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205 Cards in this Set

  • Front
  • Back
What are the most predictive factors for wound infection?
Wound location, age, depth, configuration and level of contamination.
p. 299
Which inorganic soil contaminant is the worst for infx?
Clay

p. 299- even worse than sand and black dirt from roadways
What are the most predictive factors for wound infection?
Wound location, age, depth, configuration and level of contamination.
p. 299
In terms of time to closure, which delayed healing area of the body is better, head or trunk
Head heals regardless of timing to closure (even up to 100 hrs), where as the trunk does not generally heal well (esp > 19 hrs)

p.299
What are the most predictive factors for wound infection?
Wound location, age, depth, configuration and level of contamination.
p. 299
Wounds not closed by primary closure should be considered for secondary closure when?
4 days


p. 299
Which inorganic soil contaminant is the worst for infx?
Clay

p. 299- even worse than sand and black dirt from roadways
How long can a finger tourniquet be used to maintain a bloodless field?
NLT 30 min.

p. 299
In terms of time to closure, which delayed healing area of the body is better, head or trunk
Head heals regardless of timing to closure (even up to 100 hrs), where as the trunk does not generally heal well (esp > 19 hrs)

p.299
Which inorganic soil contaminant is the worst for infx?
Clay

p. 299- even worse than sand and black dirt from roadways
Wounds not closed by primary closure should be considered for secondary closure when?
4 days


p. 299
In terms of time to closure, which delayed healing area of the body is better, head or trunk
Head heals regardless of timing to closure (even up to 100 hrs), where as the trunk does not generally heal well (esp > 19 hrs)

p.299
How long can a finger tourniquet be used to maintain a bloodless field?
NLT 30 min.

p. 299
Wounds not closed by primary closure should be considered for secondary closure when?
4 days


p. 299
How long can a finger tourniquet be used to maintain a bloodless field?
NLT 30 min.

p. 299
When evaluating a digit or extremity wound, how should it be evaluated?
In both neutral position and in the position of injury

p. 300- additionally, the wound may need to be injected to ensure there is no involvement of the joint.
What are some materials visible on plain x-ray films?
metal
bone
teeth
pencil graphite
certain plastics
glass (but only when >2mm)
gravel
sand
some fish bones
painted wood
most aluminums

p. 300
Where is the greatest site of wound infx risk on the body (head, neck, upper extremity or lower extremity)?
lower extremity

p. 301
What is the single most important step in treating a traumatic wound?
Wound repair

p. 301
What are some risk factors for poor wound healing?
1. Immunosuppression (DM, CKD,steroids)
2. Tissue Ischemia (PVD, anemia)
3. Poor Wound healing (elderly, smoking, malnourishment)
4. Wound factors ()crush injury, tissue loss...)

p. 302
T/F: Sterile technique is required to reduce wound infx of wounds.
No- this has never been proven. Clean technique is fine

p. 302
What should be done prior to the administration of local anesthesia?
sensory, motor and vascular examination at and distal to the wound site.

p. 302
T/F: The use of epinephrine mixed with local anesthetics is safe in the digits as well as the nose in those w/o small vessel dz.
True

p. 302
What is the simplest tourniquet to use in the ED?
The BP cuff, applied proximal to the wound and inflated just slightly higher than the patients systolic BP

p. 302
what are some clinical clues to FB in wound?
1. FB sensation (most reliable in adults, no children- LR 2.49, vs not reported 0.6)
2. point tenderness
3. increased pain w/ROM

p. 304
What is autolytic debridement?
The bodies natural method of wound healing. Only appropriate for non-contaminated wound. Moist environment.

p. 305
What is mechanical debridement?
The use of wet to dry dressing. USed to remove devitalized, necrotic and exudative material. Many need analgesia for this

p. 305
What is Excisional debridement?
THE MOST EFFECTIVE debridement. Using a surgical blade.

p. 305
The most important step in prevention of wound infx is...
irrigation and debridement

p. 306
if prophylactic abx's are provided, how long should they be provided for for wounds?
NMT 24 hrs. Additionally, this should be provided prior to wound manipulation. PO vs IV, no matter as long as it is provided prior to wound manipulation.

p. 306- read this...
What organisms are a concern in human/mammilian bites?
Pasteurella and Eikenella

p. 306-use augmentin
What organism is of concern when a wound is through a shoe (plantar surface) or fresh water?
Pseudmonas

p. 306
What has the most effect on cosmetic outcomes in wound closure?
1. practitioner technique
and
2. patients healing characteristics

p. 307
What has the lowest dehiscence rate but the greast cost?
Sutures

p. 307
What provides the rapid application, low tissue ractivity, low cost, low risk of harm to the examiner?
Staples

p. 307
What wound closure item is low cost, most comfortable for the patient, antimocrobial barrier product,; but has low tensile strength, dehiscence when over high tension areas?
Tissue adhesive

p. 307
What has the highest rate of dehiscence?
Adhesive Tapes

p. 307
what is a way to reduce keloids in wound repair?
Minimizing the use of foreign material into the wound (ie if you can avoid sutures or staples and use tissue adhesive or adhesive tape, use it instead)

p. 307
Why is nylon and polypropylene(synthetic monofilament) preferred as a suture device?
Due to their strength, handling and relatively low tissue activity

p. 307
How long do absorbable and non-absorbable sutures maintain their tensile strength?
Non- Absorbable: > 60 days
Absorbable: < 60 days

p. 307
Which non-absorbable suture causes the least inflammatory rxn?
polypropolene

p. 308
Which non-absorbable suture is optimal for intraoral mucosal surfaces?
Silk


p. 308
Which non-absorbable suture is ideal for use in tendon repair?
polybuster

- it expands and recoils in such a tension area, however, has one of the higher risks of inflammatory response.

p. 308
How is suture diameter identified, what is standard size and why important?
1. USP= size
2. 5 is largest, 10 is smallest
3. the larger the size the bigger the hole

p. 309
* smaller the diameter, the weaker the tensile strength so examiner has to determine: Cosmesis vs Strength need.
Ties in the knots, what determines this?
Generally, the size of the suture determines the knots. The knots do not add to strength, only to it's bulk.

p. 309
What suture technique lacks practicality for the ER?
Subcuticular sutures

p. 310
Vertical mattress sutures are appropriate for...
very thin or laxed skin.

p. 311
Which wound closure technique allows the least precision for wound approximation?
Staples

p. 312 (limited to scalp and nonfacial areas and cause more pain when removed than sutures)
Pressing firmly on the stapler can cause what to the wound edges?
Depression

p. 312
Tissue adhesive should cover over the entire wound and extend___ to ___ mmon either side of the wound edges.
5,10

p. 314
After applying one layer of tissue adhesive to the wound, how long should you wait to apply another?
30-45 seconds

p. 314
Why should wound edge debridement be kept to a minimum on the face and scalp?
The face has excellent blood supply, which can make non-viable appearing tissue heal

p. 315
how much greater is the risk of infx for blut than sharp trauma to the scalp?
10x
2/2 to the traumatic cause of the blut trauma which causes swelling and damages cells- which requires 10x's less bacteria to cause infx than for sharp

p. 315
which branches of the external carotids (3) and internal carotids (2) richly supply the scalp with blood?
External Carotids:
- occipital
- superficial temporal
- posterior auricular
Internal Carotids:
- supraorbital
- supratrochlear

p. 515
What is the advantage of a regional block over local block in wound mgt of the face?
It prevents local swelling that would distort the wound

p. 516
When should scalp sutures/staples be removed? When should non-absrobable sutures be removed from the forehead?
10 days from scalp
3-5 days from the forehead

p. 317
nerve innervation of the eyelid, is from where?
Temporal and Zygomatic braches of the facial nerve

p. 317
Why should a physician have a low threshold for referring periorbital lacerations to ophthalmologist or plastics providers?
because this area is not only responsible for cosmesis but also vital for fxn

p. 317
Nasolacrimal duct is 3-5 mm above the medial canthus. How far into an injury is measurement warranting a referral?
Injuries w/in 6-8 mm of the medial canthus warrants referral to occuloplastics or ophthalmologist.

Additionally, 1. injury to the medial eyelid 2. cutting thru the eyelid margin 3.injuries to the lacrimal duct 4.wounds associated with ptosis 5. injuries that extend into the tarsal plate

p. 318
Where should tissue adhesives definately not be used when repairing the face?
Near the eye- the tissue adhesives can abrade the cornea

p. 318
How are small nasal septal hematomas drained? Large hematomas? Do they get anything else?
1. small: 18 g needle
2. large: incision in the septal mucoperichondrium
3. anterior nasal packing if incision, as well as prophylactic abx to prevent infx of cartilage (pkg removed in 3-5 days)

p. 319. (Note, b/l septal hematomas- drained in operating room)
What nerves supply the lips (upper and lower)
Upper lip, infraorbital
Lower lip, submental

- both are from the trigeminal nerve

p. 320
T/F: intraoral lacerations, even if less than 1 cm need repair?
False, if < 1 cm, no need for repair

p. 320: if no vermillion involvement and thru and thru, start w/intraoral laceration, then muscle then skin. If vermillion- start there.

p. 320
What structure may be affected by intraoral laceration just by the second molar in buccal mucosa?
Parotid duct opening

p. 320
Reasons to close intraoral lacerations?
- > 2 cm
- large enough to trap food particles
- have a tissue flap that interferes with chewing

p.321
When assessing the tendons of the digits/hand, what does weakness, limited ROM, or pain suggest?
partial involvement of the tendon

p.322
T/F: 6 mm two pt discrimination is an appropriate sensation determination in digits when checked distal to the palm.
True.
it diminishes with age: young can feel w/in distance of 2 mm, elderly (>66y/o) 5 mm- making 6 adequate for both

- 6-10= good
-10-15= fair
-> 15= poor
When doing an allen test, if cap refill time if > 3 sec, what does this suggest?
significant vascular injury

p.322
A doppler probe can be used to determine if pulse and used to calculate the arterial pressure index. What the heck is that?
The ratio of the difference between a potentially vascular compromised extremity (arm/hand) and non-compromised. Ratio < 1 is bad. If ratio NML and pulse present, vascular compromise is unlikely.

p. 323
How soon after a finger lac repair should a patient receive f/u? And how soon after examination should they have sutures removed?
48-72 Hrs- follow up
8-10 days- removal of sutures

p. 323
What are some of the organisms transferred from human mouth contact? Which is the MC?
Staphylococcus Aureus
Streptococcus Spp
Cornyebacterium Spp
Eikenella Corrodens
Herpes
Actinomycosis
Syphillis
Tetanus
Hepatitis B and C have also occurred...

MC: Staphylococcus Aureus
p. 324
This can also occur after trauma from a toothpick, not just a fist fight
After hand injury, closed fist, why are radiogrpahs obtained?
To observe for: retained FB, such as a tooth; as well as to ensure no air in joint or soft tissue, and r/o fx.

p. 324
T/F: hand lacerations from closed fist injuries should be closed promptly.
FALSE!!!! Needs to heal by secondary intention

p. 324
When closed fist injury has occurred and the patient is to be provided prophylactic abx, what is the course of abx prophylaxis to be provided?
3-5 days augmentin

p. 324
What is to be done with hand injury that has a risk:
- non-compliance
- immunocompromise
- current evidence of infx
- joint/tendon involvement
consult hand surgeon, admit patient and begin IV abx Unasyn (ampicillin/sulbactam) or cefoxitin (Mefoxin-second generation cephalosporin)

p. 324
1. Mallet finger
2. Swan Neck Deformity
3. Boutonniere Deformity
- how are these caused?
1. Mallet finger is the separation of the extensor tendon of the DIPJ
2. Swan Neck defomrity- occurs when the DIPJ extensor tendon is not addressed promptly enough
3. Boutonniere deformity is caused by delayed mgt in tendon injury of the PIPJ

p. 325
What makes one say duh, and think about when lacerations occur on the volar surface of the wrist?
Suicidal gestures...remain the tx does not end with lac repair.
Flexor tendon injuries of the wrist need to be repaired by a hand surgeon, since they are complex. While they should be contacted early, when is it too late?
Most surgeons will not surgically repair flexor tendon injuries when presented: > 12-24 hrs out from injury

p. 326
** Urgent repair is a must, postinjury scarring and tendon retraction make flexor tendon repairs more difficult after 10-14 days

p. 326
How are finger tip lacerations <1cm squared w/o bone or nail bed involvement handled?
Serial dressing changes alone

p. 327
Flexor tendon injuries of the wrist need to be repaired by a hand surgeon, since they are complex. While they should be contacted early, when is it too late?
Most surgeons will not surgically repair flexor tendon injuries when presented: > 12-24 hrs out from injury

p. 326
** Urgent repair is a must, postinjury scarring and tendon retraction make flexor tendon repairs more difficult after 10-14 days

p. 326
Flexor tendon injuries of the wrist need to be repaired by a hand surgeon, since they are complex. While they should be contacted early, when is it too late?
Most surgeons will not surgically repair flexor tendon injuries when presented: > 12-24 hrs out from injury

p. 326
** Urgent repair is a must, postinjury scarring and tendon retraction make flexor tendon repairs more difficult after 10-14 days

p. 326
How are finger tip lacerations <1cm squared w/o bone or nail bed involvement handled?
Serial dressing changes alone

p. 327
How are finger tip lacerations <1cm squared w/o bone or nail bed involvement handled?
Serial dressing changes alone

p. 327
What produces the best outcome from subungual hematoma; regardless of size, mechanism of injury, or the presence of fracture?
Trephination

-p. 328 (the piercing of the nailr plate w/object to drain blood)
How long should wounds be covered for after repair and why?
- 24-48 hrs
- moist environment promotes healing, however, if left to dry- it will not cause infx

p. 356
Why should topical abx not be used on tissue adhesive?
It loosens the bond, promoting wound dehiscence...

- remember it is also possess natural anti-microbial properties

p. 356
Joint involvement and fx wounds, what is the abx regimen of choice?
Anti-staph agent and aminoglycoside

p. 357
What is the only contraindication to Tetanus prophylaxis?
Reaction to the previous administration: neurologic or extreme severe reaction

p. 357
How soon can post-stapled/sutured wounds be cleaned w/o increased risk of infx?
8 hrs

p. 358
T/F: Use of tap water and soap increases risk of infx.
FALSE

p. 358
How long should wound packing be placed into a wound?
Until it stops expressing/collecting purulent drainage. After the purulence stops, daily packing changes are needed until enough granulation tissue has developed and the wound is dry.

p. 358
T/F: if a drainage tube is accidentally pulled out, just slide back in using sterile technique.
FALSE- if a tube is removed, do NOT insert it

p. 358
How long before laceration pain resolves?
MC laceration pain declines in 48 hours.

p. 358
What determines the prognostic outcome in drowning?
The degree of pulmonary and central nervous system insult

p. 1372
Which is more common, dry or wet drowning?
WET DROWNING (80-90%)

Dry Drowning (10-20%)
p.1372
T/F: All patients who hav a hx of submersion where they experienced LOC, observed apnea, or required a period of ventilatory support should be taken to the ER unless they are asx.
FALSE- even if asx they should be taken to the ER.

p. 1372
How long should a patient drowning patient who has a GCS >13, SaO2>95% be watched for?
4-6 hrs.

they are at low risk for complications.
p.1372
What is done with a drowning patient who has a GCS <13, requires supplemental O2 with FiO2 40-60% (> 60 in adults and >80% in children)or more?
Intubate them

p. 1372
What organism is usually targeted with abx treatment, prophylactically, in drowning patient?
Aeromonas species

p. 1372
What will most victims of drowning benefit the most from, following ICU admission 2/2 to resuscitative efforts in the ER?
Mechanical ventillation...
especillay the use of Positive End Expiratory Pressure- this will aid in alveolar recruitment, and pushing water into the interstitium.
- some suggest abx tx for aspiration risk (Aeromonas species)
- efforts to resuscitate cardiac arrest is often short lived unless placed on epi/dopamine gtt.

- 1373
Because submerision time is not often known, what is MC used to measure the patients degree of anoxic or ischemic insult?
the extent of required resuscitation

p. 1373- Figure 209-1
- if the patient did not require resuscitative efforts, then a complete recovery is expected in 48 hrs.
What 3 factors are associated with a poor prognosis in drowning and near drowning patients?
1. bystander CPR at the scene
2. CPR in the ER
3. Asystole at the scene or in the ED after warm water drowning.

p. 1374
What extremities are MC burned by chemical exposure?
Face, eyes and extremities

p. 1381
Acid vs alkali solutions, why is alkali worse?
Acid causes a coagulation necrosis where as alkali MC causes a liquification necrosis/saponification

p. 1381
What factors influence percutaneous absorption of chemicals?
- body site of contact
- integrity of the skin at contact
- nature of the chemical that comes in contact w/the skin
- occlusion of surface (ie barrier)

p. 1381
How should dry lime be managed on exposed skin surfaces?
brush off the skin prior to irrigation

- p. 1381
how should sodium metal be managed prior to irrigation, in burn/prevention mgt?
Covered in mineral oil or excised, 2/2 severe exothermic rxn that can occur with this.

p. 1381
What is the most universally acceptable and approved tx for alkali and acid burns?
copious irrigation

p. 1381
What can be used to determine whether there is persistent alkali/acid contact on the skin while irrigation?
pH paper

- this will determine whether irrigation, which when alkali is involved this can be hours

- p. 1381 (irrigation should continue until pH is neutral)
What is the one chemical burn feature that can be altered by medical professionals?q
contact time with the substance

p. 1382
What is the MC contact burn in women (on the scalp)
Acetic Acid

p. 1382 (if burns are deep enough- oral abx are needed)
Which is more corrosive, dilute or concentrated phenol?
Dilute phenol

p. 1382- dilute pentrates tissues more. Isopropyl EtOH is the best means to clean out the area. If not available: polyethylene glycol and Industrial mineral spirits.
What exposure is associated with: conjunctivitis, lacrimation, and ulceration of the nasal septum. Systemic absorption has been liked to liver or renal failure, GI bleeding, coagulopathy, and CNS disturbances?
Chromic acid

p. 1383- 10% BSA contact with chromic acid can be fatal 2/2 systemic absorption
What has been associated with anion gap acidosis as well as decreased respiratory effort?
Formic Acid

p. 1383
What chemical is rapidly absorbed and can cause a systemic toxicity including hypocalcemia, hypomagnesemia, and hyperkalemia
Hydrofluoric Acid

p. 1383
- therefore, tx is often aimed at copious irrigation followed by Calcium and Magnesium repletion

p. 1383
T/F: when exposed to Hydrofluric acid exposure, calcium gluconate tx can be administered topically.
TRUE

- mixing 3.5 gms calcium gluconate powder in 5 oz of sterile water-soluble lubricant, or 25 mL of 10% calcium gluconate in 75mL of sterile water soluble lubricant

p. 1383
- if given as SubQ inj, 1 mL of 5% calcium gluconate per sq cm of burned skin is recommended.
what burn sites require a consultation with a medical toxicologist or plastic surgeon?
- Hands
- Feet
- Digits
- or nails

p. 1383
How is portland cement removed to prevent burns?
Removal of particulates with brush, such as a surgical brush/scrub

-p. 1383
How is tar treated to prevent burns?
application of mayonaise

p 1383
Even topical exposure to Hydrofluoric Acid, a chemical used for many things including high octane fuel, can cause what arrhythmia?
Ventricular Fibrillation

p. 1384
What two chemical burns may require calcium as a tx?
Hydrofluoric Acid and Oxalic Acid

p. 1384
Which alkali are extremely corrosive and penetrating causing burns that require copious amts of water irrigation. When related to suicidal ingestion will cause death by airway occlusion (found in drain, toilet bowl cleaners, detergents)
Lyes

p. 1384
What causes an exothermic reaction when initially contacted by water and should therefore be brushed away prior to irrigation?
Lime

p. 1384
How should you treat burning metals?
Class D fire extinguisher, as well as mineral oil...

p. 1384- some metals ignite when in contact with air, sometimes ignite more when in contact with water- worsening exothermic rxn.

p. 1384
What alkali can cause hyperkalemia and hypocalcemia and is known to continue burning from contact with air?
White Phsophorus

p. 1385
What substance will often cause a ground glass appears in the eye?
Acid

p. 1385
What is the treatment for chemical burns of the eye?
1-2 liters of NS for each eye effected, 30 minutes continuous irrigation is the minimum tx. NEUTRALIZING SUBSTANCES SHOULD NOT BE USED

p. 1386
What is AC and DC, which is dangerous and where found?
AC- more dangerous as it can lead to ventricular fibrillation.
Commonly in electrical sockets of home (DC in batteris)
The risk of fatal electrical injury increase with voltage, particularly what level?
> 600 volts. High voltage is MC defined as > 1000.

p. 1387
T/F: Patients who sustain High Voltage Shocks are at increased risk for compartment syndrome?
True

- addtionally, they should be put through ROM assessments of their extremities- as there of course is risk of fractures and other musculoskeletal injuries.
T/F: Neuropathy from contact with electrical shock can take > 2 yrs to develop?/
True

p 1388
What occular anomaly has to be examined following shock to head, neck or chest?
Cataracts

- this can take weeks or yrs to develop

p. 1388
- additionally, brief hearing examine is appropriate- tho it can take weeks and yrs to develop too
Why does an asx patient following electrical shock not need admission to ICU for monitoring?
The risk is only while in contact, if there is no EKG/Monitoring abnormality, no immediate effect, it is not just going to develop (from low voltage < 1000 v exposure)

- however, CNS deficits can develop

p 1388
Following electrical burns, monitoring of the pH is a must, esp when considering myoglobinuria- for rhabdomyolysis, renal failure. How should this be monitored?
Serum pH, not urine.

p. 1389
What three factors a prognostiocally associated the need for fasciotomy, when present in 24 hrs?
1. myoglobinuria
2. burns over 20% BSA
3. full thickness burns over 12% of the BSA

1389
What is done with a patient who sustains <240 AC V and has no EKG changes and NML exam? What about one who just doesn't feel well and has new EKG changes?
1. Can be d/c'd home
2. monitor the other for 6 hrs

1389
T/F: Any patient who has been exposed to > 600 AC V electricity should be admitted to the hospital- regardless of EKG or sxs.
TRUE

1390
injuries from tazer use have occurred, MC in individuals w/hx of psychosis and stimulant abuse. What are examinations looking when presented to the ED?
1. Hyperthermia
2. HYPERkalemia
3. Metabolic acidosis
4. Resp Acidosis
5. Rhabdomyolysis

- EKG- to quickly check for HyperKalemia, ABG- for acidosis, temperature- for hyperthermia. As well as other stabilizing measures a must

p. 1390
How long should a pregnant women > 20-24 weeks gestation undergo a period of observation for following electrical injury?
fetal monitoring should be for at least 4 hrs

- p. 1391
How long after oral electrical burn is the risk of bleeding from labial artery?
MC the bleeding will occur w/in 5 days after the eschar falls off, however, the risk is 2 weeks duration.

p. 1391
T/F: If in a group of casualties who sustained injuries from lightning, the individuals in resp arrest w or w/o cardiac arrest and no gross evidence of addtional injuries should be saved first. And in some cases prolonged CPR is appropriate and yields + results.
TRUE

p. 1392
What do you do with a patient who had been harmed by lightning and is in cardiac arrest and hypotensive?
check for a hemorrhage...
MC patients who have been shocked by lightening do not get hypotensive.

p. 1392- in fact HTN and Tachycardia are common in lightening injuries, and self limiting therefore do not require tx.
In what group of people are prolonged resuscitive efforts often successful?
Lightning strike victims in cardiac and respiratory arrest.

p. 1393
In what electrical shock is compartment syndrome not common (AC/DC electrical shock or lightning)
Lightning victims

- it is common in other electrical traumas
p. 1393
What should always be in the differential of a patient with comatose patient, patients with AMS, patients noted to have increased anion gap acidosis or unexplained anion gap acidosis?
Carbonb Monoxide poisoning

p. 1411
What is believed to be one of key factors associated with carbon monoxide poisoning?
it causes a release of nitric oxide...
- this causes HoTn and relative hypoxia- which leads to ischemia

p. 1411
What effect does carbon monoxide have on the oxyhemaglobin dissociation curve?
Shifts it to the left

p. 1410
What is the most efficient means to assess serum carbon monoxide levels?
Venous blood, using co-oximeter.

p. 1412
For those with Carbon + Monoxide exposure in need of tx, what is that tx?
Supplemental oxygen with the highest concentration

p 1412
What are the following, as it pertains to Carbon Monoxide poisoning?
- syncope
- confusion/AMS
- syncope
- coma
- focal neurologic deficit
- pregnancy with Carboxyhemaglobin level > 15%
- blood level > 25%
- evidence of acute myocardial ischemia
reasons for the hyperbaric oxygen tx.

p. 1412
What are some complications reported from hyperbaric tx?
- PTX
- barotrauma to the ears
- seizures from oxygen toxicity
- gas embolism

p 1412
How high should carboxyhemaglobin levels be before a prego is referred for hyperbaric treatment center?
> 15% levels

p. 1415- see also the table 217-4
What does the ED assessment begin with in the trauma patient?
Potentially life threatening/serious injuries

p. 1671
How is airway mgt provided for the patient with suspected bibasilar skull fx?
2 person technique, one focuses on spinal immobilization and the other focuses on the airway.
AND FOR THE LOVE OF PETE, NO NASAL AIRWAY INSERTION!!!!

p. 1671
What technique is used in almost all trauma patients requiring urgent intubations?
Rapid-Sequence Intubation technique

p. 1671
How many cervical spine fx's are missed on plain radiograph?
up to 15%

p 1672
CT of the cervical spine is superior to the plain film. But why in a patient with AMS (who is also receiving a head CT), receiving a neck CT all the way down to T3 of the chest?
to r/o PTX that may have been missed on chest x-ray

p. 1672
Early operative mgt of what trauma patient, who is in shock, yields better outcomes?
penetrating trauma victims

p. 1673
What is the optimal ratio of PRBC's/FFP/Platelets, in the treatment of trauma patient?
1:1:1

p 1674
Massive Transfusion Protocol
the risk of bleeding diathesis in trauma patients is almost immediate. Remember the risk: hypothermia, acidosis coagulopathy...
T/F: GCS 15 excludes TBI s/p trauma
False

p. 1674
What are some special provisions for the head trauma patient- with regard to serum glucose and capnography?
1. Serum glucose should be kept euglycemic (or slightly elevated, ie do not be aggressive and risk hypoglycemia)
2. slightly hypocarbic (slight hyperventilation, not aggressive), this causes vasoconstriction- reducing intracranial pressure. intubated patients= continuous capnography (30-35 mmHg)

p. 1674
T/F: IN the setting of a gundshot wound to the abdomen, the FAST exam is contraindicated.
True

p1675
And individual sustained a pentrating trauma to the chest, witnessed signs of life in the field and at least PEA on arrival to the ED. Is he a candidate for thoracotomy?
Yes

p 1676
- do not perform in blunt trauma, or those without respirations or cardiac activity in the field.
What is performed prior to the insertion of as foley in a trauma patient known to have blood in urethral meatus and/or high prostate?
Retrograde urethrogram

p. 1676
When there is facial trauma or evidence of bibasilar skull fx, where should the gastric tube be inserted?
Through the mouth, NOT the nose.

p. 1676
What are the most frequently missed conditions in trauma, provoking the need for a tertiary examination?
Orthopedic injuries

p. 1676
T/F: intubation is associated with better outcomes in the field with pediatric trauma patients, over BVM
False- there is no mortality associated benefit with intubation over BVM- as this requires skill to perform.

p. 1677
In peds trauma patient, if head immobilization is performed, but in the absence of a collar, why do you not place the tape under the chin?
Because it can inhibit access to the airway by forcibly closing the mouth

p 1677
Why is it important to listen for breath sounds in the axilla of the pediatric trauma patient?
Because breath sounds are easily transmitted across lung fields

p. 1678
When should operative thoracotomy be performed in a pediatric trauma patient?
If initial drainage of thoracostomy is > 15 mL/kg or the output exceeds >4mL/Kg/Hour

p. 1678
What is the rate of pRBC's in peds patient when needing to volume resuscitate?
10cc/kg boluses

p. 1678
When treating a traumatic peds patient, and suspect cardiac tamponade...what is the difference between fluid and pericardiocentesis or thoracotomy
- fluid resuscitation is temporizing
- pericardiocentisis and thoracotomy are life saving

p. 1678
What is an exposure consideration in the peds patient, that is not as looming a concern in adult counterpart, when resuscitating trauma patient?
Hypothermia...cover the peds patient, warm fluids, etc. While adults get hypothermic, it is far quicker in peds.

p. 1678
So, your peds patient is ready for transfer to another dept: PICU, Rads, etc. Why do you want to be vigilent while observing them?
They can deteriorate rapidly:
1. ET tube dislodgement
2. development of PTX
3. Regurge of stomach contents
4. occult hemorrhage causing shock can occur
5. worsening neuro fxn
these are all important to anticipate

-remember too that these guys still need analgesia and sedatives>>>p. 1678
What is the leading cause of death 2/2 to injury in a child?
TBI

p. 1679
What are some signs of increased ICP in the peds patient?
MC: vomiting, dizziness, HA, irritability, decreased LOC

p. 1679: remember to mildly, not aggressively, hyperventilate, hemodynamic status should be maximized to prevent shock.
How do you optimize venous drainage in patient with Increased ICP?
Raise HOB to 20-30 degrees and keep head straight
- also, mannitol 1 gram/kg or lasix 1 millig/kg in peds patients

p 1680
Traumatic peds patient who experiences two or more seizures lasting longer than a few minutes should receive what therapy?
Anticonvulsant

- however, some argue for prophylactic anyway 2/2 to the risk of the seizure and the risk for the increase in intracranial pressure.
What percent of intracranial injuries are not associated with skull fx?
50%

p. 1680, of course the presence of a fx is the most sensitive finding
What are the best predictors of intracranial injury in the peds trauma patient < 2 y/o? (4)
1. Neurologic complications
2. AMS
3. Any scalp abnormalities (contusions, lacerations, abrasions, cephalohematoma)
4. vomiting

p. 1680
* HAVE A LOW THRESHOLD TO IMAGE YOUNG BABIES/TODDLERS, THEIR SUTURES HAVE NOT FUSED...THE CAN TOLERATE RISE IN ICP, UNTIL THIS REACHES IT'S LIMIT- THEN REAL BADNESS
What are the MC causes of spinal cord injuries in the pediatric trauma population?
1. MVC
2. falls
3. sports injuries

p. 1680
Where in the cervical spine do most fractures occur in the < 12 y/o age group?
MC between in the occiput and the C2 vertebra (67%)

p 1680: do not forget SCIWORA- spinal cord injury w/o radiographic abnormality
How long are most SCIWORA delayed by in up to 50% of peds trauma patients?
4 days

p. 1681
Plain radiographic clearance of the c-spine requires what three views?
Lateral, anteroposterior (AP) and odontoid view

p 1681
What do you do if you suspect c-spine insult in spite of NML plain radiograph?
CT scan. If you get a CT of the head and anticipate neck may be required, skip the plain film

p 1681
What percent of spinal cord injuries in the peds patient do not have rad abnormalities?
66%...SCIWORA, therefore if evidence to support spinal cord insult: MRI and Neurosurg referral

p. 1681
With regard to abdominal trauma, gross blood in UA or >50 RBC's per hpf requires what?
Diagnostic imaging...MC CT scan

p. 1862
in peds patient, which has the higher rate of hemorrhage: liver trauma or splenic trauma?
Liver trauma. However, both liver and spleen can often be handled non-operatively in the peds patient.

p. 1862
Handlebars are the most common cause of what abdominal trauma in the peds patient?
Pancreatic injury

p. 1683- enzyme elevation does not reflext the degree of insult.
What in the abdomen is particularly prone to hematomas and obstruction?
Duodenum

-1683
Why do children, even with negative CT, but with abdominal pain and a MOA supporting bowel injury, need admitted for observation and serial PE's?
Because CT cannot r/o bowel injury

- 1683
What is the area between the anterior and posterior axillary lines, with the superior border at the level of the sixth rib and inferiorly the iliac crest?
The flank

p. 1771
After a traumatic GSW to the flank, you perform a rectal examination and find blood. So, what does that mean?
Damage to the bowel

p. 1771
What are the 5 diagnostic modalities for eval of flank trauma?
1. CT
2. u/s
3. dpl
4. local wound exploration
5. Laparoscopy

p. 1771
What is the diagnostic study of choice in an individual who has sustained a penetrating flank trauma and is stable?
Abdominal CT

p. 1771
What is done for someone with GSW to the flank?
exploratory laparotomy

p1772
GSW to the buttocks, what factors are associated with surgical interventions?
1. peritonitis
2. gross hematuria
3. entrance wound above the level of the greater trochanter
4. transpelvic course of the projectile, as opposed to extrapelvic

p. 1772
What are the 5 baseline studies for penetrating flank or buttock trauma?
1. hematocrit
2. Type and screen
3. CXR
4. Urine Prego test
5. UA

p. 1772
T/F: UA is an important lab study for suspected renal injury, because there is a direct relationship between the presence, absence or degree of microscopic hematuria and the severity of injury.
False, while UA important there is no correlation between this and the severity of the injruy

p. 1773
What is the gold standard for examination of the stable patient w/suspected renal injury?
IV contrast- enhanced CT of the abdomen and pelvis

p. 1773
Indications for abdominal pelvis, contrast enhanced CT of the pelvis, for suspected renal trauma? (4)
- gross hematuria
- adult w/BP systolic < 90 and any degree of hematuria
- child with >50 RBC's per hpf
- high index of suspicion for renal trauma

p. 1773
What are the ABSOLUTE indications for renal exploration and intervention? (3)
- life threatening hemorrhage 2/2 renal injury
- expanding pulsatile, or noncontained retroperitoneal hematoma
- renal avulsion injury (grade V vascular injury)- on imaging studies

p1774
What is predictive of the need for nephrectomy s/p renal trauma?(3)
1. high grade injury severity score
2. large blood transfusion requirement
3. hemodynamic instability

p1774
What is the gold standard for imaging of the bladder, for dx of bladder rupture (which is common following a direct blow in distended bladder)
Retrograde Cystogram

p. 1776
How is urethral trauma/injury diagnosed?
retrograde urethrogram

p. 1777