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MBBS Orthopedics > Emergencies > Flashcards

Emergencies Flashcards

1
Q

4 characteristic/ major criteria of fat embolism syndrome

A
  1. hypoxia
  2. CNS depression (confusion)
  3. pulmonary edema (SOB)
  4. petechial rash (axillary, conjunctivae, oral mucosa)
    (lung brain skin)
    Gurd’s diagnostic criteria
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2
Q

Tx and prevention of fat embolism syndrome

A

Non op: mechanical ventilation with high levels of PEEP

Prevention:

  • early # stabilisation (within 24h) of long bone #
  • decrease over-reaming of femoral canal
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3
Q

4 compartments of LL

A

anterior, lateral, superficial posterior, deep posterior

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4
Q

Pathophysiology of compartment syndrome

A
  • local trauma and ST damage
  • bleeding and edema
  • increased interstitial pressure
  • vascular occlusion (dec venous output, and arterial inflow)
  • myoneural ischemia
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5
Q

Diagnosis of compartment syndrome

A

5Ps: pain out of proportion, parasthesia, pallor, palpable tense swollen compartment, blistering
late: pulselessness, paralysis

Compartment pressure (split catheter) measurements for

  • polytrauma pt
  • pt not alert/ unreliable
  • inconclusive physical exam findings

look for perfusion pressure - delta p <30mmhg (DBP - compartment pressure) or absolute pressure >30mmhg

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6
Q

Mgx of compartment syndrome

A

This is a surgical emergency (muscle will die within 4-6h of ischemia)

  • bivalving the cast, loosening circumferential dressings
  • elevation to lvl of heart
  • hyperbaric oxygen therapy
  • OP: emergent fasciotomy of all 4 compartments (dual medial-lateral incision or single lateral incision)
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7
Q

Cx of compartment syndrome

A
  • Volksmann ischemic contracture
  • Permanent functional impairment
  • Renal failure from release of myoglobin from muscle necrosis (rhabdomyolysis)
  • Death
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8
Q

Red flags of back pain

A 
INFECTION/CANCER
- non mech pain: night pain, rest pain, night sweats
- LOW, LOA, fever
- prev ca, recent infection
- <20yo, >55yo
- hx of TB
SPINAL #
- trauma, osteoporosis
SERIOUS INJURIES
- cauda equina: saddle anaesthesia, bladder/ bowel incontinence, disturbed gait
- neuro deficits
- persistent pain, failure of tx
- progressive
SYDNROME
- hairy patch/ cafe au lait spots (kids)
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9
Q

Classification of open fractures

A

Gustilo Anderson Classification

I:

  • small <1cm
  • low impact
  • minimal ST injury
  • mild contamination

II:

  • 1-10cm
  • moderate impact, ST injury, contamination

III:
- >10cm
- significant contamination, ST injury, high impact
(soft tissue coverage after formal debridement)
A: cover adequate
B: cover inadequate, periosteal stripping/ exposure of bone, severe comminution
C: arterial injury which needs repair

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10
Q

Empiric abx tx for open fractures?

A

Broad spectrum: benzylpenicillin + flucloxacillin + 1st gen cephalosporin

if heavily contaminated:
- add gentamycin/ metronidazole for gram neg cover

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11
Q

Important timing for open #?

A

must get into OT within 6 hours (GOLDEN hours)

- info increases after this time

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12
Q

How to differentiate live from dead muscle

A

4C: consistency, colour, contraction when stimulated, capillary

Live: turgid, pink/ bright red, contracts, bleed when cut

Dead: mushy, pale/ purple, absent contraction, no bleed when cut

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13
Q

Sx mgx of open fractures

A

Irrigation and debridement (within 6 hour and leave good bs)

  • reexamine intra-op for NV function
  • remove foreign material and dead tissue (medium for bacteria growth), remove comminuted fragments
  • wound cleansing with saline
  • repair vascular injuries
  • amputate if non viable
  • wound cultures

Stabilisation of #: reduce, maintain #
Early wound/ skin coverage since exposed tendons do not last long (by 48th hour)
Mgx of bone loss

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14
Q

Classification for closed fractures and soft tissue injury

A

Tscherne classification
C0: no ST injury
C1: superficial abrasion
C2: deep, contaminated abrasion with local contusional damage to skin or muscle
C3: extension skin contusion/ crushing or muscle destruction

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15
Q

Severity scoring to determine if limb is salvageable or to be amputated in trauma setting

A

Mangled extremity severity score (MESS)

  • energy of injury
  • shock group (BP)
  • ischemia of limb
  • age group

6 or less: salvage
else amputate

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16
Q

Complications in polytrauma

A
  • compartment syndrome
  • crush syndrome (traumatic rhabdomyolysis > myoglobinuria > acute renal failure)
  • thromboembolism (DVT/ PE)
  • tetanus
  • fat embolism
  • SIRS
  • DIVC
  • hypothermia
  • 2nd hit phenomenon
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17
Q

Classification of shock

A

I (<15%): widened pulse pressure, normal RR, urine output, mental status

II (15-30%): dec pulse pressure, RR20-30, urine 20-30, mild anxiety

III (30-40%): BP drop, RR 30-35, urine 5-15, confused

IV (>40%): BP drop, RR>35, urine negligible, obtunded

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18
Q

Definitions

  • SIRS
  • ARDS
  • MODS
A

SIRS: 2 or more of the following without evidence of infection

  • temp >38, <36
  • HR>90
  • RR>20
  • TW <4k, >12k, >10% immature

ARDS: berlin definition

  • acute: 1w or less
  • bilateral opacities consistent with pul edema
  • PF ratio on minimum 5cmH20 PEEP
  • not fully explained by cardiac failure or fluid overload

Multi organ dysfunction syndrome
- debt of progressive and potentially reversible physiologic dysfunction in 2 or more organs induced by an acute insult

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19
Q

electrolyte abnormalities in crush syndrome

A

Muscle cell die, they absorb Na, water and calcium > hypoNa, hypotension, hypoCa

Release K, myoglobin, creatine, CK > hyperK, ATN and AKI

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20
Q

Benefits of early stabilisation of #

A

Crucial for the healing of soft tissue and bone

  • prevent further injury to surrounding soft tissue
  • limit inflammatory response
  • reduces infection spread
  • facilitate tissue perfusion
  • encourage early wound repair
  • allows early mobilisation
21
Q

principles in # stabilisation (in open#)

A
  • should provide free wound access for repeated debridement and placement of local or distant flaps and bone grafts
  • should not interfere with blood supply of # segments
  • should be sufficiently rigid - allow early joint motion and at least partial weight bearing
22
Q

options for # stabilisation

A

Simple 1/2 #: slings, splints, casts, traction
Internal fixation: screws, plates, intramedullary nails
External fixation

23
Q

Internal fixation

  • criteria in setting of open #
  • pros
  • cons
A

Criteria: minimal contamination, within 8 hours
Pros:
- good stabilisation
- allow early ROM
- facilitates # consolidation while preventing malalignment
- superior healing compared to external fixation
Cons:
- must strip soft tissue (avoid in grade 2 and above)
- cause partial loss in periosteal, cortical or intramedullary blood supply
- risk of infection

24
Q

External fixation

  • indications in setting of open#
  • pros
  • cons
A

Indications:
- v comtaminated/ high impact/ grade #
Pros:
- no foreign material in wound
- applied without additional soft tissue dissection (additional trauma)
- less risk of infection
- allow easy reassessment/ additional debridement
- easy dismantled if needed
Cons:
- risk of pins injuring neuromuscular structures or tie down muscle-tendons > interfere with joint motion and rehab
- pins may interfere with reconstructive procedures
- pin loosening risk: not as definitive as int fixation
- risk of pin tract infection

25
Options for wound coverage
primary closure - only in small grade1 wounds wound left open for 2 days until dangers of tension and infection has passed 1. delayed primary closure 2. skin graft (no blood supply): split thickness, full thickness 3. flaps (has own blood supply): local/ pedicled vs free > 4 types: skin, fasciocutaneous, muscle, musculocutaneous) 4. Vacuum assisted closure/ negative pressure wound therapy
26
MOA of VAC dressing
stimulate angiogenesis by stimulating granulation tissue reduce edema and fluid - expedite healing reduce size of wound reduce bacterial count
27
Mgx of bone loss - MOA of bone graft - types of bone grafts
MOA - osteoinduction (most imp): undeveloped tissue transformed to bone by inducing agent - osteoconduction: transferred bone as scaffold for new bone to grow - osteogenesis: from osteoblasts in transplanted autografts Types of bone grafts - autografts (same pt): cortical graft, cancellous graft, vascularised grafts - allografts (cadaver) - demineralised bone matrix - synthetics - bone morphogenetic proteins
28
Complications of open #
``` {LOCAL} Early: - neurovasc injury - swelling, compartment syndrome - infection Late: - malunion, non union, delayed union - AVN - Arthritis - OM - heterotrophic ossification - growth disturbance in children - joint instability/ stiffness - complex regional pain syndrome ``` ``` {SYSTEMIC} Early: - hemorrhagic shock - sepsis - fat embolism - dvt/ pe - ARDS Late: - MODS - renal failure ```
29
causes of malunion
- failure to reduce # adequately - failure to hold reduction during healing process - gradual collapse of comminuted bone
30
Delayed union - causes - rx
causes: - biological: poor blood stream, severe soft tissue damage, infection - biomech: periosteal stripping, imperfect splint age, over rigid fixation Rx: - adequate immobilisation - internal fixation - bone grafting
31
Non union - causes - RF
Causes: SPLINTS - Soft tissue interposition - Position of reduction - Location (lower third of tibia) - Infection - Nutrition (diseased bone, damaged vessels) - Tumor - Severity of injury RF: smoking, DM, infection, old age, anaemia, NSAIDs
32
Types of non union
1. Hypervascular/ hypertrophic - due to premature weight bearing/ insecure fixation - elephant foot, horse hoof, oligotrophic 2. Avascular/ atrophic - due to poor BS, ends osteoporotic - torsion wedge, comminuted, defect, atrophic pattern
33
RF of necrotising fasciitis
1. Immune suppression: DM, AIDS, cancer 2. Bacterial introduction - IV drug use - insect bites - skin abrasion - abdominal and perineal injury
34
Classification of Nec Fasc
T1: polymicrobial: non grp A strep, anaerobes, enterobac T2: monomicrobial: grp A strep T3: vibrio T4: MRSA
35
How to assess likelihood of Nec Fasc
LRINEC scoring >6: 92% likely components: - CRP - WBC - Hb - Na - Cr - Glucose
36
Bedside tests for nec fasc
Finger test - area infiltrated with LA - 2cm incision incision to fascia: lack of bleeding, dishwater fluid - push finger along deep fascia. if no resistance - nec fasc
37
Empiric abx for nec fasc
penG: strep/ clostridium imipenem/ meropenem: polymicrobial vancomycin: if MRSA suspected
38
RF for gas gangrene
``` Post traumatic - car accidents - crush injuries - gun shot wounds - burns - IV drug abuse Post op - bowel resection/ perforation - biliary sx Spontaneous - colon cancer ``` etiology: clostridial species (gram pos bacilli)
39
PE findings of gas gangrene
- sweet smelling odor - swelling, edema, discoloration and ecchymosis - blebs and hemorrhagic bullae - "dishwater pus" discharge - crepitus - altered mental status
40
Abx for clostridium
Penicillin G and clindamycin (helps inhibit toxin synthesis)
41
Characteristic lab/ histo findings for gas gangrene
Lab: elevated LDH, WBC, met acidosis, renal failure Histo: - gram pos bacilli - absence of neutrophils (lack of acute inflammatory response is hallmark of gas gangrene)
42
RF for osteomyelitis
- recent trauma or surgery - immunocompromised patients - illicit IV drug use - poor vascular supply - systemic conditions such as diabetes and sickle cell - peripheral neuropathy
43
Classification of osteomyelitis
``` Hematogenous - most commonly in vertebrae - S aureus Non hematogenous - contiguous spread - direct innoculation: penetrating injuries, sx ```
44
Imaging Ix and findings for osteomyelitis
<2w: MRI (X ray findings lag by 2w) >2w: X ray In to out - sequestrum: devitalised bone - bone lucency - sclerotic rim - osteopenia periosteal reaction - involucrum: formation of new bone
45
Mgx of osteomyelitis
abx irrigation and debridement - remove all devitalised soft tissue and sequestrum - debride bone until punctate bleeding seen (paprika sign) - hardware removal - dead space mgx (graft/ flap/ VAC) - instrumentation: ext fix, surgical fixation - amputation
46
RF for septic arthritis
``` age>80 Med: DM, RA, cirrhosis, HIV crystal arthropathy endocarditis, recent bacteremia IV drug user recent joint surgery ```
47
Red flags suggestive of septic arthritis
``` fever appear toxic abnormal posturing for maximal joint volume inability to bear weight inability to tolerate PROM ```
48
What to send for in joint fluid aspirate
``` cell count with differential gram stain culture glucose lvl crystal analysis ``` WBC>50k: septic arthritis >1K in prosthetic joint

MBBS Orthopedics (13 decks)

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