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129 Cards in this Set
- Front
- Back
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Layers of epidermis.
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stratum corneum
stratum lucidum stratum granulosum stratum spinosum stratum basale |
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Layers of dermis.
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papillary dermis
reticular dermis |
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Name the three zones of thermal injury.
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1. zone of coagulation: central most severely injured area, full thickness burn
2. zone of stasis: vasoconstriction and ischemia, partial thickness burn 3. zone of hyperemia: outermost superficial area, heals quickly scarring. |
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Name some alkali burns.
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- cement
- lime - KOH/NaOH - bleach |
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Name some acid burns.
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- formic acid
- HF: Ca chelation -> insoluble salt formation -> hypocalcemia, dysrhythmia (should treat the arrhythmia, not the burn) |
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How does hydrocarbon create injury?
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cause cell membrane dissolution and skin necrosis
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What is considered high voltage burns? what kind of work up should you do?
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voltage > 1000 watts
- check for rhabdomyolysis - opthalmologic examination to exclude cataract formation - monitor median nerve function - treatment with escharotomy or fasciotomy |
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What is considered low voltage burns?
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voltage < 1000 watts
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What is the most sensitive sign of upper airway thermal injury?
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lip edema
symptoms manifest within 1st 6 hrs diagnosis confirmed by layrngoscopy |
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Treatment for upper airway thermal injury.
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- humidified O2
- pulmonary toileting - bronchiodilators |
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What are some indications for endotracheal intubation in upper airway thermal injuries?
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- posterior pharyngeal swelling
- mucosal sloughing - carbonaceous sputum |
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How do you diagnose lower airway thermal injury?
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- bronchoscopy
- xenon ventilation-perfusion scan |
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What is considered 1st degree burns?
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- injury is confined to the epidermis
- epidermal barrier is intact ex: scalds, sunburn |
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How to treat 1st degree burns?
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salves
NSAIDs |
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Do 1st degree burns leave scars after healing?
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No
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What is considered 2nd degree burns?
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injury involve dermis to varying degreees
1) superficial partial thickness burns: erythematous, painful, blaching, blisters. No scarring. Ex: scalding, flashing flame injuries 2) deep partial-thickness burns: injury extending into reticular dermis. Pale, mottled, nonblaching. |
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What is considered 3rd degree burns?
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injury extends into the subcutaneous fat
- painless, hard leathery eschar |
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Treatment for 3rd degree burns.
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burn/eschar excision
skin grafting |
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What is considered 4th degree burn?
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injury involves other organs beneath the skin such as muscle, brain, bone.
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What is the Parkland formula for calculating resuscitation fluid for burn patients?
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4ml/kg/%total body surface area burn
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What is the Galveston(pediatric) formula for calculating resuscitation fluid for burn patients?
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5000ml/m2 TBSA burned +1500/m2 TBSA
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What is the Brook formula for calculating resuscitation fluid for burn patients?
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1.5ml/Kg/%TBSA burned
- colloid fluids |
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What is the difference in resuscitating adult and pediatric burn patients?
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Adult
- dextrose not used - urine output should be maintained at 0.5ml/kg.hr Peds - Dextrose used in children less than 20kg: D5 1/2NS - urine output should be maintained at 1-2 mg/kg/hr |
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List some complications of burn patients.
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- constrictive eschar
- extremity compartment syndrome - rhabdomyolysis |
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Treatment for this systemic complication of burns:
- constrictive eschar |
escharotomy
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Treatment for this systemic complication of burns:
- extremity compartment syndrome |
- diagnosed by >30mm Hg compartment pressure
- treat with fasciotomy |
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Treatment for this systemic complication of burns:
- rhabdomyolysis |
- mainatain urine output of 100ml/hr
- urine alkalinization with IV NaHCO3 |
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List the stages of burn healing.
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1. inflammatory phase: 7-10 days
2. proliferative phase: day5- 3wks. fibrin, collagen synthesis, angiogenesis. VitC important in this phase. 3. remodeling phase: 3wks -1yr. Scarring occurs |
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Which prophylactic vaccine should be given to all patients with >10% burn area?
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tetanus toxoid
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Side effects of this topical agent for burn treatment:
- silvadene (silver sulfadiazine) |
neutropenia
* not helpful in infected burn because it does not penetrate eschar. |
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Side effects of this topical agent for burn treatment:
- sulfamylon (mafenide acetate) |
metabolic acidosis
- painful on application but can penetrate eschar, good for full thickness infected burns. |
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Side effects of this topical agent for burn treatment:
- neomycin |
nephrotoxicity
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Side effects of this topical agent for burn treatment:
- polymyxin B |
nephrotoxicity
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What to do next?
- teenage boy, bicycle vs truck - awake, alert, no distress - Chest xray: air fluid levels in left lower lung, NG tube coil up to left chest |
Diaphramatic rupture
- immediate celiotomy |
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List some injuries associated with rapid-deceleration.
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- mesenteric vascular injury
- superior mesenteric thrombosis - avulsion of splenic pedicle - renal vascular injury |
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List some injuries assoicated with compression type abdominal injury (ex. seat belt sign).
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diaphragmatic hernia
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Name the 5 P's with arterial injury.
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pain
paresthesia pallor pulselessness paralysis |
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Name the 6 P's with compartment syndrome.
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pain out of proportion
paresthesia pallor paralysis pulselessness poikilothermia (cold) |
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How do you diagnose compartment syndrome?
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intracompartment pressure > 20mmHg
fasciotomy is indicated when intracompartment pressure >30mmHg |
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What is the conservative treatment for chronic compartment syndrome?
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rest
anti-inflammatories leg raise mannual decompression hyperbaric O2 |
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What to do next?
- 25 y/o F MVC - dyspneic, R 60/min - breath sounds diminished on the R side |
tension pneumothorax
- decompress the R pleural space |
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What are the following hormone responses to trauma?
- insulin - thyroxine - ADH - glucagon - aldosterone |
injured patients are highly hypermetabolic
- catecholamines release cause initial drop in insulin, but significant increase afterwards - normal thyroxine - high ADH - normal or increased glucagon - high aldosterone |
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What to do next?
- complete transection of common bile duct |
repair with Roux-en-Y choledochojejunostomy
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What is this? What to do next?
- abdominal trauma - pain, nausea, vomit - duodenal obstruction with a coiled spring appearance in 2nd and 3rd portion |
duodenal hematoma from blunt trauma
- nonsurgical management: NG suction and observation |
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What is this? What to do next?
- marked wt loss - nausea, biliois vomit - stabbing postprandial pain |
SMA syndrome
- nutritional repletion and replenishment of retroperitoneal fat pad |
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List some indications for neck exploration for a cervical laceration.
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- airway distress: stridor, hoarseness, dysphonia
- visceral injury: subcutaneous air, hemoptysis, dysphagia - hemorrhage - neurologic injury referable to carotid injury (stroke or mental status change) |
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Which is the most rapid treatment to decrease ICP?
- hyperventilation - dexamethasone (Decadron) - mannitol infusion - craniotomy |
hyperventilation
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Management of flail chest.
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- pain: intercostal nerve blocks
- Airway: pulmonary toileting with tracheostomy, or thoracotomy with wire stabilization or mechanical ventilation with PEEP |
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What is the initial treatment for the following types of neck laceration?
- zone I (inferior to cricoid cartilage) - zone III (between angle of the mandible and the skull) - multiple neck wounds |
angiography
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Which fracture or dislocation is most likely to result in an associated vascular injury?
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knee dislocation
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Where is the injury?
- MVC, scalp laceration - HR120, BP 80/40, RR 35. no change after 2L saline bolus |
thoracic/abdominal/pelvic hemorrhage
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What is this injury?
- LOC following head trauma |
assumed to be due to intracranial hemorrhage until proven otherwise
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What type of shock is this?
- skin: cool - jugular venous pressure: decreased - cardiac output: decreased - pulmonary capillary wedge pressure: decreased - systemic vascular resistance: increased |
hypovolemic/late septic shock
- peripherally vasoconstricted - tachycardic |
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What type of shock is this?
- skin: cool - jugular venous pressure: increased - cardiac output: decreased - pulmonary capillary wedge pressure: increased - systemic vascular resistance: increased |
cardiogenic shock
- acute MI - vavular stenosis/regurgitation - cardiomyopathy |
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What type of shock is this?
- skin: warm - jugular venous pressure: decreased - cardiac output: decreased - pulmonary capillary wedge pressure: decreased - systemic vascular resistance: decreased |
neurogenic shock
- vasodilation (warm) |
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What type of shock is this?
- skin: warm - jugular venous pressure: decreased/increased - cardiac output: increased - pulmonary capillary wedge pressure: decreased - systemic vascular resistance: decreased |
early septic shock
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What to do next?
- GSW to the buttock, bullet in the RLQ of abdomen - hemadynamically stable |
- sigmoidoscopy
- if inconclusive, use watersoluble Gastrografin contrast |
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What to do next?
hematoma at the pinna of ear |
incision, drainage, pressure bandage
*if left alone, will develop into cauliflower ear (cartilage necrosis, fibrosis) |
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What are some indications for thoracotomy?
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1. cardiac tamponade in patients with penetrating thoracic trauma who is deteriorating too fast for a subxiphoid pericardial window to be created.
2. intraabdominal bleeding for which other measures are not effective in maintaining blood pressure |
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Complications of fistula.
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- fluid/electrolyte depletion
- skin necrosis - malnutrition |
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What to do next?
- distal small bowel fistula, low output |
conservative management
- TPN - fluoroscopic guided fistula drainage |
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What to do next?
- proximal small bowel fistula, high output |
somatostatin
TPN |
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What is PASG?
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pneumatic antishock garment
- elevates BP by increasing peripheral vascular resistance - beneficial for controlling bleeding from pelvic fracture - pressure must be released slowly to avoid development of hypotension |
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What are some indication of peritoneal lavage?
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- identify occult intraperitoneal injury in patients with abdominal trauma
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What organs could be injured?
- deceleration MVC, seat belt on, air bag inflated |
small intestine
large intestine kidneys |
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What organs could be injured?
- GSW in mid-abdomen at the level of umbilicus |
small intestine
large intestine great vessels |
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What organs could be injured?
- baseball bat struck in the upper abdomen |
liver
spleen kidneys pancreas |
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What is the GCS score?
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Glascow coma scale
Eye opening: 1-4 Motor response: 1-6 Verbal response: 1-5 |
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What is the GCS score for this?
EYE - open to pain |
2
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What is the GCS score for this?
EYE - open to speech |
3
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What is the GCS score for this?
EYE - open spontaneously |
4
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What is the GCS score for this?
Motor - externsion (decerebrate) |
2
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What is the GCS score for this?
Motor - abnormal flexion (decorticate) |
3
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What is the GCS score for this?
Motor - withdraws to pain |
4
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What is the GCS score for this?
Motor - localizes pain |
5
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What is the GCS score for this?
Motor - obey command |
6
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What is the GCS score for this?
Verbal - inconprehensible sounds |
2
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What is the GCS score for this?
Verbal - inappropriate words |
3
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What is the GCS score for this?
Verbal - confused conversation |
4
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What is the GCS score for this?
Verbal - oriented |
5
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How do you treat high ICP?
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- hyperventilation: cerebral vasocconstriction
- IV manitol 1g/kg (should not be used unless patients are adequately resuscitated) |
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What to do next in this trauma case?
- dilation of pupil with a sluggish response to light |
sign of temporal lobe herniation on the same side of the lesion
- reduce ICP with hyperventilation or IV manitol - if deteriorate, burr hole placement |
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What to do next in this burn patient?
- house fire, found unconscious, body covered with carbonaceous deposits - oropharynx dry, red, blistered |
early intubation is indicated before a surgical airway is required secondary to pharyngeal and laryngeal edema.
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T/F: All patients injured in closed space fires should have their COHgb level determined.
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True.
- COHgb >30% indicate significant CNS dysfunction - COHgb >60% may portend coma and death. |
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What is the side effects of this drug for burn treatment?
- silver nitrate |
- profround hyponatremia and hypochloremia
- turns the burn area black, does not penetrate eschar |
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Burn complication:
- neurologic |
- transient delirium
- altered mental status: require evaluation for anoxia and metabolic abnormality |
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Burn complication:
- pulmonary |
- pneumonia
- respiratory failure |
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Burn complication:
- cardiovascular |
- venous thrombosis
- supprative thrombophlebitis: can lead to bacteremia, ehich may cause endocarditis along with local venous abscess |
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Burn complication:
- GI |
- ulcers (decrease in splanchnic blood flow): may need early gastric tube feeding
- critically ill patients may develop acalculous cholecystitis, pancreatitis, hepatic dycfunction |
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Burn complication:
- renal |
- ATN due to inadequate resuscitation or myoglobinuria
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Burn complication:
- ophthalmic |
- corneal abrasion: should be examined using fluorescein and treated with antibiotic lubrication
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What is the criteria for positive diagnostic peritoneal lavage in patients with blunt trauma?
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- gross aspiration of 10ml of blood
- aspiration of fecal contents - presence of >100,000/mm3 RBC - 500/mm3 WBC in lavage fluid |
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T/F: DPL is not a sensitive test for injuries to the diagphragm or retroperitoneal structures.
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True
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Which imaging study is better for evaluating penetrating abdominal trauma?
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CT
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What are the advantage and disadvantage of diagnostic laparoscopy?
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- accurate in detecting diaphragm injuries and injuries that can be repaired using laparoscopic techniques.
- lack of sensitivity in detecting hollow visous injuries and the requirement of an operative procedure. |
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What imaging study should be done for this penetrating abdominal injury?
- rigidity, guarding, significant tenderness distant from the stab wound |
celiotomy
- better at detecting hollow viscus injuries. |
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Blunt trauma: What are some major locations of major blood loss?
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- external
- pleural space: bilateral chest tube or chest xray. - intraperitoneal: FAST, DPL - retroperitoneal: FAST - pelvic: pelvic xray - soft tissue |
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Should CT be used for hemodynamically unstable pt in a trauma situation?
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NO.
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Advantage and disadvantage of CT in a trauma case.
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- accurate in identifying solid organ and retroperitoneal injuries
- lacks sensitivity for hollow viscus injuries. |
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Chest blunt trauma:
management for rib fracture. |
- pain management: may need epidural anesthetics to prevent hypoventilation
- 1st and 2nd rib fractures may indicate presence of more severe associated injuries (vascular). |
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What does this indicate in a chest blunt trauma case?
- lungs fail to re-expand after chest tube placement - significant air leakage |
patient may have a major tracheobroncheal injury.
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What is the gold standard for diagnosis of traumatic rupture of the aorta?
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- aortogram
but CT angiography is more widely used because it is less invasive. |
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What is the diagnosis?
- femur fracuture - PO2: 60mmHg despite the use of 100% O2 by mask - confused - chest xray: clear lung fields, normal cardiac size |
fat embolism
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What is the diagnosis?
- apical cap - deviated NG tube - obliteration of the aortic knob - hemomediastinum |
thoracic aortic rupture
- associated with 1st and 2nd rib fracture, scapular fracture |
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What are some indications for wound debridement?
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- necrotic tissue
- foreign material - debris - blisters - callus |
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What are the 4 types of wound debridement?
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1. sharp: removal of tissue with scalpel or scissors
2. autolytic: providing an environment for the body's own defense system to work 3. enzymatic: fibrinolytics, proteolytics, collagenases 4. mechanical: wet-to-dry dressings, whirlpool, scrubbing |
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Burn patient:
early excision should be done except these areas. |
- palms, soles
- genitals - face * there areas contain end arteries. |
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When should excision of deep burns be done?
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between 3-7 days after injury
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When should permanent skin graft be done for burn patient?
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after 1 week of injury
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What to do next?
- common bile duct transection - patient is unstable |
- T-tube placement
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What to do next?
- common bile duct transection - patient is stable |
- choledochojejunostomy
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What to do next?
- GSW to colon - minimal fecal soilage |
primary repair
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What to do next?
- GSW to colon - large fecal soilage |
- primary repair contraindicated
- colostomy with mucous fistula or Hartman's pouch or - exteriorization of primary repair or - protection of a primary repair in the distal colon by formation of a proximal colostomy |
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What is the gold standard to diagnose myocardial contusion?
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- RNA: radionuclide angiography
- echo |
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What are some risk factors for spontaneous pneumothorax?
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- rupture of subpleural blebs
- bullous emphysematous disease - cystic fibrosis - secondary cancers - necrotizing jnfections with pneumocystis carinii, TB |
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What is the cause of primary spontaneous pneumothorax?
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rupture of subpleural blebs
- more common in young adults without comorbidities |
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What are some causes of secondary spontaneous pneumothorax?
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- bullous emphysematous disease
- cystic fibrosis - malignancy |
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When is surgery indicated for first time spontaneous pneumothorax?
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- persistent air leakage 3-5 days
- lung fails to expand - high risk for recurrence - people who have limited access to care - people whose occupations produces an increased risk (scuba divers, pilots) |
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What to do next?
- second time spontaneous pneomothorax |
surgery
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What are some surgical options for spontaneous pneumothorax?
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- VATS: video assisted thoracoscopy
- open thoracotomy: bleb resection, machanical pleurodesis |
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What is the diagnosis?
- respiratory stress post trauma day 2 - PaO2:FiO2 < 300 - bilateral lung infiltrates - PCWP <18mmHg |
acute lung injury
DDX - aspiration pneumonia - atypical pneumonia - atelectasis - PE |
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When is diagnostic bronchoscopy and bronchoalveolar lavage indicated?
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immunocompromised individual with new onset fever and bilateral pulmonary infiltrates.
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What test can differentiate ARDS from cardiogenic pulmonary edema?
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pulmonary artery catheter reading
- if <18: ARDS (leaky capillaries) - if high: cardiogenic pulmonary edema |
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What are some complications of abdominal fascial dehiscence?
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- incisional hernia
- enterocutaneous fistula |
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Risk factors for wound dehiscence.
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- technical failure of surgical techniques and anesthetic relaxation
- deep wound infection - old age - comorbidities: DM, malnutrition, post-op pulmonary disease |
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What are the two factor that guide the management of fascial dehiscence?
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- stability of abdominal contents
- presence or absence of ongoing infection |
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What is the treatment for stable wound dehiscence?
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- local wound care
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What to do next?
- wound dehiscence - patient at risk for enterocutaneous fistula or sepsis |
early reoperation
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Why is incisional hernia repair not done frequently?
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- high risk of infection
- high recurrence rate |
