Trauma & Shock

Front 1

diaphragmatic rupture

Back 1

blunt; mb air-fluid level in chest, NGT coiled up into chest; do emerg. celiotomy

Front 2

left sided rib fx...next step?

Back 2

peritoneal lavage to r/o splenic trauma

Front 3

frequency of dmg w/ blunt abd. trauma

Back 3

spleen>kidney>intestine>liver>abd. wall>mesentery>pancreas>diaphragm

Front 4

venous repair v. ligation

Back 4

always repair! ligation takes less time, allows you to focus on other injury, but repair = better limb salvage, lower r/o chronic venous insuff.
-note: ligated veins won't recanalize

Front 5

signs of arterial injury

Back 5

5 Ps (pain, paresthesia, pallor, pulselessness, paralysis); 6-8h before irrev. ischemia, loss limb fx; in the periphery, nerves/striated m. most sensitive to anoxia; signs warrant sx/exploration...do fasciotomy after you reestablish perfusion (after 4-6h ischemia)
-presence of pulses doesn't r/o art. injury

Front 6

EPI & insulin

Back 6

initially, EPI dec. insulin but then it increases

Front 7

CBD transection

Back 7

roux-en-y; if only lacerated, mb primary repair/end-to-end of CBD; if unstable, not roux-en-y, stage w/ temporary T tube

Front 8

neck injury

Back 8

absolute surgical indications: airway distress (stridor, hoarseness, dysphonia), visc. injury (subQ air, hemoptysis, dysphagia), bleed, neuro sxs indicative of carotid/CN/BP injury
-zIII/I? can do angiography
-ZIII mandible & above, ZII mandible to cricoid, ZI below cricoid

Front 9

duodenal hematoma

Back 9

sxs of high bowel obstruction, abd pain, mb palp ruq mass; upper GI series ~ coiled spring 2nd/3rd parts of duodenum 2/2 crowded valvulae conniventes; typ. sp. resolution; evac. w/ NGT

Front 10

SMA syndrome

Back 10

obstruction ~ weight loss, retro-P fat pad lost which nl'ly elevates SMA from distal duodenum

Front 11

peripheral nerve regrowth

Back 11

axons start proximally, if they contact distal neurilemmal sheath, regrow @ 1mm/d; get neuroma if no contact b/w axons (trauma, infection, fx, etc); delay sx reapprox. of nerve ends if soft tissue dmg, bleed

Front 12

closed head trauma

Back 12

1st sign inc. ICP = change in MS; most rapid dec. ICP by hyperventilating (can also use dexamethasone/decadron, mannitol)

Front 13

flail chest

Back 13

2+ rib fx in consec. ribs; get segmental pulm. hypoperfusion > infection > resp. failure; tx=tracheostomy, mechn. vent., PEEP if necessary

Front 14

CO poisoning

Back 14

MC toxin-induced c/o death in US; tissue hypoxia; continue O2 tx till COHb @ 10%; O2 @ 100% makes COHb HL 80min (v. 520 min. @ room air); if coma/sz/resp failure...hyperbaric chamber (Patm 2.8) ... 23min HL COHb

Front 15

pelvic fx

Back 15

type II? (single break in ring) in non-wt bearing area...bed rest
-lateral compression classifications (transverse fxs):
type I - i/l to impact; type II - i/l to impact, post iliac/crescent; type III - ass'd c/l SI jt injury
-open book: typ. heavy impact to pubis, ie w/ motorcycle accident; lt/rt pelvices separated at front & rear (front>rear, like opening a book)...sx reconstruction

Front 16

electrical burn

Back 16

tissue dmg typ. deeper than 1st inspection (fluid not = SA); heat ~ resistance to current (bone, fat, tendon have most resistance); typ need massive fluid replacement, fasciotomy MC than escharotomy; px abx against clostridia (PCN...also mafenide acetate topically...deep eschar penetration)

Front 17

thermal burns & parkland formula

Back 17

LR in 1st 24h: 4mL x (% total SA w/ non-superficial burns) x (wt kg).....give 1/2 over first 8h, 1/2 over next 16h

Front 18

MC jt fx ass'd w/ vascular injury?

Back 18

knee (huge force needed to fx, so inc. r/o vascular injury)...only 1.5% vascular injury ass'n w/ fxs in general

Front 19

penetrating trauma & abdomen

Back 19

anything below T4 (or nipples/inf. angle scap post) requires work-up...exploratory celiotomy

Front 20

colonic injury & primary repair indications

Back 20

primary ok w/ small caliber GSW, C/I if gross contamination; can do mucus fistula/hartmann's pouch, exteriorization of primary; early broad-spectrum IV abx

Front 21

anaerobic cellulitis

Back 21

common w/ IVDA; "gas abscess/local gas gangrene"; clostridia ~ large, boxcar, g+ bacilli (high dose IV PCN-G); clinda/streptomycin if polymicrobial

Front 22

myocardial contusion

Back 22

only <10% have abn. EKG; dx ~ RNA/echo but these are poor px indicators; mgmt ~ 24h telemetry

Front 23

molecular sequellae of injury/sepsis

Back 23

largely catabolic..inc. protein degradation, BUN loss, aa release...alanine > liver for acute phase reactant synth (fibrinogen, complement, haptoglobin, ferritin...also inc. hep. GNG, use of FAs to conserve protein); glutamine dec. in blood as it's used for fibroblasts, lymphs, intest. epith cells; IL1/TNF from macrophages assist in catabolism

Front 24

penetrating rectal injury

Back 24

sigmoidoscopy in ED not OR (emerg.); if contrast studies, use water-sol. (ie gastrogaffin)

Front 25

blunt hepatic trauma

Back 25

hep. a. ligation not ideal; hep. fragmentation tx'd by non-anatomic debridement; suture ligation of individual bleeds

Front 26

shock & K+

Back 26

initial increase in plasma from tissue release, anaerobic metabolism, dec. renal perfusion...if kidney fx nl, should nlize as it's excreted

Front 27

subperichondrial pinna hematoma

Back 27

can yield AVN of cartilage, fibrosis, etc > cauliflower ear; need to evacuate and tight pack skin (perichondrium on cartilage w/ pressure dressing)

Front 28

GU trauma

Back 28

stable? do IV urogram; 70-80% blunt renal trauma tx'd conservatively

Front 29

penetrating pancreatic injury

Back 29

most tx'd w/ drainage; pancreaticoduodenectomy for blunt injury injury to head or duodenum, add roux-en-y if ductal injury; mc cod exsanguination from splenic/mesenteric/Ao/IVC BV injury

Front 30

thoracotomy in ER if?:

Back 30

tamponade & rapid deterioration, to clamp Ao, for cardiac massage w/ faint pulse, absent pulse & distant HS
-NOT: no pulse, no pup. rxn, no sp. resp., multi-organ blunt trauma w/o vitals

Front 31

enterocutaneous fistula

Back 31

typ. ~ intraop. trauma; risk ~ radiation, obstruction, inflamm; stable? do barium swallow; distal? mb TPN if uncomplicated

Front 32

rules for arterial injury repair

Back 32

>5cm? can't do primary anastomosis, do saphenous graft instead; don't ligate (gangrene, etc)

Front 33

DPL

Back 33

occult intraperit. injury; stable but physical signs of abd. bleed; CT also good for abd. blood and shows retroperitoneal injury but neither good for D/SI injury; IR angiography for dx of extravasation...tx w/ embolization

Front 34

deceleration (ie seatbelt) vulnerable structures?

Back 34

SI, LI, kidney

Front 35

bullet @ umbilicus...vulnerable structures?

Back 35

SI/LI/great vessels