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USMLE2 Surgery 2

Trauma 2

Pt with stab wounds to the neck and subQ emphysema in neck and chest tissues. What do you do and how? Need to intubate since airway might be compromised soon. Need fiberoptic bronchoscopy to intubate.
Person with facial trauma bleeding into airway. What are your options? Need to secure an airway. Since can't do orotracheal intubation, should do either cricothyroidotomy or PERCUTANEOUS tracheostomy (not surgical tracheostomy).
3 most common reasons for shock in trauma 1. hypovolemia (bleeding), 2. tension PTX, 3. cardiac tamponade
ABC's. What is done in the "circulation" portion of care for a gunshot wound victim? 1. IV, 2. Foley, 3. Abx IV, 4. IVF, 5. pRBC's -- in that order.
Pt has bright squirting blood from groin/arm/wherever. What do you do? direct local pressure to stop the bleeding with a gloved finger or sterile pressure dressing
A child in shock - what is the initial bolus of IVF that child should get (i.e. amount of fluid in the first hour)? 20ml/kg
distended neck veins, high CVP, respiratory distress, tracheal deviation, absent breath sounds on hemithorax that is hyperresonant to percussion, hypotensive, diaphoretic, pale, cold, shivering, anxious, thirsty tension PTX
How to tx pericardial tamponade? pericardial window --> thoracotomy
anaphylactic shock - how to treat? epinephrine (vasoconstriction)
what kind of intracranial bleeding is responsible for hypotension and fast heart rate? hypotension and fast heart rate - shock. Intracranial bleeds can't cause shock. Look for blood loss elsewhere in the body (abd, pelvis, thigh)
pt shot in the upper part of neck, still bleeding despite pressure - what to do? no important structures up there, prob vascular injury --> angiography for dx and embolization
gunshot to base of neck - what to do? lots of vital structures at thoracic outlet. If pt is stable and even if asx, angiography --> soluble-contrast esophagogram --> barium swallow --> esophagoscopy --> bronchoscopy.
pt stabbed once in the neck in sternocleidomastoid, asx, with nl vitals stab wounds to middle and upper neck PLUS asx --> observe for 12 h
Tx of pulmonary contusion IVF restr, use plasma/albumin (not regular IVF) to replace vol, use diuretics, monitor bld gases. If ABG deteriorates, put pt on vent & place BL chest tubes (if lungs puctured, could leak air once pos P frm ventilator --> tension PTX), monitor 48 hr
Diagnosing traumatic transection of the aorta CT and CXR. If CT no lesions and CXR no wide mediastinum, then no further w/u. If CT non-dx and CXR wide mediastinum, then arteriogram.
three things that can cause thoracic subQ emphysema rupture of the esophagus (usu after endoscopy), tension PTX, rupture of the trachea or major bronchus
pt with rupture of the trachea - what to do? CXR to dx, then fiberoptic bronch to confirm dx and secure airway. Surg repair after that.
pt with chest tube for traumatic pneumothorax, lots of air coming out the tube and collapsed lung is not expanding. What is the problem? major bronchial injury
What dx tests to run for pt with gunshot to abdomen? no tests; penetrating gunshot to the abdomen gets ex lap every time.
gunshot through bowel - primary repair or colostomy? primary repair
rib fractures --> gross hematuria. What to do next? must be coming from kidney injury because trauma so high up. Blunt trauma to the kidney does NOT need surgery. Operate only if renal pedicle is avulsed or the pt is exsanguinating.
pt with kidney injury, then 6 weeks later, pt develops acute SOB and flank bruit traumatic av fistula --> CHF. Should get arteriogram and surgical correction.
treatment of myoglobinemia IVF, diuretics, alkalinization of urine
Electrical burns - what non-obvious injuries must you look for? myoglobinemia, and violent muscle contractions --> posterior dislocation of the shoulder and compression fractures of vertebral bodies, cataracts, demyelination syndromes
how to dx smoke inhalation? bronchoscopy and monitor blood gases
what should you remember about circumferential burns? How to treat them? leathery exchar will not expand --> area under burn will have edema --> curculation will be cut off. Compulsive monitoring of doppler signals of peripheral pulses and capillary filling, escharotomies if compromised circulation.
burn that is painful with moist blisters - what degree? second degree burn
burn in child that is deep bright red and not painful - what degree? third
burn in adult that is white and leathery and anesthetic third
what is the goal UOP for burns pt? 0.5 to 1 ml per kg PER HOUR; electrical or respiratory burns or escharotomies need more.
Pt with envenomated are on leg - what to do? draw blood to type and cross, get coags, LFT's and renal function labs
How much antivenin to give pt with poisonous bite? at least 5 vials, but if systemic sx's then can be 10 or 20 vials
Created by: christinapham



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