home if have 24h supervision (ensure they don't go into coma) |
| Basilar skull fracture - how to recognize and how to tx? | raccoon eyes, ecchymosis behind ear. Expectant management, C-spine survey, no abx |
| Trauma, unconcious, lucid, coma. | Acute epidural hematoma |
| Exam of pt with acute epidural hematoma | Fixed dilated pupil on side of hematoma, contralateral hemiparesis and decerebrate |
| lens shaped hematoma on head CT (bi convex) | epidural bleed () |
| crescent shaped hematoma on head CT | subdural bleed (( |
| how to tx epidural hematoma | emergency craniotomy |
| How to tx subdural hematoma? | If midline structures deviated: craniotomy. If not, medical theraphy to prevent increased ICP. |
| How to tx increased ICP | 1. elevate head, 2. hyperventilate, 3. do not fluid overload, 4. mannitol, 5. furosemide |
| blurring of the gray-white matter interface on head CT | diffuse axonal injury |
| small punctate hemorrhages on head CT | diffuse axonal injury |
| how to tx diffuse axonal injury? | Prevent increased ICP (no surgery if no hematoma) |
| what kind of hematoma does an old person or severe alcoholic get? How to tx? | chronic subdural (shrunken brain rattled around the head by minor trauma); tx with cervical evacuation |
| When is surgical exploration necessary after penetratin neck trauma? | 1. expanding hematoma, 2. deteriorating vitals, 3. esophageal or tracheal injury (coughing up blood) |
| What to do for gunshot shoot to upper and middle neck? Stab wound? | (face) arteriographic/ bronch (not necessarily surgical exploration). Stab wound: if asx, can observe. |
| Severe blunt trauma to the neck - what to do? | C-spine CT in pts with neuro deficits or pts with pain to local palpation over C-spine |
| spinal cord injury with ipsilateral loss of proprioception and contralateral loss of pain sensation; what kind of injury? | Brown-Sequard (hemisection) - clean cut injury, knife blade |
| spinal cord injury with BL loss of motor function, pain, and temp sensation with intact vibration sense and proprioception; what kind of injury? | Anterior cord syndrome; curst fractures of vertebral bodies |
| spinal cord injury with paralysis and burning in upper extremities and intact lower extremities; what kind of injury? | Central cord syndrome; forced hyperextension of neck, rear end collision |
| Tx for spinal cord injury? | MRI for diagnosis and high-dose steroids |
| Tx for rib fracture | local nerve block to prevent hypoventilation and atelectasis 2/2 nonmovement from pain |
| Tx of hemothorax | chest tube placed low to drain blood; surgery seldom required (required when >1500mL from chest tube or >600mL in 6 hrs) |
| flail chest | rib broken in two places so that you have one segment of chest doing paradoxical breathing (in during insp and out during exp) |
| What to worry about with flail chest? | presence of pulmonary contusion or traumatic transection of the aorta |
| Tx for pulmonary contusion | fluid restriction, use plasma or albumin (not regular IVF) to replace volume, use diuretics |
| what is usu location of traumatic rupture of aorta? Why is it dangerous? | jxn of aortic arch and descending aorta -- asx until hematoma blows up and kills pt |
| chest bones that are very hard to break (where if you see it broken, means really big injury) | first rib, sapula, sternum |
| what to do if trauma to chest, but absence of wide mediastinum on CXR? What to do if there is a wide mediastinum? | only non-invasive tests (TEE, CT, MRI); if wide mediastinum, aortogram --> surgical repair. |
| sudden death in chest trauma pt who is intubated and on respirator | consider air embolism |
| Pt whose subclavian vein was open to the air and suddenly collapses/has cardiac arrest | consider air embolism |
| How to tx air embolism? How to prevent? | cardiac massage with pt positioned with left side down; trendelenberg when doing procedures entering great veins of the neck |
| Pt with long bone trauma, petechial rashes in acillae and neck goes into rull respiratory distress with hypoxemia and BL patchy infiltrates on CXR | consider fat embolism |
| Tx of fat embolism | respiratory support |
| how to dx fat embolism? | fat droplets in urine |
| management of gunshot wound to the abd | surgical exploration, not necessary to remove bullet |
| For gunshot wound, what is considered to involve the abdomen? | Any entrance or exit wound below the level of the nipple line |
| When is it mandatory to do an exploratory laparotomy if you have a stab wound? | if it's clear that penetration has occurred (protruding viscera), hemodynamic instability, or peritoneal irritation. If not these, then can just digitally explore the wound +/- CT scan (if penetrate the fascia). |
| When is it mandatory to do an exploratory laparotomy if you have a stab wound? | peritoneal irritation or signs of internal bleeding (shock, hypotension, fast thready pulse, low CVP, low UOP, cold pale anxious, shivering, thirsty, sweating profusely, no obvious source of blood loss) |
| sx's when person has lost 25-30% of intravascular volume | approx 1500mL: hypotension, fast thready pulse, low CVP, low UOP, cold pale anxious, shivering, thirsty, sweating profusely |
| where can internal bleeding from blunt trauma hide? (3) | abdomen, thighs (secondary to femur fractures) and pelvis |
| If pt is not hemodynamically stable in the ER, how to dx intraabdominal bleeding? | FAST ultrasound or diagnostic peritoneal lavage |
| Most common source of intra-abdominal bleeding in blunt trauma; of significant intra-abdominal bleeding? | bleeding overall is liver; significant bleeding is splenic rupture |
| Vaccines for someone with splenic rupture | PIN to keep spleen together: Strep pneumo (pneumococcus), H influenza, Niesseria mening |
| If pt develops coagulopathy during prolonged abdominal surg, what to do? What if there's also hypothermia and acidosis? | give plts and FFP. If hypothermia and acidosis as well, must close immediately --> warm pt, tx coagulopathy --> resume surg when pt stable. |
| when does abdominal compartment syndrome occur? | lots of fluids and blood given during the course of prolonged laparotomies (tissues are swollen by the time of closure) --> abd can't be closed without tension --> temporary cover --> close when distension resolved |
| pt exploratory laparotomy 2/2 bullet wound, POD | 2, now abd distension with retention sutures cutting thru tissues, can't breathe --> hypoxia, renal failure (2/2 P on vena cava). What to do now? |
| what to do with pelvic hematoma? | if not expanding, leave alone |
| what other things need to be r/o in pelvic hematoma | 1. digital rectal exam, 2. proctoscopy, 3. bladder studies - retrograde cystogram (should include post-void films), 4. pelvic exam in woman, 5. retrograde urethrogram in men. |
| what is the hallmark of urologic injuries? | blood in the urine in someone who's sustained abdominal trauma |
| what if an adult pt with abdominal trauma has microscopic hematuria? What about a child? | Adult if asx, no need to w/u. In child, needs to r/o vulnerable GU tract congenital abnlity. |
| when does a urologic injury need to be surgically explored? | penetratin uro injuries |
| what do you need to know if pt has a urethral trauma? | should not insert a Foley (if insert a Foley, could be met with resistance), should do a retrograde urethrogram |
| How to tx anterior vs posterior urethral injury | anterior - surgically repaired; posterior - suprapubic drainage and delayed repair |
| how to protect surgical repair of bladder/urethral injury? | suprapubic cystostomy |
| What to do if you suspect a renal injury in blunt trauma? | CT, usu don't need surgical intervention |
| person with blunt trauma to the abdomen, then later develops CHF | rare sequela of renal injury from blunt trauma --> AV fistula --> CHF |
| person with blunt trauma to the abdomen, then later develops HTN | rare sequela of renal injury from blunt trauma --> renal artery stenosis --> reno-vascular HTN |
| How to assess a scrotal hematoma? | US |
| What will happen if you don't repair a fracture of the penis immediately? | AV shunts develop --> impotence |
| What to do about a penetrating injury of an extremity? | If no major blood vessels in the area: tetanus prophy and clean wound. If near major vessels and asx, then Doppler US or arteriograms. If vascular injury (no distal pulses or expanding hematoma) --> surgery. |
| Injuries of the extremities, order in which you repair structures: | 1. bone, 2. vessels, 3. nerves, 4. fasciotomy to avoid compartment syndrome. |
| how to treat hyperkalemia | alkalinization of urine |
| how to tx chemical burns | massive irrigation - do not try to neutralize the agent!! |
| which is worse - alkaline or acid burns? | alkaline (liquid plumr or Drano) is worse than acid (battery acid) |
| Fluid needs for burns pt | Ringer lactate. 1st 8 hrs 50% of 24-hr requirement. Next 16hrs, should get the rest. Should also get 2L D5W in addition since pt is NPO. |
| Parkland formula for IVF for adult burns pt (Day 1) | Body weight (kg) x %burned (max 50%) x 4ccRL + 2L D5W |
| IVF requirements for Day 2 post-burn | half of what was calculated in the Parkland formula for the first day |
| In pt with >20% body surface area burned, what fluid should you start with and how much? | start with 1L RL, then incorporate the Parkland formula and adjust as needed. |
| Rule of 9's for adult | 9 head, 4x9 torso front and back, 4x9 lower extremities, 2x9 upper extremities |
| Rule of 9's for infant | 2x9 head, 4x9 torso front and back, 3x9 lower extremities, 2x9 upper extremities |
| Parkland formula for IVF for infant burns pt (Day 1) | Body weight (kg) x %burned (max 50%) x 6ccRL + 2000cc D5W |
| Burns care | IVF, tetanus prophy, cleaning, topical silver sulfadiazine or mafenide acetate for deeper penetration (eschar or cartilage) |
| Care for burns near eye | triple antibiotic ointment (silver sulfadiazine is irritating to eyes) |
| Burns early excision and grafting | remove burned areas in OR and immediate skin grafting -- but can only be done on very limited burns (<20%) |
| What should you give to any pt with an animal bit? | tetanus |
| Dog bite that was provoked should get what? Unprovoked dog bite? | Provoked - don't need rabies except near the eyes because close to brain. Unprovoked - more likely to have rabies, animal should be killed and brain examined for signs of rabies, but should also get IVIg plus vaccination. |
| How do you know someone was bitten with venous animal bite? What should you do? | severe local pain, swelling and discoloration developing within 30 min of bite. Should draw blookd and type and crossmatch. |
| What is the tx of venomous bite based on? | The size of the envenomation (how big the area affected is) and not the age of the pt |
| What is the only valid first aid thing you should do for a venous bite? | splint the extremity; should NOT suck out the venom, wrap in ice, or apply a tourniquet. |
| antidote to bite of black widow | Ca gluconate |
| Which animal bite? skin ulcer with necrotic center and surrounding halo or erythema. How to treat? | Brown recluse spider. Tx with Dapsone. |
Created by:
christinapham
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