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USMLE2 Surgery 1


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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