Nms Sugery Trauma, Burns, And Sepsis

Front 1

In trauma, what are signs that airway is clear?

Back 1

gag reflex, ability to talk

Front 2

what are signs of airway compromise?

Back 2

stridor, hoarseness, respiratory retractions (between ribs), accessory muscle use

Front 3

What is the initial evaluation of a trauma patient?

Back 3

ABCDE
Airway
Breathing
Circulation
Disability
Environment

Front 4

What kind of history do you need to take on a trauma pt?

Back 4

AMPLE
Allergies
Meds
Previous illnesses
Last Meal
Events surrounding injury

Front 5

What are indications for intubation?

Back 5

inadequate resp effort, severely depressed MS, GCS of 8 or less, compromised resp mechanics like broken ribs

Front 6

What are 3 Criteria for GCS?

Back 6

Eye Opening Response (4)
Verbal Response (5)
Motor Response (6)

Front 7

When a trauma pt is stable, what's the first thing to do?

Back 7

CXR, pulse ox

Front 8

What do you do if you see a "sucking" chest wound?

Back 8

seal it with occlusive dressing

Front 9

What to do if a chest tube is not fully inflating the lung?

Back 9

assuming that the chest tube is working, it may be in wrong location, like subQ, clotted off. Replace or reposition. Maybe put another one in.

Front 10

If you insert a chest tube but large amounts of air continue to leak into it, what is probably going on?

Back 10

Major airway injury with disruption of bronchus or trachea. May need partial lung resection

Front 11

When is it ok to not do anything about a small pneumo?

Back 11

Not enlarging, no free fluid in pleural space, asymptomatic, no other injuries esp chest injuries

Front 12

If there's a small pneumo and the pt may go to surgery, is it ok to leave it alone?

Back 12

No, because intubation and assisted ventilation puts the tracheobronchial tree at a pressure of 20-40mmHg, which increases risk of making pneumo bigger and dev into tension pneumo

Front 13

What are sxs of a pneumo?

Back 13

Absent breath sounds, hypotension, distended neck veins. Chest tube immediately or at least needle aspiration

Front 14

What direction does the mediastinum deviate in pneumo?

Back 14

Away from side of pneumo

Front 15

What do you suspect if you have distended neck veins and hypotension but with intact breath sounds?

Back 15

Cardiac tamponade

Front 16

Beck's triad for cardiac tamponade? Other signs of tamponade?

Back 16

1. Hypotension
2. JVD
3. Distant heart sounds
Other: pulsus paradoxus, Kussmaul's sign: increase in CVP during inspiration

Front 17

Best procedure for tamponade?

Back 17

1. open using subxyphoid approach
2. Neddle aspiration using US
3. eventually should get pericardial window and find source of bleeding

Front 18

What do you do for normal neck veins, normal breath sounds, and hypotension?

Back 18

2 large bore IVs, 1-2L of NS, quick search for bleeding site, major arterial sites, long bone fractures

Front 19

What happens when you lose 15-30% of blood volume?

Back 19

mild changes, tachy, increased pulse pressure

Front 20

What happens when you lose 30-40% of blood volume?

Back 20

more severe changes, tachy, hypotension, decrease mentation

Front 21

How to evaluate adequacy of resuscitation?

Back 21

BP, HR, Urine output, Mental status

Front 22

What to do when someone is hypotensive despite resiscitation?

Back 22

Do a central line if you can do it quickly, it helps for monitoring CVP and resuscitation, but do it on the same side that you may suspect pneumo. Also search for underlying cause: laparotomy or thoracotomy

Front 23

Would you expect a closed head injury to cause hypotension?

Back 23

No, because of Cushing Reflex due to ischemia and swelling of brain leads to vasoconstriction and bradycardia to maintain BP

Front 24

Hemodynamic effects of pregnancy?

Back 24

Increase in HR, hypotension because of uterine compression of vena cava, increase in plasma vol, decrease in hematocrit such that normal is 31-35%

Front 25

Should you advance a foley into bloody urethral meatus?

Back 25

No. Could be prostate or urethral injury and worsen it. Put suprapubic catheter instead

Front 26

What is cervical spine precautions and assessment?

Back 26

Neck immobilization, palpating for tenderness or deformity, test motor and sensory function, cervical spine XR. Careful not to extend neck with intubation!

Front 27

What do you give to cervical spine injury to minimize damage from edema?

Back 27

Steroids

Front 28

What are signs of fresh spinal cord injury?

Back 28

Priapism, loss of anal sphincter tone, loss of vasomotor tone, bradycardia, intestinal ileus

Front 29

How much blood do you need out of a chest tube to warrant thorax exploration?

Back 29

>1500ml OR
>200ml for 3 hours

Front 30

Strucutres that can get damaged in stab would below clavicle?

Back 30

SCM, Omohyoid muscle, Pec minor, anterior scalene, External Jugular vein, Transverse cervical vein, Anterior jugular vein, Subclavian A and V, Thyrocervical trunk

Front 31

What should you do if subclavicular stab would pt is stable?

Back 31

angiogram

Front 32

What to do for suspected diaphragmatic injury?

Back 32

Explore abdomen/thorax

Front 33

What to do for gunshots?

Back 33

Mark entrance and exit wounds, do radiography to locate bullet, surgically explore

Front 34

What are radiographic findings on aortic transection?

Back 34

1. Obliteration of aortic knob/aortic-pulmonary window
2. Deviation of trachea to right
3. Pleural cap filled with pleural fluid or blood
4. Dev of esophagus to right
5. Depression of L main bronchus or Elevation of R main bronchus
6. widened mediastinum on PA chest

Front 35

How to diagnose damaged aorta?

Back 35

CT/aortic angiography

Front 36

What are 3 categories of trauma that require further eval based on mech of injury?

Back 36

1. Unprotected trauma
2. High energy trauma
3. Minor trauma to those with limited reserve to tolerate injury (elderly, chronic dz, immunocompromised)

Front 37

If a car accident pt is stable with no swelling or abdominal pain or lesions, do you explore? what do you do?

Back 37

When exploration not necessary or if you need a quick diag, do imaging (CT or FAST) and Diagnostic Peritoneal Lavage

Front 38

How do you do a Diagnostic Peritoneal Lavage? Pros and cons?

Back 38

1. empty bladder
2. midline incision
3. fluid lavage
4. If no blood, place 1L saline and then remove for analysis
Pros: fast, low false neg, cheap
Cons: misses retroperitoneal injury if there is no communication

Front 39

Except for abdominal fluid/blood, what else can FAST diagnose?

Back 39

Pericardial effusion

Front 40

Why should CT be avoided in unstable pts?

Back 40

Requires them to be away from resuscitation unit

Front 41

What to do for suspected pelvic injury?

Back 41

1. FAST
2. pelvic angio if no blood seen where they can do an embolization of a branch of internal iliac is bleeding
3. reduction and internal fixation

Front 42

Branches of internal iliac from top to bottom?

Back 42

1. Iliolumbar
2. Superior gluteal
3. Lateral sacral
4. Inferior gluteal
5. Internal Pudendal
6. Obturator
7. Middle hemorrhoidal
8. Vesical

Front 43

Branches of external iliac that could get damaged with pelvic fracture?

Back 43

1. Deep circumflex iliac
2. Superior hemorrhoidal
3. Superficial external pudendal

Front 44

What grade spleen injury warrants exploration?

Back 44

Stage IV

Front 45

What should splnectomy pts always get?

Back 45

Vaccines for diplococcus, Meningococcus, Haemophilus (encapsulated organisms)

Front 46

What determines whether or not liver lesions get explored or not?

Back 46

Stable or unstable

Front 47

What imaging do you get before going in to remove a kidney?

Back 47

IV pyelorogram to make sure they've got 2

Front 48

What to do for partial transection of pancreas?

Back 48

Exploration, debriedement and drainage, repair, for severe cases duodenal diverticularization to divert fluids away from pancrease to allow for healing

Front 49

When should you explore a duodenal hematoma?

Back 49

After 5-7 days of observation and NPO

Front 50

3 zones of the retroperitoneum and significance?

Back 50

1. Central, usually surgically explored
2. Flank: can be observed in stable
3. pelvic: observed in stable, angiogram and embolization with bleeds

Front 51

Why does exploration of pelvis worsen bleeding?

Back 51

B/c it's being tamponaded by intact peritoneum

Front 52

How do you stop a liver bleed?

Back 52

Pack it with gauze

Front 53

What does a rapid neuro exam consist of?

Back 53

1. pupillary response
2. LOC/GCS
3. CNs
4. Motor and sensory

Front 54

What are some sxs of a basal skull fracture?

Back 54

Loss of consciousness, blood in ear, orbits, Battle's sign (ecchymosis in mastoid region), ecchymosis around the eyes, CSF from the ear or nose

Front 55

What's the very least that warrants a head CT?

Back 55

Loss of consciouness, change in MS

Front 56

When should someone with loss of consciousness stay overnight?

Back 56

If the episode was longer than 5 min

Front 57

How do you minimize brain edema?

Back 57

Elevate head to 30 deg, hyperventilate to 26-28 PCO2 (should promote vasoconstriction) with impending brain herniation like a blown pupil. Slow Mannitol. Phenytoin for 1 wk for seizure prophylaxis. Limit fluids.

Front 58

What kind of injury usually happens after a coma-producing head injury?

Back 58

Diffuse axonal injury

Front 59

What are signs of a large neuro focal lesion?

Back 59

Lateralizing motor deficits, unequal pupils

Front 60

Signs of epidural hematoma?

Back 60

Loss of consciousness, lucid interval, second loss of consiousness, dilated fixed pupil on same side as lesion

Front 61

What do eccymosis in the mastoid region mean?

Back 61

Battle's sign: basal skull fracture

Front 62

What's safer than an NG tube in the presence of a CSF leak?

Back 62

Orogastric tube an endotracheal tube so that Cribriform plate doesnt get punctured

Front 63

Why do brain injuries get hyponatremic?

Back 63

b/c brain injury can cause SIADH from direct response of hypothalamic osmoreceptors

Front 64

What are sxs of SIADH?

Back 64

High urine Na, expanded fluid volume, can cause cerebral edema. Can lead to restlessness, irritability, confusion, convulsions, coma

Front 65

Treatment of SIADH?

Back 65

Water restriction, 3%NaCl solution 200-300 given over 3-4 hours

Front 66

How much of the Na deficit should be correct the first day?

Back 66

Only half of the Na deficit should be corrected in first 24h to avoid central pontine myelinosis

Front 67

Why can brain injuries get hypernatremic?

Back 67

b/c brain injury can also lead to DI and dehydration without access to water or loss of consciousness

Front 68

How to treat DI?

Back 68

Vasopressin or Desmopressin, access to free water

Front 69

Why is hypothermia concerning in trauma pts?

Back 69

It leads to coagulopathies from platelet dysfunction and prolongation of PT and PTT, also predictor of poor outcome

Front 70

How to treat hypothermia?

Back 70

rewarm however possible. Correct persistent coagulopathies with FFP

Front 71

What do you do if someone's platelets gets too low?

Back 71

Could be DIC, give platelets to keep count above 60,000

Front 72

What can cause metabolic acidosis in trauma pts?

Back 72

hypothermia, hypovolemia, subsequent tissue hypoperfusion

Front 73

How do you get abdominal compartment syndrome?

Back 73

Continued hemorrhage from liver which causes decrease renal blood flow due to a tense abdomen, elevated diaphragm, difficulty breathing

Front 74

How do you manage postop blood loss?

Back 74

Give same amount of blood ml for ml, or 3ml NS for every ml lost

Front 75

What's the target urine output postop?

Back 75

.5-1 ml/kg/hr

Front 76

When should we be really careful with fluid replacement?

Back 76

Lung contusion, because damaged lung is more susceptible to pulmonary edema

Front 77

What's going on if you're fluid resuscitating but vitals are not responding?

Back 77

Probably has third space losses. Need to look at CVP: tells you RA pressure. IF CVP is normal (normally 3-8) and vitals still not responding, it could mean that they need more fluids, have low CO from abnormal heart, or CVP is not reflecting L heart filling pressures

Front 78

What does a Swan Ganz tell you?

Back 78

CO, RA, PA, PCWP (LA) pressures and SVR, and temp

Front 79

What do a low or high PCWP tell you?

Back 79

Low or high L heart preload= volume status

Front 80

When do you get arrhythmias when placing a Swan Ganz?

Back 80

When cath is in RV. advance or withdraw.

Front 81

What is normal SVR? PA? PCWP? CO?

Back 81

SVR: 800-1400 dynes-sec/cm^5
PA: Systolic 15-30 Diastolic 4-12
PCWP: 2-15
CO: 4-8 L/min

Front 82

What can cause increased SVR?

Back 82

Cardiogenic shock, hypovolemic shock, HTN, vasoconstrictors

Front 83

What causes reduction in SVR?

Back 83

Septic shock, neurogenic shock, vasodilators

Front 84

What's the picture when PCWP is low, CO is low, and SVR is high?

Back 84

Hypovolemia

Front 85

What's the picture then PCWP are normal, CO is high, and SVR is low?

Back 85

High output septic shock after fluid resuscitation. usually comes later in sepsis. in early or decompensated sepsis the CO is low

Front 86

What's the picture when PCWP is high, CO is low, and SVR is high?

Back 86

Cardiogenic shock: SVR increased because of high sympathetic impulses

Front 87

What are the hemodynamic parameters of neurogenic shock? what type of trauma usually causes it?

Back 87

Low PCWP, low CO, low SVR.
Can be caused by spinal cord injury

Front 88

How do you treat neurogenic shock?

Back 88

fluids. Vasoconstrictors and cardiac drugs to increase HR is usually not necessary

Front 89

What kind of heart failure do you get from a traumatic AV fistula?

Back 89

High output cardiac failure

Front 90

How to diagnose AV fistula?

Back 90

Palpable thrill and audible bruit, if you put pressure on it and the HR drops by 10 or more, that's Branham's sign. due to baroreflex activation

Front 91

When can you treat an AV fistula?

Back 91

After cardiac status is stable

Front 92

What are hemodynamic parameters of traumatic AV fistula?

Back 92

High PCWP, high CO, low SVR

Front 93

What other types of fistulas can be problematic?

Back 93

Hemodialysis fistulas, abdominal aneurysms that fistulize with IVC

Front 94

What's the danger of severe rib pain?

Back 94

Compromised breathing which leads to atelectasis, hypoxia, increase risk for pna. Give analgesics

Front 95

What do you do for moderate respiatory distress?

Back 95

Check airway, get ABG, place on O2, check the chest tube, get a CXR to confirm. are they chest splinting? pain?

Front 96

How do you get a flail chest?

Back 96

Multiple rib fractures leave a segment of chest wall unstable causing paradoxical movement of that segment

Front 97

What kind of analgesics appropriate for chest wall pain?

Back 97

thoracic epidural cath with bupivicaine and morphine

Front 98

What to do for severe resp distress?

Back 98

intubate, mechanical vent, CXR, ABG

Front 99

How do you correct a high or low PCO2?

Back 99

adjust vent rate

Front 100

What can cause hypoxia even with intubation?

Back 100

worsening ARDS, mucous plus, incorrect positioning of endotracheal tube. Reposition and suction

Front 101

How do you correct a low PO2?

Back 101

Increase FIO2, maybe give a little PEEP to help keep alveoli patent

Front 102

What to do if mechanical ventilation is failng?

Back 102

Jack up the FIO2 to 100%, add 10cmH2O of PEEP, perform arterial line for monitoring BP and getting easy ABGs, CXR

Front 103

What hemodynamic effect does PEEP have?

Back 103

Causes CO to drop by impairing venous return to heart, thus lowers urine output

Front 104

What to do for tension pneumo and failure to ventilate?

Back 104

Could be tension pneumo. Listen for lung sounds. If no breath sounds on one side: needle thoracostomy with angiocath in 2nd intercostal space midclavicular. Then chest tube in fifth intercostal space midaxillary then get CXR

Front 105

What are borders of zones of the neck area?

Back 105

Zone 1: Up to the cricoid
Zone 2: Cricoid to angle of mandible
Zone 3: Angle of mandible and up

Front 106

What is significance of zones of the neck?

Back 106

Trauma to zone 1 and 3 if stable should get angiogram if evidence of vascular injury.
Trauma to zone 2 should be explored if evidence of vascular injury

Front 107

What does subq emphysema in neck mean?

Back 107

airway injury, must explore

Front 108

What can blunt trauma to the neck cause?

Back 108

Damage to carotids. Tx for it is controversial, from anticoag alone to thrombectomy

Front 109

First thing to do on burn patient?

Back 109

Remove clothes, put on dry sheets, determine if airway burn is likely: black sputum, facial burn, hoarseness, low O2sat, dyspnea

Front 110

Assessment of burns?

Back 110

1. depth
2. type: flame, contact, scald with liquid, steam
3. percentage body surface area (BSA)

Front 111

What is rule of 9s?

Back 111

In adults: Head and upper extremities are 9% each
Lower extremities and anterior and posterior trunk are 18 each
Neck/Hand is 1 each

Front 112

Describe degrees of burns?

Back 112

First deg: superficial layer of epidermis
Second: through epidermis into dermis "partial thickness burns", blistering
Third: full thickness down to subq tissue, white waxy appearance, no sensation or capillary refill, req skin grafting

Front 113

Indications for transfer to burn center?

Back 113

1. Full thickness burn >5%BSA
2. Parital thickness burn >20% BSA
3. Age <5 or >50
4. Burns of face, hands, genitalia, perineum, major joints, feet
5. Inhalation injury
6. Cicumferential burns of chest or extremities
7. Chemical or electrical burns

Front 114

What is Parkland's formula?q

Back 114

Used for estimating fluids for first 24 hours after burn
TotalVol of LR=(%BSA)(kg)(4ml/kg)
give half in first 8 hours and second half over next 16 hours

Front 115

What other solutions do you need to give burn pts in addition to LR?

Back 115

D5W for evaporative water loss, keep an eye on serum Na and give .5ml plasma/%BSA over 8 hours to maintain colloid oncotic pressure

Front 116

Why no colloids in first 24 hours?

Back 116

capillaries are too leaky

Front 117

What are some abx for topical tx of burns?

Back 117

Silver sulfadiazine, Mafenide, Povidone-Iodine. no prophylactic systemic abx

Front 118

How often do you change burn dressings?

Back 118

2x daily

Front 119

How to manage third degree burn?

Back 119

Regular debridement until split thickness skin graft can be put into place

Front 120

What to do for dark urine after a burn?

Back 120

It's myoglobinuria: risk for ATN, fluids to ensure urine output at least 2-3x normal, alkalinization of urine (sodium bicarb) and osmotic diuretics (Mannitol) can also be used in extreme cases

Front 121

How do you diagnose CO poisoning?

Back 121

CarboxyHg of 5% in nonsmokers and 10% in smokers indicates it. Give 100% O2 until normalized. Hyperbaric chambers also used.

Front 122

How to diagnose methemoglobinemia?

Back 122

Chocolate brown appearance of blood, central cyanosis, seizures, pulse ox canNOT diff b/w met and normal Hg, so do an ABG!. Specific tx for MetHg is Methylene blue. Reduces MetHg at low doses

Front 123

What's the danger of a circumferential burn of the thorax?

Back 123

Can rapidly become thickened and limit motion and impairs ventilation. Do escharotomy.

Front 124

What to do for electrical burns?

Back 124

EKG, cardiac enzymes

Front 125

What is the protein requirement for nondepleted, depleted, and hypermetabolic patients?

Back 125

1g/kg/d nondepleted
2.5-3 g/kg/d hypermetabolic

depleted is somewhere in between

Front 126

How do you calculated caloric needs?

Back 126

Weir Formula for Resting energy expenditure and Harris-Benedict Eq for Basal energy expenditure

Front 127

How many calories does average male need on a daily basis?

Back 127

2100kcal

Front 128

What's a severe complication of long term TPN?

Back 128

Metabolic coma from Hyperglycemia Hyperosmolar Nonketotic coma secondary to dehydration due to excessive diuresis due to hyperglyemia. d/c TPN and give insulin, monitor glucose and lytes

Front 129

What happens to liver on TPN?

Back 129

LEFTs can be abnormal in 30% of TPN pts. Reduce rate of infusion. TPN can also cause fatty liver and structural damage and cirrhosis over years.

Front 130

Why would you get dry scaly skin on TPN?

Back 130

FFA def. Give lipids