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MRCS Critical care > Burns, wound healing and orthopaedics > Flashcards

Burns, wound healing and orthopaedics Flashcards

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1
Q

Describe possible reasons for low gcs in burns patient

A

-Hypoxia
-Inhalation injury
-Head injury

Possible:
–> drug/alcohol overdose
–> hypoglycaemia

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2
Q

When would you expect inhalation injury from history?

A

-Burns occuring in enclosed space
-Smoke during incident
-Injury from blast
-Pt brought in unconcious/decreased GCS

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3
Q

What are the signs of smoke inhalation injury?

A

-Facial +/- neck burns
-Singed hairs (eyebrows, nose hairs)
-Soot in airway
-Hoarseness/stridor
-Carbonaceous sputum
-Hypoxia
-Low GCS

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4
Q

How would you initially manage burns pt?

A

-Manage according to ATLS guidelines
-A-E
-Analgesia, tetanus, investigations, fluid resuscitation

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5
Q

What investigations would you request in burns pt?

A

-FBC, U + E, coag, G + S
-ABG, COHb levels
-CT head
-CT trauma if evidence of trauma

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6
Q

What is half life of carbon monoxide?

A

-Room air: 250 mins
-100% O2: 40 mins

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7
Q

How would you clinically assess depth of a burn?

A

-Colour
-Cap refill
-Presence/abscence of blisters
-Sensation

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8
Q

How would you estimate the extent of the burn as mesaured by TBSA?

A

-Hand surface area = 1% (patient’s hand)
-Rule of 9’s
-Lund and browder chart

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9
Q

Describe rule of 9s

A

Head = 9%
Arm = 9%
chest = 9%
abdomen = 9%
Back: 18%
Leg = 18%
Genitals = 1%

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10
Q

What are the indications for fluid resuscitation in burns?

A

->10% deep partial/full thickness in children
->15% deep partial/full thickness in adults ?? 20% according to new atls guidelines

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11
Q

What fluid resuscitation is given? When is it indicated?

A

New ATLS guidelines:
-2ml x body weight Kg x % TBSA
-Half over 8 hrs, subsequent over 16
-Indicated if over 20% deep partial thickness or full thickness burn

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12
Q

What would you expect in a deep dermal burn?

A

-Dry, blotchy red cherry skin
-Absence of a capillary refill
-Loss of sensation

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13
Q

What emergency treatment is required for circumferential burns?

A

Escharotomy

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14
Q

What are the indications/criteria for referring to the burns unit?

A

-5% TBSA full thickness burn in adults
-5% TBSA in children (any depth)
-10% TBSA in adults (any depth)
-Burns + inhalation
-Burns + trauma
-Electrical and chemical burns
-Burns in certain anatomical areas e.g. face, hands, feet, perineum and genitals
-Circumferential full thickness burns

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15
Q

Healing by primary intention

A

-Wound edges are approximated by sutures, glue, staples or steristrips
-Healing occurs in an orderly manner
-Good cosmetic outcome

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16
Q

Healing by delayed primary intention

A

-Used in bites (human/animal) or contaminated wounds
-Following thorough debridement, the wound is left open for 24-48 hrs and then primary closure is performed

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17
Q

Healing by secondary intention

A

-The wound edges cannot be approximated (tissue loss)
-Wound heals by contraction
-Poorer cosmetic outcome compared to healing by primary intention
-Myofibroblasts are the predominant cell type in this type of healing

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18
Q

Healing by re-epithelialisation

A

-Only epiderms and superficial part of the dermis are injured
-Adnexal structures are intact and the wound heals by re-epithelialisation
-Seen in abrasions and split-skin donor sites

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19
Q

What are the stages of wound healing?

A
  1. Haemostasis
  2. Inflammation
  3. Proliferation
  4. Re-modelling
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20
Q

Haemostasis

A

-Vasoconstriction
-Platelet aggregation and activation
-Fibrin clot formation

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21
Q

Describe inflammation stage of wound healing

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A

-Early phase (first 24 hrs) - neutrophils are the predominant cell type
-Late phase (>24 hrs) - lymphocytes and macrophages are seen

22
Q

Proliferation

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A

-Extracellular matrix formation
-Collagen deposition
-Fibroblast proliferation
-Angiogenesis
-Epithelialisation

23
Q

Re-modelling

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A

-Decresased fibroblast formation. Collagen is rearranged along tension lines
-Gradual increase in tensile strength of wound

24
Q

What is the fundamental difference between a ‘graft’ and a ‘flap’?

Study These Flashcards
A

-A graft relies on recepient wound bed for vascularity and nutrition
-A flap brings its own blood supply

25
How would you classify skin grafts?
-SSG -Full thickness
26
Describe split thickness graft
-Used for large surface area e.g. extensive burns -Epidermis and part of dermis taken, donor site left to heal by re-epithelialisation -Common donor sites: lateral aspects of thigh, buttocks, back
27
Describe full thikness grafts
-Used in areas e.g. digits of hand or over joints to minimise contractures -FT skin grafts have better colour match and are therefore preferred in exposed areas e.g. face -Common donor sites for FT graft: pre and post-auricular region, supraclavicular region, medial surface of forearm/arm
28
How would you classify 'flaps'?
-Random patterns (does not have named blood vessel) -Pedicled (has named blood vessel) -Free (blood supply is disconnected from one part of body and connected to a vessel at recipient site)
29
What types of flaps are used in which locations?
-Face: mostly random pattern flaps -Breast recon: pedicled flaps (LD) and free flaps (DIEP) is used -Pedicled and free flaps also used in variety of recons following trauma (e.g. gracillis musculocutaneous free flap to cover defect over dorsum of foot)
30
Name some types of dysfunctional wound healing
Non-Healing wounds Healing with hypertrophic scar Healing with formation of keloid
31
What are the differences between hypertophic and keloid scar?
Borders --> confined to original wound --> outgrows wound area Incidence --> usually develops in weeks following surgery/injury --> can develop months or years from original injury Site --> usually in flexor surfaces --> predilection for sternum, shoulder and ear lobes Aetiology --> Usually related to wound factors (e.g. infection/haematoma/dehiscence) and those crossing tension lines --> unknown Racial predisposition --> Not race related --> non whites >whites
32
How would you manage hypertrophic scars?
-Subside with time and respond to conservative measures e.g. pressure treatment/silicone gel/plasters
33
How would you manage keloid scars?
-No effective treatment -Conservative: steroid injections, pressure treatment, silicone gel -Surgery rarely advocated, only if severe/for cosmetic purposes -Rarely subside, do not have established treatment option -No treatment is proven to be effective, recurrence is common following excision -Commonly used symptom control measures include pressure treatment, intra-lesional steroid + silicone gel/plasters -Surgery rarely advocated and is performed if symptoms severe/for cosmetic purposes -Surgery includes debulking keloid by ensuring incision is kept within margin of keloid and does not overrun into normal skin
34
What is the aetiology of septic arthritis?
-Micro-organisms invade joint by direct penetration into joint, spread from adjacent soft tissue infection or via blood stream
35
What micro-organisms are known to cause septic arthritis?
Bacterial -Staph -Haemophilus -E.coli Viruses -Heptatitis A, B, C -Herpes viruses Fungi -Histoplasma
36
What are risk factors for developing septic arthritis?
-previous joint disease/injury/surgery -IV drug abse -Immune deficiency/immunosuppression Underlying medical illness: -Diabetes -Alcoholism -Rheumatic diseases
37
Which investigations would you perform in septic arthritis?
-Bloods: FBC, CRP, Urate -X-ray -joint aspiration for M, C and S
38
How would you manage a pt with septic arthritis?
-Bloods including urate, CRP, FBC -Analgesia, immobilisation -Aspirate joint -IV abx -Washout of joint -Surgery to remove prosthesis (if present) -IV abx -Analgesia -Immobilisation -Washout/aspiration of joint -Surgery to remove prosthesis (if present)
39
What are the complications of septic arthritis?
-Soft tissue injury -Degenerative joint disease -Osteomyelitis -Sepsis
40
Can you differentiate between septic arthritis and other inflammatory joint diseases e.g. gout or reactive arthritis?
-Septic arthritis is mono-articular, inflammatory arthropathies can be mono or poly-articular
41
What is the difference between gout and pseudogout
Joints --> affects smaller joints --> affects larger joints Investigations --> Associated with high serum urate levels --> not associated with high serum urate levels Crystals --> monosodium urate crystals, needle shaped crystals, negatively birefringent on polarised light microscopy with rhomboid shaped crystals --> Positively birefringent on polarised light microscopy
42
How would you treat gout?
During acute flare up: Colchicine, NSAIDs or corticosteroids (intra-articular or systemic) To induce remission: allopurinol, dietary advise (reduce alcohol intake, reduce red meat consumption, good hydration)
43
Define compartment syndrome
-Increase in interstitial fluid pressure within osseo-fascial compartment with sufficient magnitude to cause compromise of microcirculation leading to myoneural necrosis
44
What are the signs and symptoms of compartment syndrome?
-Pain on passive stretch of affected compartment -Paraesthesia -Paralysis -Pallor -Pulslessness -Perishingly cold leg
45
What is the normal compartment pressure in the lower leg?
Normal resting pressure 0-6mmhg
46
What happens to this pressure in compartment syndrome?
-Pressure is >30mmhg or difference in diastolic pressure and compartment pressure is <30mmhg
47
Name the compartments in the lower leg
-Anterior -Lateral -Superficial posterior -Deep posterior
48
Name structures present in deep posterior compartment of lower leg
-Tibialis posterior -Flexor hallucis longus -Flexor digitorum longus -Popliteus Nerve -Tibial nerve Artery -Posterior tibial artery -Peroneal artery
49
How would you treat compartment syndrome in this pt?
-Immediate fasciotomies -Address underlying cause
50
Describe incisions for fasciotomies
Two longitudinal incisions on medial and lateral sides of leg --> medial longitudinal incision 1-2cm posterior to medial border of tibial to release superficial and deep posterior compartments --> Lateral longitudinal incision 2cm lateral to anterior border of tibia releases anterior and lateral compartments

MRCS Critical care (11 decks)

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