Ch 5. Analgesia and sedation, Hand injuries

Question 1

What is your target MAP for septic shock, hemorrhagic shock in trauma, and traumatic brain injury (3)?

Answer 1

1. Septic shock: MAP >65
   
2. Hemorrhagic shock in trauma: MAP >40

2. TBI: MAP >90


Question 2

What is normal CVP, and how do you use CVP to measure “volume responsiveness”?
 (2)

Answer 2

1. Normal CVP is 2-8. <4 suggests volume responsive, 2. CVP >12 suggests high right-sided pressures

Question 3

How do you assess volume responsiveness? (3)


Answer 3

1. Passive leg raise: like a 300mL bolus in 1 min (lasts 2-3mins). Assess for HR, BP, CVP.

2. If you have CVP? Infuse 250mL NS. CVP increases <3 = volume responsive, CVP increases >5 = volume overload
   
3. Mechanically ventilated? Pulse pressure variation >10% predicts volume responsiveness


Question 4

What is the Frank-Starling curve? (1)


Answer 4

Increased preload initially leads to a large increase in CO, and increasing preload past that gives modest increases in CO, and eventually too much preload decreases CO as the myocardium is stretched too far. 


Question 5

What is Beck’s triad for cardiac tamponade (3)?


Answer 5

1. Low BP

2. Distended neck veins

3. Muffled heart sounds

Question 6

What is the toxic limit for local anaesthetics? (3)


Answer 6

7:5:3 rule

1. 7mL/kg lidocaine w epi

2. 5mL/kg lidocaine

3. 3mL/kg bupivacaine

* 1% lidocaine is 10mg/mL, so you can use 40mL in an 80kg human


Question 7

What is the treatment of local anaesthesia systemic toxicity? (1)


Answer 7

1. Intralipid 20% 1.5mL/kg
*

Beware peri-orbital numbness, tinnitus, seizures, tachy-arrhythmia


Question 8

How do you test the motor function of the radial, median, and ulnar nerve? (3)


Answer 8

1. Radial = thumbs up
2. Median = A-OK (anterior interosseous nerve)
3. Ulner = Peace sign (also PAD DAB)

Question 9

What is the hands position of safety (1)


Answer 9

1. Sandwich holding position!
-

Because of the CAM effect (lessens contractures in the hand)


Question 10

Describe the anatomy of FDS and FDP.


What does a laceration of each produce? (3)


Answer 10

Laceration of FDS – cant flex PIP


Laceration of FDP – cant flex DIP


Question 11

What is the sensory innervation of the leg and foot? (5)


Answer 11

1. Saphenous nerve = medial leg
2. Superficial peroneal = lateral leg and dorsum of foot
3. Deep peroneal = first-second webspace
4. Lateral foot = Sural
5. Plantar foot = Tibial nerve

Question 12

Describe the arterial supply to the leg (5)


Answer 12

1. The aorta

2. Common iliac into internal and external iliac

3. External iliac into superficial and deep femoral artery

4. Superfical femoral into popliteal artery

5. Popliteal into Anterior tibial, posterior tibial, and fibular (peroneal)

Question 13

Complete: receptor, dosing, peak effect, half life (15)


1. Midazolam: 

2. Fentanyl: 

3. Ketamine: 

4. Propofol: 

5. Etomidate: 


Answer 13

1. Midazolam: GABA receptor, 0.1mg/kg IV, 2 mins, 20 mins
   
2. Fentanyl: opioid receptors, 1-2mcg/kg IV, 3 mins, 30 mins
   
3. Ketamine: NMDA antagonist, 1mg/kg IV, 1 min, 20 mins

2. Propofol: GABA receptor, 0.5-1mg/kg IV, 30 seconds, 5 mins
   
5. Etomidate: GABA receptor, 0.15mg/kg IV, 30 seconds, 5 mins

Question 14

Non-opioid medications for chronic pain (8)


Answer 14

1. Ibuprofen

2. Tylenol 

3. Topical diclofenac

4. Local injection/anaesthesia

5. Ketamine

6. Haloperidol

7. Amitriptyline

8. Gabapentin

9. Duloxetine/Cymbalta


Question 15

Which human bites, dog bites, cat bites of the body need antibiotics? (3)


Answer 15

1. Human: hands, feet, face (Eikenella)
   
2. Dog: hands, feet, face (Capnocytophagacanimorsus)
   
3. Cat: all (Pasturella multicida)


Question 16

Septal hematoma: treatment (3)


Answer 16

1. Surgical drainage (18 guage needle)

2. Anterior nasal pack to stop reaccumulation

3. Rx Clavulin (poor evidence)


Question 17

Treatment of an auricular hematoma (3)


Answer 17

1. Drain the blood

2. Apply a pressure dressing

3. FU with plastics/ENT


Question 18

Treatment of fight bite injuries (4)


Answer 18

1. Visualize the full extent of the wound

2. Irrigate copiously

3. Splint in position of function

4. Injury to extensor tendons or joint capsule? Surgery FU

5. PO Clavulin or IV cefazolin


Question 19

Treatment of extensor tendon laceration (3)


Answer 19

1. <50% transection: 5-0 absorbable suture

2. > 50% transection: Figure-of-8 stitch, 5-0 non-absorbable

3. Splint in position of comfort
   
4. FU with plastics


Question 20

What is the injury?

1. Mallet finger deformity
2. Swan neck deformity
3. Boutinniere deformity
4. Jersey finger (3)


Answer 20

1. Mallet finger deformity – loss of the DIP extensor
2. Swan neck deformity – from unrepaired mallet finger (transected DIP extensor)
3. Boutinniere deformity – injury to the PIP, with central slip rupture, allowing the lateral bands to slip and flex the PIP instead of extend it – splint and refer urgently to minor surgery
4. Jersey finger – avulsion of FDP – splint and refer urgently to minor surgery

Question 21

Treatment of mallet finger deformity? (1)


Answer 21

1. Splint the DIP, the PIP should be mobile. 6-8 weeks. Follow-up hand surgeon

Question 22

What is Gamekeeper’s thumb? What is the pathological problem? Dx? Treatment? (4)


Answer 22

1. Gamekeeper’s = UCL injury at the MCP joint
   
2. The problem is a Stener lesion (entrapment of adductor pollicis between the UCL ends, which impairs healing)

2. Dx = joint laxity >30 degrees, or 15 degrees more than the other thumb

3. Treatment: thumb spica. Refer to plastics within 7 days


Question 23

Terry Thomas sign? (1)

Spilled teacup sign (1)?


Answer 23

1. Terry Thomas sign = Scapholunate dissociation

2. Spilled teacup sign = Lunate dislocation

3. Carpal bones not lining up in the lateral = perilunate dislocation


Question 24

Flexor tendons in the forearm (6)


Answer 24

1. Flexor carpi radialis

2. Flexor carpi ulnaris
3. Palmaris longus
   
4. Flexor pollicis longus

4. Flexor digitorum superficialis

5. Flexor digitorum profundus

   ** Treatment: splint in position of safety. Urgent plastics FU (before the tendon retracts)

Question 25

What is the Gustilo Classification system for open fractures (4)


Answer 25

I. Wound <1cm - Ancef
 II. Wound >1cm, - Ancef 
III. Wound >10cm, severe mechanism/contamination - Ancef + Gent
 IIIC. Wound >10cm, severe mechanism/contamination/soft tissue loss/vascular injury Ancef + Gent + Penicillin (concern for anaerobes/clostridia)


Question 26

Q. What are the bones of the wrist? (8)


Answer 26

1. Scaphoid
 2. Lunate 3. Triquetrum
 4. Pisiform
 5. Trapezium 6. Trapezoid 7. Capitate 8. Hamate

Question 27

Q. Joints of the thumb? (3)


Answer 27

1. Carpometacarpal (CMC) 
2. Metacarpophalangeal (MCP) 3. Interphalyngeal (IP)

Question 28

What is the motor and sensory test for radial nerve, median nerve, ulnar nerve (6)?


Answer 28

1. Radial - M= thumb or wrist extension "power to the people or thumbs up". S=dorsal thumb webspace 2. Median - M=thumb opposition. "A-OK" S=Distal pointer finger 3. Ulnar - M=fingers "peace" S=Outside small finger

Question 29

Fingertip amputation classification and treatment (6)

Answer 29

Zone I - no bone - heal by secondary intent Zone II - some distal phalynx - rongeur bone and close (or call plastics) Zone III - distal phalynx - rongeur bone and close (or call plastics)

Question 30

Fingertip amputation classification and treatment (6)

Answer 30

Zone I - no bone - heal by secondary intent Zone II - some distal phalynx - rongeur bone and close (or call plastics) Zone III - distal phalynx - rongeur bone and close (or call plastics)

Question 31

What is jersey finger? (1)

Answer 31

Rupture of the FDP tendon

Question 32

Acceptable degree of angulation for metacarpal neck/shaft fractures? (5)

Answer 32

``` D1 0  D2 0 D3 10 D4 20 D5 30 ```

Question 33

What is a Bennett and Rolando fracture? (2)

Answer 33

1. Bennett: 2 part intra-articular fracture at the base of the thumb 2. Rolando: 3 part intra-articular fracture at base of thumb * Remember because BEN-NETT (2) and RO-LAN-DO (3)

Question 34

Treatment of clinical scaphoid fracture? (2)

Answer 34

1. Thumb spica. 2. Repeat Xray in 10 days * 20% are radiographically occult*

Question 35

Treatment of high pressure injection injuries? (3)

Answer 35

1. Broad spectrum antibiotics (cefazolin) 2. tetanus 3. Emergency consultation with plastics * Avoid ice, digital nerve blocks, local anaesthetic (theoretical risk of worsening vascular status)

Question 36

Indications for antibiotics in hand lacerations (6)

Answer 36

1. Immunocompromised 2. Open fracture (except Tuft fracture) 3. Gross contamination 4. Animal bites / fight bite 5. Penetrating tendon injury 6. Crush injury

Question 37

Management of Tuft fracture? (2)


Answer 37

1. Trephination if the hematoma is >25% (make 3-4 holes!)
2. Splint the DIP
-Tell them that this will be painful for a few weeks!


Question 38

Kanavel signs of flexor tynosynovitis (4)


Answer 38

1. Pain and redness along the tendon
 2. Finger held in slight flexion 3. Pain with passive ROM
 4. Swelling of the digit

Question 39

Treatment of flexor tynosynovitis (3)


Answer 39

1. Splint
 2. IV antibiotics
 3. Urgent plastics referral (STAT if sausage digit ++ bad)


Question 40

Fracture with pain over the hypothenar eminence (1)


Answer 40

1. Hook of hamate fracture