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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
Q

Options for wound coverage

A

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
Q

MOA of VAC dressing

A

stimulate angiogenesis by stimulating granulation tissue
reduce edema and fluid - expedite healing
reduce size of wound
reduce bacterial count

27
Q

Mgx of bone loss

  • MOA of bone graft
  • types of bone grafts
A

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
Q

Complications of open #

A 
{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
Q

causes of malunion

A
  • failure to reduce # adequately
  • failure to hold reduction during healing process
  • gradual collapse of comminuted bone
30
Q

Delayed union

  • causes
  • rx
A

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
Q

Non union

  • causes
  • RF
A

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
Q

Types of non union

A
  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
Q

RF of necrotising fasciitis

A
  1. Immune suppression: DM, AIDS, cancer
  2. Bacterial introduction
    - IV drug use
    - insect bites
    - skin abrasion
    - abdominal and perineal injury
34
Q

Classification of Nec Fasc

A

T1: polymicrobial: non grp A strep, anaerobes, enterobac
T2: monomicrobial: grp A strep
T3: vibrio
T4: MRSA

35
Q

How to assess likelihood of Nec Fasc

A

LRINEC scoring
>6: 92% likely

components:

  • CRP
  • WBC
  • Hb
  • Na
  • Cr
  • Glucose
36
Q

Bedside tests for nec fasc

A

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
Q

Empiric abx for nec fasc

A

penG: strep/ clostridium
imipenem/ meropenem: polymicrobial
vancomycin: if MRSA suspected

38
Q

RF for gas gangrene

A 
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
Q

PE findings of gas gangrene

A
  • sweet smelling odor
  • swelling, edema, discoloration and ecchymosis
  • blebs and hemorrhagic bullae
  • “dishwater pus” discharge
  • crepitus
  • altered mental status
40
Q

Abx for clostridium

A

Penicillin G and clindamycin (helps inhibit toxin synthesis)

41
Q

Characteristic lab/ histo findings for gas gangrene

A

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
Q

RF for osteomyelitis

A
  • recent trauma or surgery
  • immunocompromised patients
  • illicit IV drug use
  • poor vascular supply
  • systemic conditions such as diabetes and sickle cell
  • peripheral neuropathy
43
Q

Classification of osteomyelitis

A 
Hematogenous
- most commonly in vertebrae
- S aureus
Non hematogenous
- contiguous spread
- direct innoculation: penetrating injuries, sx
44
Q

Imaging Ix and findings for osteomyelitis

A

<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
Q

Mgx of osteomyelitis

A

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
Q

RF for septic arthritis

A 
age>80
Med: DM, RA, cirrhosis, HIV
crystal arthropathy
endocarditis, recent bacteremia
IV drug user
recent joint surgery
47
Q

Red flags suggestive of septic arthritis

A 
fever
appear toxic
abnormal posturing for maximal joint volume
inability to bear weight
inability to tolerate PROM
48
Q

What to send for in joint fluid aspirate

A 
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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