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129 Cards in this Set

  • Front
  • Back
Layers of epidermis.
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum basale
Layers of dermis.
papillary dermis
reticular dermis
Name the three zones of thermal injury.
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.
Name some alkali burns.
- cement
- lime
- KOH/NaOH
- bleach
Name some acid burns.
- formic acid
- HF: Ca chelation -> insoluble salt formation -> hypocalcemia, dysrhythmia (should treat the arrhythmia, not the burn)
How does hydrocarbon create injury?
cause cell membrane dissolution and skin necrosis
What is considered high voltage burns? what kind of work up should you do?
voltage > 1000 watts
- check for rhabdomyolysis
- opthalmologic examination to exclude cataract formation
- monitor median nerve function
- treatment with escharotomy or fasciotomy
What is considered low voltage burns?
voltage < 1000 watts
What is the most sensitive sign of upper airway thermal injury?
lip edema
symptoms manifest within 1st 6 hrs
diagnosis confirmed by layrngoscopy
Treatment for upper airway thermal injury.
- humidified O2
- pulmonary toileting
- bronchiodilators
What are some indications for endotracheal intubation in upper airway thermal injuries?
- posterior pharyngeal swelling
- mucosal sloughing
- carbonaceous sputum
How do you diagnose lower airway thermal injury?
- bronchoscopy
- xenon ventilation-perfusion scan
What is considered 1st degree burns?
- injury is confined to the epidermis
- epidermal barrier is intact

ex: scalds, sunburn
How to treat 1st degree burns?
salves
NSAIDs
Do 1st degree burns leave scars after healing?
No
What is considered 2nd degree burns?
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.
What is considered 3rd degree burns?
injury extends into the subcutaneous fat
- painless, hard leathery eschar
Treatment for 3rd degree burns.
burn/eschar excision
skin grafting
What is considered 4th degree burn?
injury involves other organs beneath the skin such as muscle, brain, bone.
What is the Parkland formula for calculating resuscitation fluid for burn patients?
4ml/kg/%total body surface area burn
What is the Galveston(pediatric) formula for calculating resuscitation fluid for burn patients?
5000ml/m2 TBSA burned +1500/m2 TBSA
What is the Brook formula for calculating resuscitation fluid for burn patients?
1.5ml/Kg/%TBSA burned
- colloid fluids
What is the difference in resuscitating adult and pediatric burn patients?
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
List some complications of burn patients.
- constrictive eschar
- extremity compartment syndrome
- rhabdomyolysis
Treatment for this systemic complication of burns:

- constrictive eschar
escharotomy
Treatment for this systemic complication of burns:

- extremity compartment syndrome
- diagnosed by >30mm Hg compartment pressure
- treat with fasciotomy
Treatment for this systemic complication of burns:

- rhabdomyolysis
- mainatain urine output of 100ml/hr
- urine alkalinization with IV NaHCO3
List the stages of burn healing.
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
Which prophylactic vaccine should be given to all patients with >10% burn area?
tetanus toxoid
Side effects of this topical agent for burn treatment:

- silvadene (silver sulfadiazine)
neutropenia

* not helpful in infected burn because it does not penetrate eschar.
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.
Side effects of this topical agent for burn treatment:

- neomycin
nephrotoxicity
Side effects of this topical agent for burn treatment:

- polymyxin B
nephrotoxicity
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
List some injuries associated with rapid-deceleration.
- mesenteric vascular injury
- superior mesenteric thrombosis
- avulsion of splenic pedicle
- renal vascular injury
List some injuries assoicated with compression type abdominal injury (ex. seat belt sign).
diaphragmatic hernia
Name the 5 P's with arterial injury.
pain
paresthesia
pallor
pulselessness
paralysis
Name the 6 P's with compartment syndrome.
pain out of proportion
paresthesia
pallor
paralysis
pulselessness
poikilothermia (cold)
How do you diagnose compartment syndrome?
intracompartment pressure > 20mmHg

fasciotomy is indicated when intracompartment pressure >30mmHg
What is the conservative treatment for chronic compartment syndrome?
rest
anti-inflammatories
leg raise
mannual decompression
hyperbaric O2
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
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
What to do next?

- complete transection of common bile duct
repair with Roux-en-Y choledochojejunostomy
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
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
List some indications for neck exploration for a cervical laceration.
- airway distress: stridor, hoarseness, dysphonia
- visceral injury: subcutaneous air, hemoptysis, dysphagia
- hemorrhage
- neurologic injury referable to carotid injury (stroke or mental status change)
Which is the most rapid treatment to decrease ICP?

- hyperventilation
- dexamethasone (Decadron)
- mannitol infusion
- craniotomy
hyperventilation
Management of flail chest.
- pain: intercostal nerve blocks
- Airway: pulmonary toileting with tracheostomy, or thoracotomy with wire stabilization or mechanical ventilation with PEEP
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
Which fracture or dislocation is most likely to result in an associated vascular injury?
knee dislocation
Where is the injury?

- MVC, scalp laceration
- HR120, BP 80/40, RR 35. no change after 2L saline bolus
thoracic/abdominal/pelvic hemorrhage
What is this injury?

- LOC following head trauma
assumed to be due to intracranial hemorrhage until proven otherwise
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
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
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)
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
What to do next?

- GSW to the buttock, bullet in the RLQ of abdomen
- hemadynamically stable
- sigmoidoscopy
- if inconclusive, use watersoluble Gastrografin contrast
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)
What are some indications for thoracotomy?
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
Complications of fistula.
- fluid/electrolyte depletion
- skin necrosis
- malnutrition
What to do next?

- distal small bowel fistula, low output
conservative management
- TPN
- fluoroscopic guided fistula drainage
What to do next?

- proximal small bowel fistula, high output
somatostatin
TPN
What is PASG?
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
What are some indication of peritoneal lavage?
- identify occult intraperitoneal injury in patients with abdominal trauma
What organs could be injured?

- deceleration MVC, seat belt on, air bag inflated
small intestine
large intestine
kidneys
What organs could be injured?

- GSW in mid-abdomen at the level of umbilicus
small intestine
large intestine
great vessels
What organs could be injured?

- baseball bat struck in the upper abdomen
liver
spleen
kidneys
pancreas
What is the GCS score?
Glascow coma scale
Eye opening: 1-4
Motor response: 1-6
Verbal response: 1-5
What is the GCS score for this?

EYE
- open to pain
2
What is the GCS score for this?

EYE
- open to speech
3
What is the GCS score for this?

EYE
- open spontaneously
4
What is the GCS score for this?

Motor
- externsion (decerebrate)
2
What is the GCS score for this?

Motor
- abnormal flexion (decorticate)
3
What is the GCS score for this?

Motor
- withdraws to pain
4
What is the GCS score for this?

Motor
- localizes pain
5
What is the GCS score for this?

Motor
- obey command
6
What is the GCS score for this?

Verbal
- inconprehensible sounds
2
What is the GCS score for this?

Verbal
- inappropriate words
3
What is the GCS score for this?

Verbal
- confused conversation
4
What is the GCS score for this?

Verbal
- oriented
5
How do you treat high ICP?
- hyperventilation: cerebral vasocconstriction
- IV manitol 1g/kg (should not be used unless patients are adequately resuscitated)
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
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.
T/F: All patients injured in closed space fires should have their COHgb level determined.
True.
- COHgb >30% indicate significant CNS dysfunction
- COHgb >60% may portend coma and death.
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
Burn complication:

- neurologic
- transient delirium
- altered mental status: require evaluation for anoxia and metabolic abnormality
Burn complication:

- pulmonary
- pneumonia
- respiratory failure
Burn complication:

- cardiovascular
- venous thrombosis
- supprative thrombophlebitis: can lead to bacteremia, ehich may cause endocarditis along with local venous abscess
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
Burn complication:

- renal
- ATN due to inadequate resuscitation or myoglobinuria
Burn complication:

- ophthalmic
- corneal abrasion: should be examined using fluorescein and treated with antibiotic lubrication
What is the criteria for positive diagnostic peritoneal lavage in patients with blunt trauma?
- gross aspiration of 10ml of blood
- aspiration of fecal contents
- presence of >100,000/mm3 RBC
- 500/mm3 WBC in lavage fluid
T/F: DPL is not a sensitive test for injuries to the diagphragm or retroperitoneal structures.
True
Which imaging study is better for evaluating penetrating abdominal trauma?
CT
What are the advantage and disadvantage of diagnostic laparoscopy?
- 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.
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.
Blunt trauma: What are some major locations of major blood loss?
- external
- pleural space: bilateral chest tube or chest xray.
- intraperitoneal: FAST, DPL
- retroperitoneal: FAST
- pelvic: pelvic xray
- soft tissue
Should CT be used for hemodynamically unstable pt in a trauma situation?
NO.
Advantage and disadvantage of CT in a trauma case.
- accurate in identifying solid organ and retroperitoneal injuries
- lacks sensitivity for hollow viscus injuries.
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).
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.
What is the gold standard for diagnosis of traumatic rupture of the aorta?
- aortogram
but CT angiography is more widely used because it is less invasive.
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
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
What are some indications for wound debridement?
- necrotic tissue
- foreign material
- debris
- blisters
- callus
What are the 4 types of wound debridement?
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
Burn patient:

early excision should be done except these areas.
- palms, soles
- genitals
- face

* there areas contain end arteries.
When should excision of deep burns be done?
between 3-7 days after injury
When should permanent skin graft be done for burn patient?
after 1 week of injury
What to do next?

- common bile duct transection
- patient is unstable
- T-tube placement
What to do next?

- common bile duct transection
- patient is stable
- choledochojejunostomy
What to do next?

- GSW to colon
- minimal fecal soilage
primary repair
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
What is the gold standard to diagnose myocardial contusion?
- RNA: radionuclide angiography
- echo
What are some risk factors for spontaneous pneumothorax?
- rupture of subpleural blebs
- bullous emphysematous disease
- cystic fibrosis
- secondary cancers
- necrotizing jnfections with pneumocystis carinii, TB
What is the cause of primary spontaneous pneumothorax?
rupture of subpleural blebs
- more common in young adults without comorbidities
What are some causes of secondary spontaneous pneumothorax?
- bullous emphysematous disease
- cystic fibrosis
- malignancy
When is surgery indicated for first time spontaneous pneumothorax?
- 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)
What to do next?

- second time spontaneous pneomothorax
surgery
What are some surgical options for spontaneous pneumothorax?
- VATS: video assisted thoracoscopy
- open thoracotomy: bleb resection, machanical pleurodesis
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
When is diagnostic bronchoscopy and bronchoalveolar lavage indicated?
immunocompromised individual with new onset fever and bilateral pulmonary infiltrates.
What test can differentiate ARDS from cardiogenic pulmonary edema?
pulmonary artery catheter reading
- if <18: ARDS (leaky capillaries)
- if high: cardiogenic pulmonary edema
What are some complications of abdominal fascial dehiscence?
- incisional hernia
- enterocutaneous fistula
Risk factors for wound dehiscence.
- technical failure of surgical techniques and anesthetic relaxation
- deep wound infection
- old age
- comorbidities: DM, malnutrition, post-op pulmonary disease
What are the two factor that guide the management of fascial dehiscence?
- stability of abdominal contents
- presence or absence of ongoing infection
What is the treatment for stable wound dehiscence?
- local wound care
What to do next?

- wound dehiscence
- patient at risk for enterocutaneous fistula or sepsis
early reoperation
Why is incisional hernia repair not done frequently?
- high risk of infection
- high recurrence rate