SR 4: Trauma, Critical Care, Burns, Plastics, Skin, Soft Tissue
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| What is the LD50 and LD90 of falls? | LD50 = 48 feet (4 stories), LD90 = 84 feet
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| What is a positive DPL? | Gross blood (>10cc), or identification of bile, bacteria, food particles, or >500 WBCs or >100,000 RBCs
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| What does a DPL miss? | retroperitoneal bleeds and contained hematomas
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| What does FAST scan miss? | retroperitoneal bleeding and hollow viscus injuries
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| What are the signs of abdominal compartment syndrome? | Bladder pressures >25-30, increased ventilatory peak pressures (upward displacement of diaphragm), hypotension, decreased urinary output (renal vein compression)
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| What are the operative indications for intracranial hemorrhage? | Significant neurologic degeneration or mass effect (>5mm)
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| How do you calculate cerebral perfusion pressure? | CPP = MAP – ICP, keep >60
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| What is the cause of an epidural hematoma? | arterial bleeding from middle meningeal artery
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| What is the cause of a subdural hematoma? | Most commonly from tearing of venous plexus (bridging veins) between dura and arachnoid
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| What are the possible supportive treatments for elevated ICP? | Treat if >20: sedation (barbituate coma) and paralysis, elevate head of bed, relative hyperventilation (CO2 30-35), keep Na 140-150 and serum osm 295-310, mannitol, ventriculostomy with CSF drainage, decrompressive craniotomy
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| When does peak intracranial pressure occur after traumatic brain injury? | 48-72 hours
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| What does a dilated pupil after TBI suggest? | Uncal herniation on same side (CN III compression)
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| What cranial nerves are commonly injured with temporal skull fractures? | CN VII and VIII
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| What is the most common site of facial nerve injury? | Geniculate ganglion
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| What are the operative indications for a skull fracture? | Significantly depressed (8-10mm), contaminated, or persistent CSF leak
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| What are the signs of basal skull fractures? | Anterior fossa fracture – raccoon eyes; middle fossa fracture – battle’s sign
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| What is a Jefferson fracture? | C1 burst fracture caused by axial loading (diving into shallow water)
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| What is a hangman’s fracture? | C2 fracture caused by distraction and extension
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| What are the types of odontoid fractures? | I – above base, stable; II – at base; III – extends into vertebral body. II+III are unstable and need fusion or halo
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| Describe the columns of the thoracolumbar spine | Anterior – anterior longitudinal ligament and ½ of vertebral body; Middle – posterior ½ of vertebral body and posterior longitudinal ligament; Posterior – facet joints, lamina, spinous processes, and interspinous ligaments
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| When is a thoracolumbar spinal fracture considered unstable? | If more than one column is disrupted
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| What fractures are at risk from an upright fall? | Calcaneus, lumbar, and wrist/forearm
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| What is the number 1 indicator of mandibular injury? | Malocclusion
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| Describe the zones of the neck | I – clavicle to cricoid cartilage; II – cricoid to angle of the mandible; III – angle of the mandible to base of skull
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| What is the best modality to diagnose traumatic esophageal injuries? | Rigid esophagoscopy and esophagogram – finds 95% of injuries when combined
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| What is the operative approach to esophageal injuries? | Neck – left side, upper 2/3 of esophagus – right thoracotomy, lower 1/3 – left thoracotomy
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| What are the indications for thoracotomy after chest tube placement? | >1500 cc blood initially, >200 cc/hr x3 hrs, or >2500 cc x 24hrs
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| What is the operative approach to traumatic tracheobronchial injury? | Operate if large air leak and respiratory compromise or after 2 weeks of persistent air leak. Left thoracotomy only for distal left mainstem injuries, all others get right thoracotomy to avoid aorta
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| What do you suspect if an air-fluid level is seen in the left chest after blunt injury? | Diaphragm rupture with stomach herniation into chest
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| What is the treatment for traumatic diaphragmatic injury? | Approach via abdomen if <1 week, via chest if >1 week since injury
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| Where are traumatic diaphragm injuries usually located? | 8:1 on the left
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| What are the signs of aortic transection? | widened mediastinum, 1st rib fracture, apical capping, loss of aortopulmonary window, loss of aortic contour, left hemothorax, tracheal deviation
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| Where is the most common location of aortic transection? | At ligamentum arteriosum just distal to subclavian takeoff
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| What is the treatment of penetrating “box” injuries? | Borders are clavicles, xiphoid process, and nipples – need pericardial window, bronchoscopy, esophagoscopy, and barium swallow
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| What is the treatment of a penetrating chest wound outside the “box” without pneuomothorax or hemothorax? | Still needs chest tube if patient required intubation, otherwise follow CXRs
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| What type of bleeding is associated with pelvic fractures? | Anterior pelvic fractures are more likely to have venous bleeding whereas posterior fractures have arterial
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| What is the most common area of duodenal trauma? | Second portion near ampulla of vater
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| What is the surgical treatment for duodenal trauma? | 80% can be treated with debridement and primary closure, but may need pyloric exclusion and gastrojejunostomy to allow healing
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| What is the cause of a high SBO 12-72 hours after blunt traumatic injury? What is the treatment? | Missed duodenal hematoma – treat with TPN and NGT – 90% cured over 2-3 weeks
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| What is the treatment for traumatic common bile duct injury? | <50% circumference – repair over stent; >50% - choledochojejunostomy
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| When has conservative management of a blunt liver injury failed? | Patient is unstable despite aggressive resuscitation, or requires >4 units RBC to keep Hct over 25 – Go to OR
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| When has conservative management of a blunt splenic injury failed? | Patient is unstable despite aggressive resuscitation, or requires >2 units RBC to keep Hct over 25 – Go to OR
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| Which is performed first: vascular repair or orthopedic repair? | Vascular repair
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| What is the best way to repair a posterior IVC repair? | Through the anterior wall
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| What is the best indicator of renal trauma? | Hematuria
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| What is the treatment of a left renal vein injury? | Can ligate near IVC because of adrenal and gonadal vein collaterals, cannot do this on right
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| What is the treatment for a traumatic bladder injury? | Extraperitonal - a/w pelvic fx, foley only for drainage; Intraperitoneal - no pelvic fx, more likely in kids, usually dome rupture - laparotomy with multi-layer closure and foley
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| How is a traumatic urethral injury diagnosed? | retrograde urethrogram (RUG), do not place foley - needs suprapubic catheter
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| What is a test can you do to assess fetal maturity in a pregnant trauma patient? | lecithin:sphingomyelin (LS) ratio > 2:1; positive phosphatidylcholine
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| What is the Kleihauer-Betke test? | Test for fetal blood in maternal circulation – sign of placental abruption
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| What are the indications for C-section during trauma ex-lap? | persistent maternal shock, near term (>34 wks) and mother with severe injuries, pregnancy a threat to mother’s life (DIC, hemorrhage), mechanical limitation to life-threatening vessel injury, direct uterine trauma
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| What determines stroke volume? | LVEDV, contractility, and afterload
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| What is the Anrep effect? | automatic increase in contractility secondary to increased afterload
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| What is the Bowditch effect? | automatic increase in contractility secondary to increased HR
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| What equation describes O2 delivery? | CO x CaO2 = CO x (Hgb x 1.3 x SpO2)
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| What causes a right shift of the oxygen disassociation curve? | Oxygen unloading – increased CO2, temperature, ATP, 2,3DPG, or decreased pH
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| What does an elevated mixed venous oxygen saturation (SvO2) indicate? | >77% - shunting or decreased O2 extraction – sepsis, cyanide poisoning, cirrhosis, hypothermia, paralysis, coma
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| What does a decreased mixed venous oxygen saturation (SvO2) indicate? | <66% - decreased cardiac output or decreased oxygen saturation
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| What are relative contraindications to placing a Swan-Ganz catheter? | previous pneumonectomy or left bundle branch block
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| What do you do if you encounter hemoptysis after Swan placement? | Pull catheter back slightly and inflate balloon and increase PEEP (will tamponade the pulmonary artery bleed), mainstem intubate nonaffected side; may need thoracotomy and lobectomy
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| What are the approximate Swan distances to wedge from the various central access locations? | R SCV – 45cm, R IJ – 50cm, L SCV – 55cm, L IJ – 60cm
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| Where does blood have the lowest venous saturation? | Coronary venous blood (30%)
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| What is the initial alternation in hemorrhagic shock? | Increased diastolic blood pressure
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| What is the cause of petechiae, hypoxia, and confusion/agitation after a femur fracture? How is the diagnosis made? | Fat emboli; sudan red stain may show fat in sputum and urine
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| What is the treatment for air emboli? | Place patient head down and roll to left (keeps air in RV and RA), then aspirate out air with central line or PA catheter to RA/RV
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| What are the effects of an intraaortic balloon pump (IABP)? | Augments diastolic coronary blood flow and reduces afterload by inflating during diastole (inflates 40msec before T wave, deflates with p wave)
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| What do dopamine receptor agonists do? | Relax renal and splanchnic smooth muscle
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| What are the effects of alpha-1, alpha-2, beta-1, and beta-2 adrenergics? | alpha-1 – vascular smooth muscle/gluconeogenesis, alpha-2 – venous smooth muscle, beta-1 – myocardial contraction and rate, beta-2 – relaxes bronchial smooth muscle and vascular smooth muscle
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| What is the mechanism and effect of milrinone/amrinone? | phosphodiesterase inhibitor (increases cAMP) resulting in increases Ca flux and myocardial contractility - inotrope, increases CO and decreases SVR
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| What is a potential side-effect of excessive nipride infusion? What is the treatment? | cyanide toxicity, can check thiocyanate levels – treat with amyl nitrite then sodium nitrite
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| What is the difference between nipride and nitroglycerine effects? | Both work via nitric oxide (vasodilation) but nipride is an arterial and venous dilator whereas nitroglycerine is predominantly venodilatation; both can lead to pulmonary shunting
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| What is the effect of increased PEEP? | improves oxygenation by alveoli recruitment and increases FRC
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| What are the effects of aging on the pulmonary system? | Increased FRC, decreased compliance and FEV1
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| What is functional residual capacity (FRC)? | air in lungs after normal exhalation [expiratory reserve volume (ERV) + residual volume (RV)]
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| What is inspiratory capacity? | maximum amount of air able to be inhaled (TV + IRV)
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| What is vital capacity? | greatest volume of air that can be exhaled (TV + IRV + ERV), also called forced vital capacity (FVC)
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| How does restrictive lung disease differ from obstructive lung disease on pulmonary function studies? | Restrictive – decreases TLC, RV, and FVC; Obstructive – increases TLC, RV, but decreases FEV1
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| What are the physiological effects of ARDS? | decreased pulmonary compliance and increased protinaceous material, causing increased gradient and increased shunt
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| What is Mendelson’s syndrome? | chemical pneumonitis from aspiration of gastric secretions
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| What is the most frequent site of aspiration? | posterior portion of RUL and superior portion of RLL
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| What are 3 laboratory indicators of low volume, “pre-renal” azotemia? | FeNa < 1, urine Na < 20, or BUN/Cr ratio >30
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| What triggers renin release? | Low Na sensed by macula densa of JG apparatus or decreased BP sensed by baroreceptors
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| Where is angiotensin I converted into angiotensin II? | In the lung by angiotensin converting enzyme (ACE)
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| What are the effects of angiotensin II? | vasoconstrictor, increases HR/contractility, inhibits renin release, releases aldosterone
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| What is the treatment of carbon monoxide poisoning? | 100% O2 – decreases CO half life from 5 hrs to 1 hr
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| What are admission criteria for burns? | 2nd + 3rd degree >10% TBSA patients <10 or >50, or >20% TBSA in other patients; >5% 3rd degree burns, suspected abuse
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| What is the parkland formula? | For burns >20% - 4cc x kg x %TBSA. LR fluid is given over 24 hours but 1/2 is given in first 8 hours
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| What is the cause of inhalational injury? | carbonaceous materials and smoke, not heat
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| What are risk factors for airway injury? | EtOH, trauma, closed space, rapid combustion, extremes of age, delayed extrication
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| What is the most common infection in burn wound patients? | Pneumonia
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| Which chemicals produce deeper burn wounds: acids or alkalis? | Alkalis due to liquefaction necrosis
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| What is the hallmark of acid burn wounds? | coagulation necrosis
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| What is the treatment for hydrofluoric acid burns? | spread calcium on wound
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| What is the treatment for tar burns? | Cool, then wipe away with lipophilic solvent
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| What is the treatment for electrical burns? | Cardiac monitoring, monitor for rhabdomyolysis and compartment syndrome
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| What is a contraindicated to skin grafting a burn wound? | Cultures positive for beta-hemolytic strep or bacteria >10^5
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| How long do homografts and xenografts generally last? | homografts 2-4 weeks, xenografts 2 weeks
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| What are the goals for surgery in burn wound excision and grafting? | <1L blood loss, <20% skin excised, and <2 hours in OR
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| What is the most common reason for skin graft loss? | hematoma or seroma formation under graft
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| What is the treatment for extensive deep burns to the palm? | Splint hand in extension for 1 week, then graft in week 2 with FTSG
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| What is the most common organism in burn wound infections? | Pseudomonas, common in burns >30% TBSA
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| What are the characteristics of silvadene? | Poor eschar penetration, risk of neutropenia and thrombocytopenia, good candida/pseudomas coverage, do not use if sulfa allergy
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| What are the characteristics of sulfamylon? | Painful, can cause metabolic acidosis (carbonic anhydrase inhibitor), good eschar penetration
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| What are the characteristics of silver nitrate? | Can cause hyponatremia and hypochloremia due to leeching of NaCl
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| What is the most common viral infection in burn wounds? | HSV
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| What is the best way to detect burn wound infection (and differentiate from colonization)? | biopsy of wound
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| What is symblepharon? | Eyelid stuck to conjunctiva after burn, treat with release with glass rod
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| What is a Marjolin’s ulcer? | SCCA that develops in a chronic burn wound
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| What is the pathophysiology and treatment of toxic epidermal necrolysis? | Epidermal-dermal separation; supportive care, topical abx, xenografts – NO steroids
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| What is the pathophysiology and treatment of Stevens-Johnson syndrome? | hypersensitivity reaction – more severe TEN with subepidermal bullae, epidermal cell necrosis, and dermal edema; Tx – supportive care, topical abd, xenografts – NO steroids
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| What is the function of Pacinian corpuscles? | sense pressure
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| What is the function of Ruffini’s endings? | sense warmth
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| What is the function of Krause’s end-bulbs? | sense cold
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| What is the function of Meissner’s corpuscles? | tactile sense
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| Which skin grafts are more likely to survive, split thickness or full thickness? | split-thickness because graft is not as thick so easier for imbibation and subsequent revascularization to occur
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| What are the three steps to the healing of a skin graft? | Imbibition, inosculation, revascularization
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| What is the most common cause of pedicled or anastomosed free flap tissue necrosis? | venous thrombosis
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| What is the most important determinator of TRAM flap viability? | periumbilical perforators
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| What are risk factors for melanoma? | dysplastic, atypical or large congential nevi (10% risk), familiar BK mole syndrome (essentially 100% risk), xeroderma pigmentosum, fair complexion, sun exposure, previous skin cancer/XRT
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| What are the common sites of melanoma? | Skin > eyes > rectum; #1 skin site for men = back, women = legs; Worse prognosis on "BANS" – back, arms, neck, scalp
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| What is the most common location of metastases from melanoma? | lungs
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| What is the most common primary with a metastases to the small bowel? | melanoma
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| What are the four major types of melanoma? | superficial spreading (most common), acral lentiginous, lentigo maligna, and nodular
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| What types of melanoma have the best and worst prognosis? | Best – lentigo maligna; Worst – nodular
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| What are the surgical margins for resection of a melanoma? | in situ = 0.5cm margin; <1mm depth = 1 cm margin; 1-2mm depth = 1-2 cm margin (with SNL); >2mm depth = 2 cm margin
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| What is the Breslow classification of melanoma and associated survivals? | <1mm thickness (95% 5 yr survival); 1-2mm (80-95%); 2-4mm (60-75%); >4mm (50%)
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| What is the most common malignancy in the United States? | Basal cell carcinoma
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| What type of skin cancer has a pearly appearance and rolled borders? | basal cell carcinoma
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| What type of cancer demonstrates “peripheral palisading” of nuclei and “stromal retraction artifact”? | basal cell carcinoma
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| What is the most aggressive subtype of BCC and what is it characterized by? | morpheaform – has collagenase production
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| What type of skin cancer has overlying erythema and is papulonodular with crust and ulceration? | Squamous cell carcinoma
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| What is the three most common soft tissue sarcomas? | 1 – malignant fibrous histiosarcoma, 2 – liposarcoma (thigh, retroperitoneum), 3 - leiomyosarcoma
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| What are the recommendations for biopsy of an extremity sarcoma? | Excisional if < 4cm, otherwise longitudinal incision (less lymphatic disruption, easier to excise scar if biopsy positive)
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| What is the criteria for high-grade histologic grading of a sarcoma? | more than 5 mitoses per HPF, prominent vascularity, hyperchromatic nuclei, and necrosis
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| What are the indications for radiation to a sarcoma? | close margins (want at least 3 cm and one uninvolved fascial plane), >5 cm, or high grade
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| What is the difference between actinic, seborrheic, and arsenical keratoses? | actinic and arsenical are premalignant (SCCA risk, from sun or arsenic, respectively), seborrheic has no cancer risk
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| What is Bowen’s disease? | SCCA-in-situ, 10% turn invasive
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| How does brown fat differ from white fat? | less metabolically active, but more mitochondria and more capillaries – abundant in newborns and hibernating animals
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| Where is brown fat located in an adult? | Mostly located in neck, axilla, and interscapular regions
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| What is the treatment of Kaposi sarcoma | XRT – surgery indicated for biopsy purposes only
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| What is the pathophysiology of hidradenitis? | inflammatory infiltrate of apocrine glands, thus seen after puberty
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