ABS3 Flashcards
The affinity of carbon monoxide for haemoglobin is
200-250 times greater than oxygen
A 100-kg patient with a 50% TBSA full thickness burn receives 10 L of 0.9% NaCl solution in transit to the hospital. His laboratory values 6 hours after the injury are likely to reflect
Acidosis
*0.9% NaCl results in hypernatremia and hyperchloremic acidosis
The topical antimicrobial agent mafenide acetate is most likely to cause
Metabolic acidosis
*Resulting from carbonic anhydrase inhibition
*Is effective in the presence of eschar
What chemical burn should be initially treated by careful wiping or sweeping of the skin rather than water
Powdered form of lye
*In cases of concrete powder or powdered forms of lye – should be swept from the patient to avoid activating the aluminium hydroxide with water
Formic acid burns are associated with
Hemoglobinuria and hemolysis
The agent most effective in treating hydrofluoric acid burns is
Calcium
*Calcium-based therapies are the mainstay of treating hydrofluoric acid burns
Most common indication for intubation
Altered mental status
Fracture of the proximal third of the ulna with dislocation of the radial head
Monteggia fracture
Fracture of the middle-distal third of radius with dislocation of the radioulnar joint (Piedmont fracture)
Galeazzi fracture
Most commonly injured intra- abdominal organ in blunt abdominal trauma
Liver
*2nd = Spleen
Topical therapy for burn patients has a side effect of metabolic acidosis
Mafenide acetate
The following would mandate elective intubation in a patient with a normal voice, normal oxygen saturation, and no respiratory distress
Penetrating injuries to the neck and an expanding hematoma
Evidence of chemical or thermal injury in the mouth, nares or hypopharynx
Extensive subcutaneous air in the neck
Complex maxillofacial trauma
Airway bleeding
In patients under the age of 8, cricothyroidotomy is contraindicated due to
Risk of subglottic stenosis
*Tracheostomy should be performed
Emergent tracheostomy is indicated in patients with
Laryngotracheal separation or laryngeal fractures
*In whom cricothyroidotomy may cause further damage or result in complete loss of the airway
Most appropriate treatment of sucking chest wound
Occlusive dressing taped on 3 out of 4 sides
A 4-year-old is brought hypotensive to the ED after an MVA. Peripheral IV access is attempted but is unsuccessful. The next best access is
Intraosseous catheter
*Preferred site = Proximal tibia or distal femur of an unfractured extremity
During the circulation section of the primary survey, four life-threatening injuries that must be identified are
- Massive hemothorax
- Cardiac tamponade
- Massive hemoperitoneum
- Mechanically unstable fractures (e.g., femoral artery injury)
*A pericardial effusion (without tamponade) is not immediately life threatening
A massive hemothorax is define as
> 1500 mL of blood or, in the pediatric population, one third of the patient’s blood volume in the pleural space
*Blood volume can be quickly estimated by multiplying body weight (kg) x 70 (e.g., 20-kg child would have a total blood volume of 1400 mL, and one third of his blood volume is 466 mL, the amount necessary to be classified as massive hemothorax)
Best initial treatment for acute traumatic pericardial tamponade in a patient with a SBP of 90 mmHg
Ultrasound guided placement of a pericardial catheter
*Followed by transfer to the operating room for definite treatment
*Patients with SBP <70 mmHg warrant emergency department thoracotomy (EDT) with opening of the pericardium to address the injury
Management of suspected blunt cardiac injury includes
Continuous monitoring if EKG abnormalities are noted
A patient presents with stable vital signs and respiratory distress after a stab wound to the chest. Chest tubes are placed and an air leak is noted. The patient is electively intubated. The patient arrests after positive pressure ventilation is started. What is the most likely diagnosis
Air embolism
*The patient should immediately be placed in Trendelenburg’s position to trap the air in the apex of the left ventricle and the aortic root with an 18-gauge needle and 50-mL syringe
*Vigorous massage is used to force the air bubble through the coronary arteries, if this is unsuccessful, a tuberculin syringe may be used to aspirate air bubbles from the right coronary artery
*Once circulation is restored, the patient should be kept in Trendelenburg’s position with the pulmonary hilum clamped until the pulmonary venous injury is controlled operatively
What is the expected blood loss in a patient with 6 rib fractures
750 mL
*For each rib fracture = 100 to 200 mL of blood loss
*Tibial fractures = 300 to 500 mL
*Femur fractures = 800 to 1000 mL
*Pelvic fracture = >1000 mL
A 25-year-old man presents following blunt trauma to the abdomen. FAST exam shows injury to the spleen. His HR is 110, RR is 25 and he is mildly anxious. What percentage of his blood volume do you estimate he has lost
15-30%
*Class II hemorrhagic shock (based on his vital signs) = loss of between 15-30% of his blood volume
A 27-year-old man presents to the ED after receiving blows to the head. He opens his eyes with painful stimuli, is confused, and localizes to pain. What is his GCS
11
*2 (E) + 4 (V) + 5 (M) = 11
A 75-year-old woman presents to the ED following an MVA. She has decreased strength and sensation in her arms. She has normal strength and sensation in her legs. The most likely diagnosis is
Central cord syndrome
The appropriate treatment of an asymptomatic patient with a stab wound to Zone III of the neck is
Observation
*If symptomatic – should be evaluated with angiography and, if necessary, embolization of bleeding vessels
An indication for CT of the chest to rule out a thoracic aortic injury
High speed head-on MVC with normal chest radiograph
*CXR finding of a left apical cap is suggestive of a thoracic aortic injury
A 20-year-old young man presents with a left anterior 8th intercostal space stab wound. He is in no distress and a chest x-ray is normal. A diagnostic peritoneal lavage is performed and has a RBC count of 8,000/µL and a WBC count of 300/µL. Which of the following is the best treatment for this patient
Laparoscopy
*Patient with a DPL RBC count between 1000/µL and 10,000/µL – should undergo laparoscopy or thoracoscopy
*RBC count of >10,000/µL – an indication for laparotomy
A 45-year-old, otherwise healthy woman presents after a moving vehicle accident. She is hemodynamically stable and with only minimal tenderness in her right upper quadrant. A FAST exam (focused abdominal sonographic test) is positive with fluid seen in the hepatorenal fossa and the pelvis. Next best step in her management is
CT scan
*Patients with fluid on FAST examination (considered a positive FAST) who do not have immediate indications for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries
*If she has an isolated liver or spleen injury, the correct treatment is most likely observation – therefore, both laparoscopy and laparotomy would not be indicated
After CT scan, she is shown to have a liver laceration. There is a 4-cm laceration into the right lobe with a 10-cm subcapsular hematoma. What grade liver injury does she have
Grade III
*Laceration >3 cm in depth = Grade III
A stable patient with a Grade III splenic laceration has the following laboratory results 2 hours after admission: Hgb 8.7, Hct 29, Plt 70,000, INR 1.3
Transfuse PRBCs only
*In acute phase of resuscitation the endpoint is 10 g/dL
*This patient, who is in the acute phase of resuscitation, should receive PRBCs because the Hgb is less than 10
*Because platelets are >50,000 and INR is <1.5, transfusions of platelets and/or FFP are not indicated
Indication for operative intervention in a patient with an isolated duodenal hematoma
Contained retroperitoneal leak
*Patients with persistent duodenal occlusion after 3 weeks – should undergo operative exploration
*Any sign of perforation is an indication
*The size of the hematoma is not a criterion for operative intervention, nor is the degree of initial occlusion by the hematoma
An indication for a lower leg fasciotomy
> 35 mmHg difference in diastolic pressure and the compartment pressure
*Fasciotomy is indicated in:
Patients with gradient of >35 mmHg (gradient = diastolic – compartment pressure)
Ischemic periods of >6 hours
Combined arterial and venous injuries
*In the absence of clinical signs such as pain and paresthesias, compartment pressures are used to determine the need for fasciotomy
What bladder pressures is an absolute indication for a decompressive laparotomy
> 35 mmHg (≥48 cm H2O) = Grade IV abdominal hypertension
*Mortality is directly affected by decompression:
* 60% mortality in patients undergoing presumptive decompression
* 70% mortality in patients with a delay in decompression
Produced by the appendix
IgA
Lymphoid tissue in the appendix
Is maximally present during puberty
Appears approximately 2 weeks after birth
Disappears after the age of 60 years
The luminal capacity of normal appendix
0.1 mL
Appendectomy may decrease the risk of developing which disease
Ulcerative colitis
Culture should be taken at the time of surgery
For immunocompromised patients with appendicitis
Pain in the right lower quadrant with compression of the left lower quadrant
Rovsing sign
Important to consider in the differential diagnosis of an HIV positive patient with right lower quadrant abdominal pain
Cytomegalovirus infection
A patient with a 1.5 cm carcinoid tumor of the mid appendix should undergo
Appendectomy only
Appendiceal Carcinoid
* ≤ 1 cm = Appendectomy
* >1 - ≤ 2cm
o Tip or mid appendix = Appendectomy
o Base, mesoappendiceal invasion, metastases = Right hemicolectomy
* >2 cm = Right hemicolectomy
At the time of laparoscopic surgery for presumed appendicitis, the patient is noted to have a mucous-filled, distended appendix measuring 3 cm in diameter. There is no acute inflammation or signs of perforation. The correct treatment for this patient is
Diagnostic laparoscopy only (no resection) with CT scan staging before proceeding with further surgery
*An intact mucocele presents no future risk for the patient, however, the opposite is true if the mucocele has ruptured and epithelial cells have escaped into the peritoneal cavity
Indicated in a patient with pseudomyxoma peritonei of appendiceal origin
Hysterectomy with bilateral salpingo-oophorectomy
*Because 5-year survival of mucinous appendiceal neoplasms is only 30%
The treatment for lymphoma confined to the appendix is
Appendectomy alone
Half-Life of low dose radiation Iodine 123
12 - 14 hours
Half-Life of high dose radiation Iodine 123
8 – 10 days
Irreversible side effect of anti-thyroid drugs
Aplastic anemia
