Fmp - Week 9 & 10

Front 1

There are two different types of arthritis caused by two different STD's..... name them!

Back 1

Gonorrhea = septic gonococcal arthritis

Chlamydia = Aseptic reactive arthritis

Front 2

How could you tell by looking, listening & feeling that an airway was:
1. Unobstructed
2. Partially obstructed
3. Fully obstructed

Back 2

1. Unobstructed: talking normally
2. Partially obstructed: noisy breathing, chest rising paradoxically (d/t increased --ve pressure in chest), +/-- indrawing
3. Fully obstructed: no breathing, no air felt via mouth or nose

** also palpate for a midline trachea, SQ emphysema and facial anatomy

Front 3

What are 6 ways of confirming the placement of a definitive airway?

Back 3

1. visualize the tube going in
2. End-tidal CO2 - should get co2 with each breath, usually Asx'd qualitatively with an indicator that changes color if CO2 present
3. Chest rising
4. Condensation in the tube
5. Equal A/E: auscultate axilla so as not to be fooled by a tube in the R main bronchus
6. Bronchoscopy - camera through the tube

** CXR cannot confirm placement b/c on an AP view can't tell if it's in the airway or esophagus - therefore it will only confirm the level of the ETT

Front 4

Where do you put a needle for a thoracostomy?

How about a chest tube?

Back 4

2nd intercostal space (just above the 3rd rib) in the mid-clavicular line

Chest Tube:
Cut btwn 5th & 6th intercostal space, advancing slowly until you rupture the membrane. Then dissect, check with your finger, then insert the tube

Front 5

What are 2 indications for surgery among traumatic lung injuries?

What are the ATLS guidelines say about when to consider surgery in a pt with a CTube?

Back 5

1. On-going bleeding after initial stabilization
2. Persistent massive air leak (= major airway disruption or major lung laceration)

ATLS guidelines: if initial chest tube output > 1500mL OR continued hourly output of > 250mL for 3 consecutive hours

Front 6

What are the classical CXR findings in traumatic aortic rupture?

Back 6

1. widened mediastinum
2. tracheal deviation

NOT always present though!

Front 7

Where does a FAST USS look in the body?
4P's!

Back 7

. Perihepatic & hepato-renal spaces
- Perisplenic
- Pevic
- Pericardium

Front 8

What is the difference between fully cross-matched blood and type-specific blood? How long does each take?

When do you use the universal donor (and what is the universal donor?)

Back 8

Fully X-matched:
- pt's ABO and Rh status have been identifiied and matched to donor blood
- blood is then x-mixed to ensure there's no reaction
(take 45min)

Type specific:
- same as above minus the mixing
(takes ~ 10min)

Universal donor: O-type blood, give O--ve for women of childbearing age to avoid sensitization!

Front 9

After being given fluid resusitation, what do each of the following responses mean?
1. Normalization
2. Transient recovery
3. No response

Back 9

1. Normalization = volume has been replaced & there's no ongoing losses

2. Transient recovery = volume has been replaced but there is ongoing bleeding

3. No response = volume lost has not been replaced and there is ongoing bleeding --> death is imminent w/o treatment (Need definitive Tx ie. Sx!)

Front 10

What are the 6 main causes of coagulopathy in massively resuscitated trauma patients?

Back 10

1. Blood loss
2. Dilutional
3. Consumption (used up clotting factors at site of injury)
4. Hypothermia (impair plts & protein function)
5. Acidosis (denatures proteins)
6. Shock (mechanism unclear)

Front 11

What are the 5 steps to take when managing hypotension in a trauma patient?

Back 11

1. Determine the cause of the Hypotension and correct it

2. Assess severity of fluid loss

3. Resuscitate

4. Assess resuscitation efforts

Front 12

What are the causes of Shock in a trauma patient?

Back 12

S - spinal cord, sepsis

H - hemorrhagic (external, chest, abdo, pelvis, long bones)

O - obstructive (Tension PThx, HThx, pericardial tamponade)

C - cardiogenic (very rare in trauma)

K - AnaphylaKis (stupid, but everyone loves a mnemonic)

Front 13

What is the cause of abdominal compartment syndrome?

How does it affect the following systems?
C-vascular, resp, renal

What is the Tx?

Back 13

When intra-Abd volume rises (edema, ascities, etc) then the pressure will rise above a certain point and if it happens acutely it will impeded venous drainage (worsening increase in volume)

C-vascular: ↓IVC flow = ↓ BP & ↓ CO
Resp: diaphragm pushes up = collapse = V/Q mismatch = shunts = atelectasis (= ↓O2 & ↑CO2)
Renal: ↓ urine output

Tx: surgical release of fascia & skin, temporary closure with protective covering over the top that allows room to expand

Front 14

In pt's with high ICP, what is the first line treatment for each of the following:
- Hematomas
- CSF excess
- Intra Cerebral Fluid/ Interstitial Fluid
- Blood (arterial & Venous)

Back 14

- Hematomas: evacuate via craniotomy if acute; Burr hole if chronic (liquid blood)

- CSF excess: drain

- Intra Cerebral Fluid/ Interstitial Fluid:
Mannitol: (osmol = 320; brain = 300), will osmotically diurees the pt
Htonic saline: pulls fluid into vasculature but no diuretic effect

- Blood
arterial: keep CO2 between 30-35 to constrict arterioles and ↓ CBF (not too much though, don't want ischemic damage!)
Venous: elevate head to ↑ drainage, sit up pt if spine ok. DO NOT turn head though as this will kink the SVC and ↓venous drainage of head

Front 15

What are the second line treatments for high ICP? (3)

How does each one work?

Back 15

1. Barbituates: ↓ cerebral metabolism = ↓ blood flow = ↓ volume = ↓ ICP

2. Hypothermia: same mechanism as above

3. Decompressive Craniotomy: remove skull and allow the brain to expand w/o constraint (will ↓ ICP) Esp good for young/salvageable pt's

Front 16

In pt's with high ICP, at what value do you want to keep their CPP? What is one way of doing this?

CPP = Cerebral Perfusion Pressure

Back 16

Want a high CPP, i.e. >60mmHg. Generally accomplished with ICP management but if this fails then use meds like Epinephrin to raise the MAP.

Why? B/c CPP = MAP - ICP

Front 17

What is the effect of blood sugar on brain injury patients?

What two other conditions will cause a similar effect?

Back 17

Hyperglycemia is associated with worse outcomes b/c it ↑es cerebral metabolism and this is bad b/c it --> ↑ CBF & CBVolume --> ↑ICP

Cerebral metabolism is also ↑ by hyperthermia (fever) and Sz's

Front 18

What is the most common level for a C-spine #? 2nd most common?

Back 18

C2 = most common
C 6 & 7 = second most common

** very difficult to image the lower cervical spin on Xray in obese pt's or those with big shoulders

Front 19

What are the four criteria for clinically clearing the C-spine?

A pt is cleared if these criteria are all met. If they aren't and you do a scan that is normal, what do you do next?

Why don't you want to just leave a hard-collar on indefinitely in unconscious patients?

Back 19

1. Normal sensorium (A&Ox3, not intoxicated)
2. No neurological S & S
3. No C-spine/midline pain or tenderness
4. No distracting injuries

If imaging is normal MUST do a clinical exam to r/o ligamentus injuries (do ROM - ask for pain and/or neurological symptoms

Can't just leave the collars on b/c it will cause pressure sores and may impeded venous outflow (really bad in pt's with high ICP from a brain injury)

Front 20

What is the difference between a complete and an incomplete spinal cord injury?

Back 20

Complete = NO motor/sensory function below the level & will NOT improve with time (reflexes may initially be absent & return over days/weeks and be hyperactive)

Incomplete = some motor and/or sensory function below the level (even if it's just sacral sparing) MAY get some improvement over time

Front 21

What are the 4 classes of functionality when assessing a pt in terms of ADLs?

Back 21

I = no functional limitation
II = can do vocational, some limits in avocational
III = limits in vocational & avocational
IV = limited in all ADL's

Front 22

What bloodwork should you do for the following:
Sero + (4)
Sero -- (1)
Crystal (3)
Infectious (2)
Non-articular (1)

Back 22

Sero +: CBC, RF, ANA, U/A
Sero --: HLA - B27
Crystal: serum uric acid, Ca+, Lipids
Infectious: CBC, culture source
Non-articular: ESR

Front 23

In an aspirate of an inflammatory joint, what would you expect to find in the following parameters?
- WBC
- Strings?
- Glucose

Back 23

INFLAMMATORY:
- WBC > 2000
- no strings (poor or decreased)
- decreased glucose in septic/RA

Front 24

Compare & contrast x-ray findings of inflammatory vs. non-inflammatory arthritis:
- cartilage
- bone +/--
- peri-articular bone
- joint space loss

Back 24

All answers are inflam / non-inflam

- diffuse cartilage loss / local cartilage loss
- erosion / overgrowth
- osteopenia / eburnation (inc bone density +/- osteophytes
- complete loss / segmental loss of joint space

Front 25

When examining a person with potential osteoporosis you should be worried about what finidings in the following parameters of the physical exam:
- Ht loss
- Rib --> pelvis distance
- wall --> occiput distance

Back 25

1. >2cm prospectively or >6cm historically

2. <2cm between ribs & pelvis

3. > 6cm between wall & occiput

Front 26

What are the 2 broad classes of drugs to use in osteoporosis?

Back 26

1. Anti-resorptives: (inhibit O-clasts to decrease bone loss)
Bisphonates "-drate" & SERMs "Raloxifene"

2. Anabolic: stimulate osteoblasts to increase bone formation (PTH analogues "Teriparatide"

Front 27

What 3 things would you expect to find on a Xray of an OA joint?

Back 27

1. Joint space narrowing
2. Subchondral sclerosis ( +/-- cysts)
3. Marginal osteophytes

Front 28

What drugs should you avoid in gout?
- A
- H
- C
- P & E (for TB)
- E
- L

Back 28

- ASA (low dose)
- HCTZ
- Cycloscporine
- Pyrazinamide & Ethambutol (for TB)
- Ethanol
- Lead

Front 29

How does Allopurinol work?

Back 29

Decreases the formation of uric acid by inhibiting the enzyme Xanthine Oxidase
(decreases [UA] to normal in >80% of gout sufferers)

Front 30

What are the 4 extra-articular manifestations of Sero +ve arthritis?

Back 30

1. Nodules
2. Episcleritis
3. Vasculitis
4. Lower lobe fibrosis

Front 31

What are the 7 extra-articular manifestations of sero --ve arthritis?

Back 31

1. Psoriasis
2. Uveitis
3. Nail changes
4. enthesitis
5. Bowel involvement
6. Mucous membranes (oral ulcers)
7. Upper lobes of lungs

Front 32

Sclerdoerma can be diffuse or it can be limited to "CREST" syndrome. What do the CREST letters stand for?

Back 32

C = calcinosis
R = Raynaud's phenomena
E = esophageal involvement
S = sclerodactyl
T = telangectasia

Front 33

What is the difference between a Z-score & a T-score?

When would you use each?

How many SD's below the mean do you have to be for osteopenia? Porosis?

Back 33

Z-score = compared to your age cohort
T-score = comparted to healthy 25y.o

Z --> for pts < 40yrs
T --> for pts >40yrs

1.1 ---> 2.5 = Osteopenia
2.5 + = Osteoporosis

Front 34

Polyarteritis nodosum is a vasculitis affecting what size of vessel? What disease is it associated with?

Back 34

Affects the medium vessels and is associated with Hep B.

Presents with:livedo reticularis, myalgias +/- claudication, mononeuritis multiplex, renal infarcts/bowel ischemia, testicular pain

Front 35

ANCA + vasculitis affects what size of vessel?

Back 35

SMALL!!!
E.g. Wegner's Vasculitis (best diagnosed from a lung biopsy)