Gem's Crit Care: Surg

Front 1

What is the name for a fracture which involves skin and soft tissue being torn?

Back 1

compound (open)

Front 2

What is a comminuted #?
Due to which two things

Back 2

multiple breaks

1. high force trauma
2. osteoporosis

Front 3

When do you use the Salter-Harris fracture classification? Occurs only in who?
What are the 5 types?

Back 3

growth plate breaks
children
"SALTR"
Type I: Straight across the physis
Type II: Above the physis
Type III: Lower than the physis
Type IV: Through the metaphysis, physis and epiphysis (metaphysis is body of the bone and epiphysis is the ends. the physis is in between)
Type V: Rammed (ie crushed) physis

Front 4

Colle's fracture:
# of what bone?
Which part?
What sort of #?

Back 4

radius
distal
transverse

Front 5

What is a dinner fork fracture?

Back 5

Colle's

Front 6

Colle's fracture:
What position is the wrist displaced?

Back 6

dorsally

Front 7

Rx: Colle's fracture
if undisplaced
if joint disrupted, excessive shortening or impaction

Back 7

1. undisplaced: reduction (with regional analgaesia) + immobilisation with a cast
2. joint disrupted, excessive shortening or impaction:
open reduction and internal fixation (ORIF)

Front 8

What # has snuff box tenderness?

Back 8

scaphoid

Front 9

Deviation of wrist in snuff box #?

Back 9

dorsiflexed and radially deviated

Front 10

What # has base of thumb tenderness and swelling?

Back 10

snuff box

Front 11

Mechanism of snuff box #?

Back 11

fall on outstretched hand

Front 12

Mechanism of Colle's #?

Back 12

fall on outstretched hand

Front 13

2 complications of snuff box #?

Back 13

1. avascular necrosis
2. non-union

Front 14

Rx snuff box # if:
1. non-displaced
2. unstable, non-displaced
3. unstable, displaced >1mm

Back 14

1. immobilisation in cast
2. percutaneous fixation using a guide wire and screws
3. open reduction, internal fixation (ORIF)

Front 15

Is the scaphoid adjacent to the ulna or radius?

Back 15

radius

Front 16

Supracondylar #:
caused by fall on __________________ hand with a _____________________ force acting on the elbow.
Common in children.

Back 16

outstretched
hyper-extension

Front 17

Supracondylar #:
2 types.
Which is more common?

Back 17

1. extension type (more common) - distal frag displaced posteriorly
2. flexion type (rare) - distal frag d/p anteriorly (relative to prox segment)

Front 18

Supracondylar #:
How do you tell on xray if distal part is displaced posteriorly?

Back 18

draw line down anterior aspect of humerus on lateral xray
Normal: line passes through middle 3rd of capitellum (distal end of humerus)

If passes through anterior 1/3 or misses capitellum completely => displaced posteriorly

Front 19

Supracondylar #:
3 main complications

Back 19

1. ulnar nerve injury
2. brachial artery injury
3. "Gunstock" or cubitus varus deformity from malunion

Front 20

Supracondylar #:
nerve injury

Back 20

ulnar nerve injury --> ulnar claw (4th and 5th fingers flexed)

Front 21

Supracondylar #:
artery injury

Back 21

brachial artery injury --> compartment syndrome --> Volkmann's ischaemic contracture (permanent flexion of wrist --> claw like deformity of hands + fingers (flexor mm become ischaemia and fibrosed => shorten)

Front 22

Supracondylar #:
bone complication

Back 22

"Gunstock" or cubitus varus deformity --> from malunion -- forearm deviates to midline when elbow extended

Front 23

What # do you see Volkmann's ischaemic contracture in?
What is damaged to cause it?

Which pulse is absent?

Back 23

supracondylar
brachial a

radial a

Front 24

Supracondylar #:
Rx for hairline, moderate, needed operative mgmt

Back 24

1. hairline: immobilisation with cast
2. moderate: manipulation + immob
3. operative: reduce # then held in place with K wires (steel wires)

Front 25

Which nerve is damaged: sensory loss in dorsum of 1st web space

Back 25

radial n

Front 26

Features of radial nerve palsy (3)

Back 26

1. loss of finger MCP joint extension
2. loss of wrist extension
----i.e WRIST DROP
3. sensory loss in dorsum of 1st web space

Front 27

Which #s (2) can --> radial n palsy?

Back 27

midshaft and distal humerus fractures

Front 28

In a humerus #, which two types of fracture normally occur?
In which do you think about child abuse?

Back 28

transverse

spiral (child abuse)

Front 29

Which nerve palsy can you get in distal and mid shaft humerus #?

Back 29

radial n

Front 30

Proximal humerus fracture: what complication can arise?

Back 30

brachial plexus injury

Front 31

Proximal humerus fracture: Rx if not hugely displaced/angulated?

Back 31

immobilisation of shoulder in a SLING

Front 32

Clavicle #: classified into 3. What are the corresponding grades?
which is most common?

Back 32

lateral (Grade II)
middle (most common) (Grade I)
medial (Grade III)

Front 33

Clavicle #: middle 1/3 fracture
2 complications (nerve and vascular)

Back 33

brachial plexus

subclavian artery

Front 34

Clavicle #: Rx?

Back 34

middle don't required reduction

lateral and medial unless displaced

otherwise, put in sling

Front 35

6 things to do if COMPOUND #

Back 35

1. urgent ortho consult
2. analgaesia (may need sedation)
3. maintain alignment in anatomical position in a splint (less painful and less blood loss) - ie. cover wound with moist gauze and then put a backslab on
4.+/- irrigation (depends on how long the wait to theatre is)
5. check immune status to tetanus
6. ABx against S. aureus (Flucloxacillin)

Front 36

Which ABx do you give in compound # and what bug are you covering?

Back 36

fluclox

S. aureus

Front 37

Fractures and dislocations can cause severe pain. If paracetamol in standard doses is not sufficient, it is reasonable to add (2)

Back 37

OXYCODONE
with or without
NSAID

Front 38

# NOF:
How does the leg appear?

Back 38

externally rotated and shortened

Front 39

Hip # have 2 broad categories

Back 39

1. Femoral neck fractures (intracapsular)
2. Intertrochanteric (extracapsular)

Front 40

Femoral neck or intertrochanteric #:
Which has more complications?
What are they? (6 post-op)

Back 40

femoral neck (intracapsular)

1. infection
2. chronic pain
3. dislocation
4. nonunion
5. avascular necrosis
6. posttraumatic arthritic changes

Front 41

Femoral neck or intertrochanteric #: which are more likely to present with eccymoses?

Back 41

intertrochanteric

A large amount of blood can be lost into the thigh and hemodynamic status should be closely monitored

Front 42

2 complications of # hip that require prophylaxis

Back 42

Infection and thromboembolism

Front 43

Rx hip #s

Back 43

surgery: internal fixation

Front 44

Choice of pain relief for # hip (2)

Back 44

IV opiates

regional nerve block

Front 45

Femoral neck (intracapsular) or intertrochanteric (extracapsular) #: higher risk avascular necrosis

Back 45

intracapsular

Front 46

Femoral neck (intracapsular) or intertrochanteric (extracapsular) #: higher rate of mal/non-union

Back 46

intracapsular

Front 47

Most common location for tibial #?
Rx?

Back 47

shaft
long leg cast

Front 48

What is it called when you fracture the tibia just below the knee joint? What can this lead to?

Back 48

tibial plateau #

arthritis

Front 49

What is it called when you fracture the tibia at the bottom? What else can this damage?

Back 49

tibial plafond

surrounding tissue

Front 50

In all tibial #s what must you consider?

Back 50

compartment syndrome

Front 51

Most common ankle #?

Back 51

lateral malleolus

Front 52

Ankle # leads to an unstable joint if what is disrupted

Back 52

2 or more structures in the ankle joint ring (2 bones: lateral malleolus of fibula and medial malleolus of tibia
2 ligament complexes lateral and medial)

Front 53

What sort of cast do you use in an ankle #?

Back 53

short leg stirrup

Front 54

What are the 3 grades of muscle strains?

Back 54

Grade 1: mild, some muscle fibres damaged. Heals 2-3wks
Grade 2: moderate, more extensive damage. Heals 3-6wks
Grade 3: severe, complete rupture of muscle, requires surgery. Heals ~3mo

Front 55

Immediate mgmt muscle strain.
Delayed mgmt

Back 55

RICE

NSAID

Front 56

in RICE for mgmt of muscle strain, how long do you use ice for at a time?

Back 56

10-15mins every 2h

Front 57

Most common ankle sprain causes damage to what? What is the precise ligament that's most commonly damaged?
What is the mechanism of injury?

Back 57

lateral ligament sprain
anterior talofibular lig

ankle inversion

Front 58

What causes sprains?

Back 58

joint is hyperextended and ligament is overstretched causing it to tear/rupture

Front 59

Analgaesia for strains and sprains?

Back 59

start with paracetamol
if insufficient, add NSAID

Front 60

Grades of sprains

Back 60

Grade I: minor tearing, no joint instability, fn and strength normal
Grade II: moderate tearing, some jt instability, some loss of fn and strength
Grade III: total rupture of ligament, gross instability, often needs surgical repair

Front 61

Should sprains be walked on?

Back 61

yes, Advise the patient to start mobilisation and passive movement of the injured area as soon as pain permits.
This helps accelerate rehab

Front 62

Accelerating the car; dorsi or plantar flexion?

Back 62

plantar

Front 63

Ix for Achille's tendon rupture?

Back 63

Ultrasound

Front 64

Innervation of Achille's tendon?

Back 64

sural nerve

Front 65

What is Thompson test?

Back 65

For Achille's tendon rupture
calf squeeze when Pt prone; results in no movement (no passive plantarflexion) of the foot, while movement is expected with an intact Achilles tendon and should be observable upon manipulation of the uninvolved calf

Front 66

What movement will be limited/absent in Achille's tendon rupture?

Back 66

plantar flexion
won't be able to walk on toes or point toes downward

Front 67

Any RFs for Achille's tendon rupture (2 meds)

Back 67

1. fluoroquinolone ABx (ciprofloxacin)
2. glucocorticoids

Front 68

Mgmt Achille's tendon rupture (3)

Back 68

1. non-surgical: plaster cast 6-8wks
2. surgical
3. REHAB

Front 69

Patellar tendon rupture: knee fails to __________

Back 69

extend

Front 70

Biceps tendon rupture: more commonly proximal or distal tendon rupture?
Where is the pain in this type of rupture?
Loss of arm/shoulder fn?

Back 70

proximal more common
this manifests as sudden pain in shoulder with 'snap'
no loss if fn b/c other biceps head compensates

(NB distal rupture = pain in elbow)

Front 71

What injury do you see a bulge in the arm from?

Back 71

biceps tendon rupture (from ruptured tendon retracting)

Front 72

Which cruciate ligament is likely to be damaged by hyperextension of the knee

Back 72

ACL

Front 73

Which cruciate ligament is likely to be damaged by a direct blow to the front of the knee/falling onto knee when knee is bent?

Back 73

PCL

Front 74

Which cruciate ligament is likely to be damaged by pivoting in place?

Back 74

ACL

Front 75

Mgmt torn cruciate ligaments?

Back 75

Non-surg: RICE, paracetamol, ROM exercises, functional strength exercises, ACL brance, rehab
Surgical: indicated if instability is sustained - done arthroscopically using a tendon/ligament graft

Front 76

Surgical mgmt of torn cruciate ligaments: what do they use as a graft most commonly?

Back 76

patellar tendon

Front 77

Shoulder (glenohumeral joint) dislocation:
anterior/posterior more common?

Back 77

anterior

Front 78

Shoulder (glenohumeral joint) dislocation:
anterior dislocation caused by ______________ and ______________ _____________ of the humerus

Back 78

abduction
external rotation

Front 79

Shoulder (glenohumeral joint) dislocation:
anterior dislocation: caution - injury to ___________ __________
How do you test for it?

Back 79

axillary nerve

decreased sensation over the lateral deltoid

Front 80

Shoulder (glenohumeral joint) dislocation:
anterior dislocation: findings on palpation:
__________ prominent.
Humeral head is displaced _____________ & _____________

Back 80

acromion

anteriorly and inferiorly

Front 81

anterior shoulder dislocation: Rx?

Back 81

closed reduction under conscious sedation
traction-counter traction technique (pull on folded sheet wrapped around pt chest, other Dr pulls affected limb down and laterally 45deg)
Immobilise after reduction with sling and swathe

Front 82

Which direction are hip dislocations usually in?

Back 82

posterior

Front 83

Posterior hip dislocation: what does the leg look like?

Back 83

shortened and internally rotated

Front 84

Most common cause of posterior hip dislocation?

Back 84

MVA -- dashboard injury (posteriorly directed force to knee and hip flexed -- think about someone sitting in a car)

Front 85

Which nerve is most commonly injured in posterior hip dislocation?

Back 85

sciatic nerve

Front 86

2 long term complications of hip dislocation

Back 86

1. avascular necrosis of femoral head
2. osteoarthritis

Front 87

In dislocations, what do you have to do after reduction?

Back 87

immobilise

Front 88

Most common patellar dislocation direction

Back 88

lateral

Front 89

In patella dislocation there will be an ___________ and the Pt will be unable to ____________ the knee

Back 89

effusion
extend

Front 90

Fingers usually dislocate in two directions which are....?
what are the mechanisms?

Back 90

dorsal dislocation: hyperextension/hyperflexion

lateral dislocation: blow in radial or ulnar direction (collateral ligament compromised)

Front 91

What is the most common finger dislocation?

Back 91

2nd-5th PIP joints: dorsal dislocation

Front 92

Ankle dislocation:
________________ direction is most common.
Ankle is ______________ flexed. Talus moves in a ______________ direction in relation to distal ______________

Back 92

posterior
plantar flexed
posterior
tibia

Front 93

Anterior ankle dislocation happens when ankle is forced _____________ flexion

Back 93

dorsi

Front 94

After reducing ankle dislocations, apply a long leg posterior splint which immobilises the joint in a position of _____ degrees ___________

Back 94

90
flexion

Front 95

What sort of # will result with:
direct force

Back 95

transverse

Front 96

What sort of # will result with:
crushing force

Back 96

comminuted

Front 97

What sort of # will result with:
twisting force

Back 97

spiral

Front 98

What sort of # will result with:
compression force

Back 98

short oblique

Front 99

What sort of # will result with:
bending force

Back 99

triangular 'butterfly'

Front 100

What sort of # will result with:
tension force

Back 100

transverse

Front 101

If fractured segments are 'distracted', what does this mean?

Back 101

they are pulled apart

Front 102

# healing is promoted by physiological loading of bone, so muscle activity and early ______________ _______________ is encouraged, providing # stability and Pt compliance allows

Back 102

weight bearing

Front 103

What do you always have to do following reduction of a #?

Back 103

xray to check position

Front 104

3 reasons for open reduction of #

Back 104

1. closed reduction failed
2. articular #
3. as first step to internal fixation

Front 105

Method of choice for immobilising pathological #?

Back 105

internal fixation

Front 106

Method of choice for immobilising # associated with severe soft tissue damage?

Back 106

external fixation

Front 107

Method of choice for immobilising # associated with nerve/vessel injury?

Back 107

external fixation

Front 108

Method of choice for immobilising pelvic #

Back 108

external fixation

Front 109

5 early complications of #

Back 109

1. vascular injury
2. nerve injury
3. compartment syndrome
4. infection
5. # blister (elevation of superficial layers of skin by oedema)

Front 110

5 late complications of #

Back 110

1. non-union
2. malunion
3. avascular necrosis
4. growth disturbance
5. stiffness/chronic regional pain syndrome/O.A

Front 111

What nerve is commonly damaged in knee dislocation?

Back 111

peroneal

Front 112

What do you think of with pain out of proportion to injury?

Back 112

compartment syndrome

Front 113

What do you think of with pain on passive stretch post-#?

Back 113

compartment syndrome (ischaemic muscle highly Sn to stretch)

Front 114

What factors (4 classes) can cause delayed/non-union?

Back 114

1. soft tissue injury interposing the fragments
2. bone: poor blood supply, infection
3. surgeon: poor splintage
4. patient: SMOKING, NSAIDs

Front 115

3 #s notorious for avascular necrosis

Back 115

1. NOF
2. scaphoid
3. talus

Front 116

_____________________ # of scaphoid more prone to avascular necrosis because blood supply runs from _________________ to _________________

Back 116

proximal
distal
proximal

Front 117

_____________________ # of talus more prone to avascular necrosis because blood supply runs from _________________ to _________________

Back 117

body
distal
proximal

Front 118

What condition is associated with Colle's #?

Back 118

osteoporosis

Front 119

What is a Smith's #?

Back 119

reverse Colle's.

Smith's = FLEXION # of radius

Front 120

Colle's fracture = _________________ # of _____________ (bone)?

Back 120

EXTENSION (remember it's from falling on an outstretched hand)
distal radius

Front 121

What is a Bennett's fracture?

Back 121

# at base of 1st metacarpal (ie thumb). it's an intra-articular # than often has dislocation of carpo-metacarpal joint.
Caused by punching or bicycle accidents

Front 122

What is a Boxer's #?

Back 122

# to 4th or 5th metacarpal transverse neck

from punching with closed fist

Front 123

Which artery often injured in knee dislocation?

Back 123

popliteal => must examine foot circulation

Front 124

What is Monteggia #/dislocation?

Back 124

# prox 1/3 of ulna with dislocation of radial head

from fall on outstretched hand with forearm in xs pronation

Front 125

What is Galeazzi #/dislocation?

Back 125

# of radius with dislocation of distal radioulnar joint

Front 126

Rule of 9s for assessing burn size in ADULTS:
HEAD

Back 126

9%

Front 127

Rule of 9s for assessing burn size in ADULTS:
trunk and back

Back 127

18% each

Front 128

Rule of 9s for assessing burn size in ADULTS:
arm

Back 128

9% each

Front 129

Rule of 9s for assessing burn size in ADULTS:
leg

Back 129

18% each

Front 130

Rule of 9s for assessing burn size in ADULTS:
genitals

Back 130

1%

Front 131

What is the burn depth:

red, painful, no blisters

Back 131

superficial
(only epidermis affected)

Front 132

What is the burn depth:
red, painful, blisters, cap refill present

Back 132

superficial dermal
(affected epidermis + superficial dermis)

Front 133

What is the burn depth:
dark red, no cap refill, not painful

Back 133

deep dermal

Front 134

What is the burn depth:
white, waxy, charred, not painful, no blisters, no cap refill

Back 134

full thickness

Front 135

Parkland formula

Back 135

2-4mL/kg/%TBSA burned
give first half over 8h, 2nd half over next 16h

use N/S or Hartmann's
give this ON TOP OF maintenance fluids
titrate fluids to maintain U/O of > or = 1mL/kg/hr

when calculating SA of body burned, do not include epidermal burns

Front 136

Normal adult U/O

Back 136

0.5-1mL/hr

Front 137

3 medium-long term issues with burns

Back 137

1. infection risk
2. need increased nutrition
3. pain/itchiness

Front 138

Electrical burns.
What constitutes low and high voltages?

Back 138

low < 1000V (e.g home is 240V)

high > 1000V (eg. power lines)

Front 139

Electrical burns: what can happen to heart?

Back 139

arrhythmia

Front 140

High voltage electrical burns: what can happen to kidney and how?

Back 140

impairment due to myoglobin release

=> give more fluids than what the Parkland formula calculates

Front 141

What sort of burns can give a feathering appearance?

Back 141

lightening

Front 142

high voltage electrical burns or lightening: which causes more tissue damage?

Back 142

high voltage

lightening gives heaps of volts, but it happens really quickly so there is less energy delivered

Front 143

What do lightening bolts tend to do to heart?

Back 143

asystole

Front 144

Primary Survey in multitrauma

Back 144

A + B: airway: oxygen, collar to protect C-spine, maneoevres to open airway. check for PT, flail chest, haemothorax, cardiac tamponade
C: control external haemorrhages, 2x lge bore cannulae + take bloods, check vitals, if hypotensive give fluid bolus, splint unstable # to prevent further blood loss
D: intubate if GCS < or = 8

Front 145

4 Ix as adjuncts to primary survey.
What are they (in order of how you'd do them)

Back 145

1. CXR
2. pelvic Xray
3. C soine Xray
4. FAST U/S or diagnostic peritoneal lavage ONLY if HAEMODYNAMICALLY UNSTABLE (otherwise these wait til 2ndary survey)

Front 146

What is a FAST U/S?

Back 146

FAST (focused abdo sonography in trauma) U/S - if haemodynamic stability cannot be achieved -- looks for blood in peritoneum

Front 147

Ankle #
Weber classification refers to looking at # of which bone in relation to what?

Back 147

lateral malleolus (ie FIBULA) in relation to "syndesmosis" = connection b/t distal ends of tibia and fibula

Front 148

Ankle #:
Weber A = # ____________ the syndesmosis
What sort of #?
Correlates with Lauge-Hansen: _________________

Back 148

BELOW
horizontal avulsion
SA (supination adduction)

Front 149

Ankle #:
Weber B = # ____________ the syndesmosis
What sort of #?
Correlates with Lauge-Hansen: _________________

Back 149

AT THE LEVEL OF
spiral (most common mechanism for # ankle from twisted ankle)
SE (supination external rotation)

Front 150

Ankle #:
Weber C = # ____________ the syndesmosis
What sort of #?
Correlates with Lauge-Hansen: _________________

Back 150

ABOVE
oblique

C1 = PA (pronation abduction)
C2 = PE (pronation external rotation)

Front 151

What is a Maisonneuve #?
What Weber classification is it?

Back 151

fracture of proximal fibula, often involving the medial (tibial) malleolus and/or disruption of the distal tibiofibular syndesmosis

Front 152

Weber A, B, C
Status of medial malleolus/ ligaments?

Back 152

A: medial malleolus often #. Ligaments in tact.
B: medial malleolus MAY be #, deltoid (medial) lig may be torn. Tibiofibular ligaments usually intact.
C: Medial malleolus or deltoid lig injury present; tibiofibular ligaments torn

Front 153

Weber A,B,C
Which needs ORIF (open reduction internal fixation)?

Back 153

B and C need ORIF
A can usually be managed with simple measures (cast)

Front 154

11 reasons to refer a fracture to ortho

Back 154

1. open/compound #
2. neurovascular compromise
3. extreme swelling/compartment syndrome
4. can't reduce in ED
5. pathological #
6. severely comminuted #
7. displacement +++
8. angulation +++
9. multi-trauma
10. SALTR III and IV
11. NOF

Front 155

Blunt abdo trauma: Ix if hypotensive

Back 155

peritoneal lavage

Front 156

Blunt abdo trauma: Ix if haemodynamically stable

Back 156

CT

Front 157

In seat belt injuries, injuries to what 2 organs must you think of?

Back 157

bladder and bowel

Front 158

Do you use chlorhexidine to cleanse wounds?

Back 158

yes you can for the initial mgmt of traumatic wounds but not for continued mgmt

Front 159

What do you use for both gentle (low risk, non-infected) and vigorous wound cleansing?

Back 159

normal saline or tap water

for vigorous cleansing use syringe and blunt needle

Front 160

For deep wounds, what must you assess before using local anaesthetic?

Back 160

neurovascular status

Front 161

For deep wounds what must you do before exploration of the wound?

Back 161

give local

Front 162

Do not put any solution (sterile or not) into a cavity where __________________________

Back 162

the base of the wound cannot be seen

Front 163

What is a subungal haematoma?
If <50% is involved, mgmt = ____________
if > 50% is involved or sig pain, mgmt = ________________

Back 163

trauma to nail caused by blunt trauma to a digit

ice & analgaesia
create hole to relieve pressure

Front 164

What are the 3 phases of wound healing and the days on which they happen (Hint: 3 Rs)

Back 164

d0-3: REACTION (inflammatory phase) - vasodilation, macrophages, chemotaxis (cytokines), fibrin clot

d2-24: REGENERATION (proliferative phase) - angiogenesis, epitheliasation, wound debridement by macrophages, reduction in wound size by myofibroblasts

3wks-2yrs: REMODELLING (maturation phase) - collagen reorganising

Front 165

Scarring occurs when the injury extends beyond the _____________ layer of skin

Back 165

dermal

Front 166

Post-operative surgical wound that has pink (serosanguinous) fluid leaking from it is a surgical complication called what?
Usually how many days post-op?

Back 166

wound dehiscence
= premature bursting open of wound along suture line

7-10d

Front 167

7 causes/RFs of wound dehiscence

Back 167

1. poor blood supply e.g DM
2. medications e.g NSAIDs
3. physical stress/trauma of wound
4. infection --> bacterial weakening of tissue
5. poor wound closure techniques
6. Scurvy = Vit C def; Vic C needed to create strong x-links b/t collagen fibres
7. congenital e.g Ehler's Danlose = problem w/ collagen formation

Front 168

Wound dehiscence: Rx?

Back 168

return for resuture under G.A

Front 169

4 clinical criteria for SSI (surgical site infection)

Back 169

• A purulent exudate draining from a surgical
site
• A positive fluid culture obtained from a
surgical site that was closed primarily
• The surgeon's diagnosis of infection
• A surgical site that requires reopening

Front 170

What are the 3 classes of surgical site infection (SSI) and what do they include?

Back 170

1. superficial incisional SSI: skin and subcutaneous tissue
2. Deep incisional SSI: deep soft tissue + s/c tissue + skin
3: Organ/space SSI: involves anatomical structures and spaces OTHER THAN THE INCISION which was opened and manipulated during the surgery (i.e does NOT include superficial and deep incisional SSI)

Front 171

Superficial SSI occurs w/i _____ days post-op

Back 171

30

Front 172

Deep SSI occurs w/i _____ days post-op

Back 172

30-90

Front 173

Organ/space SSI occurs w/i _____ days post-op

Back 173

30-90

Front 174

Rx SSI

Back 174

• Infected wounds are opened, explored,
drained, irrigated, débrided and dressed open

• Deep wounds need wet-to-dry packing, up to 3
times daily

• Wound dressings if granulation starts

• Antibiotics only if adjacent tissue inflammation
or systemic signs are present

Front 175

Do surgical site infections need ABx?

Back 175

only if adjacent tissue inflammation
or systemic signs are present

Front 176

Clean, simple lacerations that do not involve _________ or _______________ that can be adequately debrided and irrigated and that are seen w/i ____hrs DO NOT NEED ABx prophylaxis

Back 176

tendons
joints
8

Front 177

When do lacerations need ABx prophylaxis? (7)

Back 177

1. contaminated wound (i.e dirt, manure, dust)
2. significant muscle, skeletal or soft tissue damage
3. bite
4. crush injury
5. penetrating/stab wound
6. mgmt > or = 8hrs after sustaining the wound
7. underlying medical condition e.g DM, chemo, corticosteroids

Front 178

If you've had 3 doses of tetanus toxoid and the last booster was <___yrs ago, you do not need a tetanus shot for any wound

Back 178

5

Front 179

Who needs a tetanus booster for prophylaxis after sustaining a wound?

Back 179

Hx of 3 doses of tetanus toxoid, with last booster being 5-10 years ago: only if wound is not clean and minor

Hx of 3 doses of tetanus toxoid, with last booster being >10 years ago: all wounds

Uncertain vax Hx or <3 doses: all wounds

Front 180

Who would get tetanus Ig as tetanus prophylaxis?

Back 180

uncertain vax Hx or <3 doses of tetanus toxoid and the wound is not clean and minor

Front 181

Do you suture up an infected or inflamed wound?

Back 181

no

Front 182

Do you suture up a bite wound?

Back 182

no

Front 183

Upper GI tract bleeding is from anything above the ligament of _______________, which is ________________

Back 183

Treitz
- connects duodenum to diaphragm
= anatomical landmark of duodenojejunal junction

Front 184

What are 2 good early indicator of hypovolaemia?

Back 184

1. decreased urine output (20-30 mL/hr)

decr C.O --> decr renal blood flow --> decr U.O

2. orthostatic hypotension

Front 185

Orthostatic hypotension in hypovolaemia: SBP fall of >20mmHg, HR incr >20bpm indicates blood loss of >________

Back 185

1L

Front 186

What is the lethal triad of haemorrhagic shock?

Back 186

1. hypothermia
2. acidosis
3. coagulopathy

These three factors both cause, and contribute to, acute coagulopathy of trauma/ shock which leads to, and result from, major hemorrhage. They feed off one another, such that bleeding begets more bleeding

Front 187

Does hypotension need to be present to Dx shock?

Back 187

No
It is a late sign

Front 188

4 major types of shock

Back 188

1. cardiac
2. hypovolaemic
3. distributive
4. obstructive

Front 189

in cardiac shock, heart rate is usually increased/decreased?
Vasoconstriction/dilation?
Central venous pressure?

Back 189

increased
constriction
raised

Front 190

3 causes of distributive shock

Back 190

1. sepsis
2. adrenal failure
3. neurogenic shock

Front 191

3 causes of obstructive shock

Back 191

1. tension pneumothorax
2. massive PE
3. cardiac tamponade

Front 192

Mean arterial pressure =

Back 192

(C.O x vascular resistance) + central venous pressure

Front 193

Hypovolaemic shock is caused by decreased ____________ ______________ => venous pressure = high/low
=> compensatory _____ HR and vaso____________

Back 193

circulating volume
low
increased
constriction

Front 194

the primary abnormality in distributive shock is _________________
Peripheries are _______
venous pressure is ________

Back 194

vasodilation
warm
low

Front 195

shock:
give resus fluids
If not enough, you need to give an inotrope. This decreases HR => decreases ________________ so coronary perfusion increases
If normotensive, you give _________________
If hypotensive, you give ______________

Back 195

diastole

dobutamine

noradrenaline

Front 196

Treating the cause for cardiogenic shock required early referral to __________ for _____________

Back 196

cardiology
revascularisation

Front 197

Third space losses e.g due to burns, peritonitis, pancreatitis = _________ shock

Back 197

hypovolaemic

Front 198

4 grades of intravascular blood loss - what are the associated % of blood loss? (Hint: mneumonic!)

At which grade do you become hypotensive and tachy (ie SBP <90)
And when does cap refill become delayed?

Back 198

"Tennis scores: Love - 15 - 30 - 40 - <40 = game over"
Grade I: <15% (750mL)
Grade II: 30-15% (750-1500mL) -- cap refill delayed; HR 90-110
Grade III: 30-40% (1500-2000mL)-- SBP <90; HR >110
Grade IV: >40% (>2L)

Front 199

Fluid resus for hypovolaemic shock:
______mL colloid
or
_____mL crystalloid

Back 199

500

1000

Front 200

Define massive transfusion

Back 200

Replacement of the patient's entire blood volume in 24h or >50% BV in 4h

Front 201

What are some problems associated with massive blood transfusion? (7)

Back 201

1. thrombocytopaenia
2. coagulopathy
3. hypocalcaemia
4. potassium disturbance
5. acid-base balance
6. inflammatory response
7. tissue perfusion problems (2, 3 DPG depletion)

Front 202

During active bleeding, what is the ratio of replacement for packed RBCs:platelets:FFP

Back 202

1:1:1

Front 203

During massive transfusion, when would you give cryoprecipitate?

Back 203

fibrinogen <1g/L

Front 204

Ratio of replacement of loss with crystalloid?
Colloid?

Back 204

1:3
1:1

Front 205

Fluid resus: intial bolus

Back 205

2L N/S or RL

20-40mL/kg

Front 206

What BP do you accept in hypovolaemic shock?

Back 206

permissive hypotension = SBP 80-100

Front 207

During shock, what SpO2 do you aim for?

Back 207

>94%

Front 208

Once Hb declines to <___g/L, must use blood transfusion
This is <____g/L in Pts w/ coronary or cerebrovascular disease

Back 208

70
100

Front 209

Hypovolaemic shock: max of ___L crystalloid resus.
If require more fluids, should receive transfusion with __________

Back 209

2
packed RBCs

Front 210

Acute GI bleed. First O2 and fluid resus.
Then what are the steps for UPPER GI?

Back 210

Hx +/- NG to ascertain upper or lower GI bleed
upper --> ENDOSCOPY
If cause not found --> angiography/radionucleotide imaging
If cause found:
*ulcer --> electrocoag/injection/heater probe --> PPI, stop smoking, stop NSAIDs, eradicate H.pylori
*varices --> banding/sclerotherapy + Octreotide --> beta blockers to decr portal pressure

Front 211

Acute GI bleed. First O2 and fluid resus.
Then what are the steps for LOWER GI?

Back 211

Hx +/- NG to ascertain upper or lower GI bleed
lower --> SIGMOID/COLONOSCOPY

If cause not found and bleeding continues--> angiography/radionucleotide imaging
If cause not found but bleeding stops --> elective Ix

If cause found: manage

Front 212

Bright red haematemesis --> ____________
Coffee ground haematemesis --> ___________

Back 212

arterial bleed or varices
older; upper GI bleed that has slowed or stopped with conversion of Hb to brown haematin by gastric acid

Front 213

How much blood loss in upper GIT is required to produce melaena?

Back 213

100-200mL

Front 214

In blood loss --> volume depletion, what happens to urea?

Back 214

increases relative to creatinine

Front 215

What do you do if FOB is +ve but colonoscopy/gastroscopy are -ve?

Back 215

upper GI series with small bowel follow through or capsule endoscopy or RBC scan and angiography

Front 216

What do you think of with dysphagia that starts with solids and progresses to liquids?

Back 216

oesophageal Ca

Front 217

What does it mean if you have oesophageal Ca and you have a hoarse voice?

Back 217

invasion of recurrent laryngeal n
means it's unresectable

Front 218

What is the most common sign of Osler's Hereditary Haemorrhagic Telangectasia?

Back 218

epistaxis

Front 219

Osler's Hereditary Haemorrhagic Telangectasia: mode of inheritance?

Back 219

autosomal dominant

Front 220

Pathogenesis of Osler's Hereditary Haemorrhagic Telangectasia and what does it cause?

Back 220

mutations --> change in angiogenesis --> dilated capillaries and vv --> AVMs and telangectasias
The walls of telangectasias are friable and so prone to bleed

Telangectasias present on fingertips, lips, tongue, mouth
Visceral AVMs: GI, hepatic, cerebral, pulmonary, spinal

Front 221

2 main structures involved in state of consciousness

Back 221

cerebral cortex

reticular formation

Front 222

Anterior circulation of the brain is from which artery?

Back 222

ICA

Front 223

Posterior circulation of the brain is from branches of which 2 aa?

Back 223

basilar
vertebral

Front 224

Alteplase should be given in ischaemic stroke if the onset of symptoms was < or = ______hours ago

Back 224

4.5

Front 225

Vertebrobasilar insufficiency is caused by occulsion of vertebral, basilar or ___________ arteries

Usually presents with ________________ + H/A, diplopia, numbness, weakness, N+V

Back 225

subclavian

VERTIGO

Front 226

Subdural haematoma = collection of blood between the ______ mater and ________ mater.
Arise from laceration of cortical vv or avulsion of _____________ vv between the cortex and ___________ ___________

Back 226

dural
arachnoid
bridging
dural sinuses

Front 227

Oedema and increased ICP happen in acute or chronic subdural haematoma?

Back 227

acute

Front 228

Imaging modality of choice for brain tumour

Back 228

T1 weighted MRI with gadolinium

Front 229

Two leading causes of TBI

Back 229

falls
MVAs

Front 230

Acute care of a Pt w/ head injury is focused on prompt recognition + Rx of TBI and prevention of ___________ ___________

Back 230

secondary injury (e.g from swelling, raised ICP, hypoperfusion, hypoxia...)

Front 231

Secondary TBI is primary due to what?
Often caused by___________
So what are the goals of mgmt?

Back 231

cerebral ischaemia
hypotension, hypoxia
SBP goal = 90mmHg
Adequate oxygenation and ventilation and prevention of hypercapnoea

Front 232

In brain injury, why is it essential to keep PaCO2 low?

Back 232

elevated CO2 --> cerebral vasodilation => incr cerebral blood volume
In Pts w/ raised ICP, this small incr in blood vol may --> sharp increase in ICP (Monro-Kellie doctrine)

Front 233

Any pupillary asymmetry >_______ must be attributed to ______________ injury unless proved otherwise

Back 233

1mm
intracranial

Front 234

GCS for mild, moderate and severe head injury severity

Back 234

mild: > or = 13
mod: 9-12
severe: < or = 8

Front 235

Where do most burns take place?

Back 235

in the home

Front 236

Top 2 causes of burns

Back 236

1. explosion and flame (most common in adults)
2. scald (oil, water) (most common in kids)

Front 237

The Jackson Burn Wound Model has three zones of which are what?
What do they mean?

Back 237

zone of coagulation = necrosis
zone of stasis = damage (try to save!)
zone of hyperaemia = survived cells; but releasing inflamm mediators

Front 238

4 types of thermal burns

Back 238

1. scald (usually hot water)
2. flame burns (house fire, camp fire)
3. flash burns (explosion of gas)
4. contact burns (hot metals, plastic, glass, hot coal)

Front 239

What causes chemical burns?

Back 239

strong acids or alkalis

usually industrial accidents, home use of drain cleaners or assaults

Front 240

Chemical burns are usually how thick?

Back 240

deep partial or full thickness

the skin may appear in tact during the first few days and then begin to slough spontaneously

Front 241

In electrical burns, which body parts are more damaged?

Back 241

small body parts (fingers, hands, forearms, feet, lower legs) b/c as electricity meets the resistance of body tissues, it is converted to heat in direct proportion and the amps of current and the electrical resistance of the body parts through which it passes. The smaller the body part, the more intense the heat is and the less it is dissipated.

Front 242

What other organs are often damaged in electrical burns? (4)

Back 242

1. bones: fractures assoc with falls or intense muscle contraction
2. cardiac damage: MI, deranged conduction, rupture of heart wall --> valvular incompetence
3. nervous system: loss of myelin-producing cells, brain or s/c damage, peripheral nn damaged
4. renal failure due to myoglobinuria due to disruption of muscle cells

Front 243

What constitutes 1st, 2nd and 3rd degree burns?

Back 243

1st: superficial

2nd: superficial dermal and deep dermal

3rd: full thickness

Front 244

First Aid for burns (2)

Back 244

1. remove all clothing
2. cool the burn with 15deg running water continuously for >20mins effective up to 3h

Front 245

Which burn patients in particular do you do early ETT?

Back 245

Hx of closed space fire or examination findings e.g singed facial hair, black sputum...

Front 246

Pain relief for minor burns

Back 246

Paracetamol

Front 247

Pain relief for (adults) major burns

Back 247

morphine 0.1 mg/kg (up to a maximum of 10 mg) IV as an initial dose, then titrated to effect with further incremental doses of 2.5 to 5 mg

or fentanyl 1 micrograms/kg (up to a maximum of 100 micrograms) IV as an initial dose, then titrated to effect with further incremental doses of 25 to 50 micrograms.

Front 248

When is the best time to assess the depth of a burn?

Back 248

3-5d

Front 249

Fluids are given in burns when?

Back 249

if in shock
or
>10-15% BSA

Front 250

6 complications of burns

Back 250

1. hypovolaemia
2. infection
3. hypoalbuminaemia (haemodilution 2ndary to fluid R'/protein loss into extravascular space through damaged capillaries)
4. hypothermia (from cooling with water, IV fluids, body surface exposed, loss of thermal insulating properties of the skin)
5. ventricular arrhythmias (2ndary to electrolyte abno, shock, met acidosis, hypothermia, hypoxia if smoke inhalation)
6. full thickness circumferential burns can --> constricting eschars --> act as tourniquet and cause compartment syndrome, or if around thorax -> resp failure, if around abdo, hypoperfusion of kidneys and gut (Rx = escharotomy)
5.

Front 251

What are the likely sources of major hemorrhage in trauma?
(hint: mneumonic!)

Back 251

"SCALPeR": “Think SCALPeR when finding the bleeding”

Scalp
Chest
Abdo
Long bones (esp femur)
Pelvis
Retroperitoneum