OSCE Flashcards
Neurogenic shock
Occurs after transection of autonomic spinal fibers, usually above T6
Hemodynamic phenomenon comprising loss of vasomotor tone and impaired cellular metabolism
Clinically presents with hypotension, bradycardia, and poikilothermia
Occurs within 30 minutes of cord injury, and lasts up to 6 weeks
Management includes airway support, fluid resuscitation, atropine, and vasopressors
Spinal shock
Due to acute spinal cord injury - hematoma, edema, and inflammation
Absence of all voluntary and reflex neurological activity below the level of the injury
- decreased reflexes
- loss of sensation
- flaccid paralysis
Transient - lasts days to months
May occur with neurogenic shock
Hemothorax - signs and symptoms
Hemodynamic instability Pleuritic chest pain Respiratory distress Mediastinal shift Reduced chest rise Decreased air entry Dullness to percussion Flat neck veins X-ray findings - blunting of costophrenic angle (erect film) - requires at least 350ml fluid - haziness of affected thorax (supine film) - air-fluid interface
Tension pneumothorax - signs and symptoms
Pleuritic chest pain Hemodynamic instability Respiratory distress Mediastinal shift Decreased chest rise Percussion increased resonance Distended neck veins
Simple pneumothorax - signs and symptoms
Pleuritic chest pain Dyspnea Tachypnea Subcutaneous emphysema Decreased chest movement Decreased air entry Percussion increased resonance X-ray findings - visible visceral pleural line - absence of lung markings distal to visceral pleural white line (usually apical on erect, and mediastinal on supine) - large if greater than 2cm at the level of the hilum - deep sulcus sign (larger costodiaphragmatic recess)
Site for ICD
5th intercostal space, anterior to the mid axillary line
Indications for splinting
Temporary immobilization of sprains, fractures, and reduced dislocations
Control of pain
Prevention of further soft tissue or neurovascular injuries
Burn injuries
Basilar skull fracture - clinical presentation
Raccoon eyes (periorbital ecchymosis) Battle sign (mastoid ecchymosis) Otorrhoea (blood or CSF) Rinorrhoea (blood or CSF) Seventh nerve palsy Eighth nerve palsy Optic nerve entrapment (rare) Hemotympanum and blood in external auditory canal
Zones of the neck
1 - inferior aspect of cricoid cartilage to thoracic outlet
2 - cricoid cartilage to angle of mandible
3 - angle of mandible to base of skull
Structures at risk in zone 1 of the neck
Great vessels (subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, and jugular veins)
Trachea
Esophagus
Lung apices
Cervical spine, spinal cord, and cervical nerve roots
Thyroid and parathyroid glands
Signs of a significant injury in the zone I region may be hidden from inspection of the chest or the mediastinum
Structures at risk in zone 2 of the neck
Carotid and vertebral arteries
Jugular veins
Pharynx, larynx, trachea, and esophagus
Cervical spine and spinal cord
Zone II injuries are likely to be the most apparent on inspection and tend not to be occult. Additionally, most carotid artery injuries are associated with zone II injuries.
Structures at risk in zone 3 of the neck
Submandibular and parotid glands Esophagus Trachea Vertebral bodies Carotid arteries Jugular veins Major nerves (including cranial nerves IX-XII, brachial plexus, phrenic nerve, stellate ganglion)
Injuries in zone III can prove difficult to access surgically
Examination findings for specific structures injured in the neck
Airways: Surgical emphysema
Vascular: Active bleeding, an expanding or pulsatile haematoma, a bruit, peripheral pulses, blood in sputum, air bubbling through the wound, hoarseness, and subcutaneous emphysema
Oesophagus: Surgical emphysema, odynophagia, sometimes haematemesis, and very little else
Neurological: Exclude injury to the spinal cord, Cranial nerves VII/IX/X/XII, to the brachial plexus, and the sympathetic chain (Horner’s syndrome)
Larynx: hoarseness, surgical emphysema
Management of stab neck
Airway - clear airway and intubate, ventilate and oxygenate as necessary. Consider surgical airway with tracheal and laryngeal injury
Breathing - exclude pneumothorax and hemothorax with zone 1 injuries
Circulation - fluid resuscitation, pressure, balloon tamponade, packing, Trendelenburg position to prevent air embolus, urgent surgical intervention
Disability - c-spine protection, detect head injury, consider injury to neurovascular structures of the neck with neurological fallout
Exposure - identify associated injury
Investigations
- X-ray chest and neck
- bronchoscopy
- hexabrix allow +/- esophagoscopy
- arteriography
- CT neck
- Doppler US
Balloon tamponade - technique
For penetrating injuries and significant haemorrhage/expanding haematoma
Establish definitive airway
Insert a size 18-20Fr Foley catheter into the wound
Direct it toward the site of bleeding
Inflate the balloon until bleeding resolves or moderate resistance is noted
Suture skin wound under tension
