pmaci Flashcards
pass exam on 10th (177 cards)
1
Q
when to reassess primary in secondary survey?
A
If the pt deteriorates at any stage, the primary survey must be immediately reassessed.
2
Q
when should the gcs scale be repeated during secondary survey in a trauma pt?
A
in the head to toe examination when examining head. look at pupils and PEARL during this part.
3
Q
what helps predict the injury in trauma?
A
moi - based on direction and amount of energy.
4
Q
AMPLE?
A
A-allergies
M-medications currently used
P-past illnesses/Pregnancy
L-last meal
E-events/Environment related to the injury
5
Q
in trauma once short hx ample has been obtained what can you move onto?
A
a thourough head to toe examination.
6
Q
main things to look for in head to toe when assessing neurological system in trauma?
A
ears should be examined looking at the mastoids for battle signs and nose for septal hematoma and to observe oral cavity for dental alignment and broken teeth.
7
Q
what should you look for when examining c spine in trauma when doing a head to toe?
A
the spine should be examined for midline tenderness and the need for c spine imaging assessed accordingly.
8
Q
what should you look for when inspecting the thorax in trauma head to toe?
A
shoulder girdle should be inspected for external injuries and palpated for tenderness and instability. The chest wall should be re-examined thoroughly and any injuries detected during the primary survey re-inspected. The ribs should be palpated one by one, looking for bony tenderness and/or instability.
the chest should be re-auscultated and should do a cardiovascular examination.
9
Q
what should you do when looking at adbo and pelvis in a trauma head to toe?
A
should be reinspected, looking for evidence of bruising or external injuries. the abdo should then be palpated for tenderness gaurding and rebound tenderness. pelvis should then be gentle palpated for any bony tenderness or instability. excess manipulation of the pelvis should be avoided as this can cause or worsen haemmorrhage associated with a pelvic fracture.
10
Q
what should you assess in msk in a head to toe examination in trauma?
A
all extremities should be examined, looking for bruising,lacerations and ovbious deformities. all bones should be palpated for evidence of tenderness and the range of movement of the joints assessed. small bones in hands and feeet included.
11
Q
what makes up the lethal triad?
A
hypothermia, acidosis and coagolupothy
12
Q
passive re-warming techniques of a trauma pt who is hypothermic?
A
remove from cold environments, adequate pt coverage with blankets and recover once reassessed, increasing ambient room temp.
13
Q
External active warming techniques for trauma pts with hypothermia?
A
heated blankets, convective air blankets, reflective blankets, radient heat sources, airway gas warming.
14
Q
internal active warming techniques in hypothermic trauma pts?
A
admin of warmed iv fliuds, peritoneal lavage, extracorporeal circulatory warming (cardiovascular bypass, continuous arteriovascular rewarming ((CAVR)) , venovenous techniques)
15
Q
what is severe facial trauma an indicator of?
A
potential intracranial trauma.
16
Q
how to diagnose mandibular fractures? trauma*
A
ability to occlude teeth, conscious pt should be able to close their teeth in correct position, a disrupted occlusion may be because of missing teeth, fractures or dislocations and tmj hemarthrosis.
17
Q
what are maxilliary fractures usually the result of?
A
high energy trauma
18
Q
what do pts with a maxillary fracture present with?
A
bilateral periorbistal bruising and gross facial swelling. usually occlusion of teeth is disrupted and an anterior open bite with only contact of the molar teeth.
19
Q
what is an immediate concern with a base of skull fracture?
A
haemmorrhage and airway problems.
20
Q
what signs might there be to show a base of skull fracture?
A
bruising of mastoid process and CSF rhinorrhoea.
21
Q
when are maxillofacial injuries considered in the primary survey?
A
when they cause cat haem.
22
Q
cervical injury leads to what kind of paralysis?
A
quadraplegia
23
Q
thoracic injury leads to what kind of paralysis?
A
paraplegia
24
Q
lumbar injury leads to what kind of paralysis?
A
paralegia
25
how many cervical vertebrae are there?
7
26
how many thoracic vertebrae are there?
12
27
how many lumbar vertebrae are there?
5
28
how many fused vertebrae are there?
5
29
what are in between the cervical, thoracic and lumbar vertebrae?
intervertebral discs and facet joints?
30
spinal cord injury is most likely to occur when which vertebrae is damaged?
c3
31
when does the spinal cord finish? approx*
L1
32
what are dermatomes?
sensory nerves stemming from spinal cord in specific areas of the skin
33
what are myotomes?
motor nerves in specific muscles.
34
where is zone 1 penetrating trauma to the neck?
clavical to the cricoid cartilage
35
where is zone 2 penetratig trauma to the neck?
from cricoid cartilage to angle of mandible
36
where is zone 3 in penetrating neck trauma?
from angle of mandible to bas of skull.
37
what is a primary SCI?
occurs at time of injury. the injuries will reduce the blood supply to the cord or will affect the structure
38
what will complete transection of the spinal cord result in?
death.
39
partial transection to spinal cord result depending on what?
may be temporary or perminant depending on the amount of swelling and cord tissue ischaemia that develops.
40
what is a secondary spinal cord injury?
occurs minutes or hours after the primary injury and it is the role of the health care professional to minimise the risk.
41
what happens when a secondary spinal cord happens?
secondary inj continues to swell or surrounding structures such as bone or haematoma continue to compress cord.
42
what can worsen a secondary spinal cord injury?
mechanical instability - careful handling and positioning required, mainatain in-ine immobilisation.
hypoxia - injuries at c3/4 can damage phrenic nerve causing paralysis of diaphragm. these pt require mechanical ventilation.
hypoperfusion - if a disruption to the blood flow to the spinal cord occurs spinal function is reducedand eventually cell death of spinal cord tissue occurs leading to perminant damage.
43
what is spinal shock?
complete loss of all neurological function, including reflaxes and rectal tone below level of SCI. a transient condition caused by swelling of cord following injury. can last hours to several weeks, only after swelling has reduced will the SCI be assessed to see if it is perminant or temporary.
44
Neurogenic shock is caused by?
damage to the sympathetic pathways in spinal cord.
45
why does neurogenic shock not usually occur in injuries below t6?
because the SNS pathways exit the thoracic spine at t6
46
damage to the SNS will cause?
loss of vasomotor tone as sns helps to control the muscle tone in vessels and so if disrupted vessels willl be inable to constrict. instead vasodilation will occur. causing pooling in blood vessels and consequently hypotension.
loss of sympathetic innervation to the heart as sns helps to innervate the heart causing tachycardia as a response to insult. there will be no tachycardia.
47
what is good practice to have prepared when suctioning or intubating a patient with a sci and why?
the have prepared atripine. because with a cervica or high thoracic injury where there is damage it will cause bradycardia that cannot be automatically reversed.
48
what should you do when you have a pt with a sci but they are agitated?
do not immobilise. find and correct as best you can the cause of agitation. apply immobilisation when pt is calmer.
49
why should you apply 15l high flow o2 with a sci?
it reduces risk of secondary sci. could have diaphragmatic paralysis. pts with high thoracic spinal injury are at high risk of intercostal nerve paralysis.
50
SCI and SNS damage can mask symptoms of what?
hypovolaemic shock.
51
what is management for hypotension in neurogenic shock?
admin of appropriate fliuds in boluses - to avoid hypoperfusion and minimise risk of secondary SCI
52
poikilothermia
when pt loses control of own temp, associated with SCI, they will assume temp of environment.
53
what is a primary brain injury?
result from the structural effect of the injury to the brain.
54
how to prevent secondary injury to the brain
maintain adequate oxygenation and perfusion.
55
what three things does the monro-kellie doctrine state that exist in the skull and what does it say about them?
blood, csf and brain. an increase in one must necessarily result in a decrease in one or both of the other components of the skull otherwise intercranial pressure will increase.
56
what happens if intercranial pressure increases too much?
the brain will herniate. the most important site of herniation is at the base of skull where the foramen magnum exists which is a hole.
57
what happens if the brain herniates throught hte foramen magnum?
it will affect the brain stem. the brainstem is responsible for the heart rate and breathing ect. if severe enough those autonomic functions stop working and brain death occurs.
58
is the cranium completely closed?
yes apart from the foramen magnum wherethe brainstem extends through.
59
what happens can happen if you injure your cranium or cerebral tissue?
possible intrease to intercerebral pressure which can lead to haemorrhage or oedema. if this occurs it may result in life long cerebral disease and disability or death.
60
what is an impact loading tbi?
caused by direct blow to head - tbi is caused through a mechanical resulting in deformation of brain tissue as a result of compression, stretching or shearing.
61
what is impulsive loading (acceleration/deceleration) brain injury?
occurs when head is in motion and is stopped abruptly.
62
what is static loadin gbrain injury?
injury resulting from a slowly moving object trapping the head agaist a fixed object - essentially squeezing the head.
63
what is a secondary brain injury?
neurological damage that occurs hours or days after a primary brain injury, these may be preventable o reversible at a later stage.
64
what are secondary brain injuries laargely due to?
brain tissue hypoxia, oedematous brain tissue, systemic hypotension causing the brain to be under perfused.
65
fractures of the skull are described according to what?
the shape, site, displacement, whether they are depressed or not.
66
lineear skull fracture
usually caused by blunt trauma, consist of a line or crack in bone. may not necessarily require any treatment however there is risk of underlying brain injury.
67
depressed/compound skull fracture?
injury to skull where bone is displaced inwards known as a depressed skull fracture. the bone can be broken intoa number of pieces (comminuted) and if there is and associated scalp wound present the the fracture is classified as open or compound. depressed fragments of bone can damage the underlying brain tissue. compound fractures pose a risk of infection.
68
base of skull fractures?
a large amount of force required for a base of skull fracture so more common in high mechanism trauma such as an rtc. base of skull is in close proximity to the cranial nerves and large blood vessels so a fracture here is a serious life threatening injury. battle signs and racoon eyes and csf nfrom ears or nose.
69
epidural/extradural haemorrhage?
common following a head inj. a collection of blood forms between inner surface of skull and outer layer of dura. usually associated with a skull fracture. the bleeding sources from a torn meningeal artery usually or can result from venous blood from a torn sinus. commonly pt have a period of lucidity followed by a decreasing level of consciousness, although this is not reliable enough for a solid diagnosis.
70
subdural haematoma?
collection of blood in potential space between the dura and subarachnoid matter of meninges. results from stretching and tearing of bridging cortical veins as they cross the subdural space.
71
subarachnoid haemorrhage?
a collection of blood in subarachnoid space cause by aceration of the superficial microvessels in the subarachnoid space.
72
intracerebral haemorrhage?
includes a range of conditions that share the finding of an acute accumulation of blood in the parachyma of the brain. usually result from lacerations or contusions on the brain following trauma.
73
what are the 4 areas of the head?
frontal, temporal, parietal and occipital.
74
what is the scalp made up of? (SCALP)
- Skin
- subCutaneous tissue
- galea Aponeurosis (fibrous muscle layer)
- Lose areolar tissue (beneath the galea where the emissarys veins are situated)
- Periosteum
75
galea aponeurosis
part of scalp. a fibrous muscle layer
76
what does the loose areolar tissue consist of?
emissary veinse
77
what are emissary veins?
emissary veins are connecting veins that drain blood from the sinuses in the dura to the central circulation. they are situated in the loose areolar tissue that makes up part of the scalp.
78
what makes the cranium a "fixed box"?
when the fontanelles are fused
79
what do facial bones do for the face?
provide structure
80
where are the meninges situated?
inside of the skull and brain
81
what are the three layers of the meninges?
the dura mater, the arachnoid layer and the pia mater.
82
what is the dura mater?
the outer fibrous membrane that lies close to the skull. part of the meninges.
83
what is the arachnoid layer of the meninges?
the soft cobweb-like structure beneath the dura mater which csf circulates.
84
what is the pia mater of the meninges?
the soft membrane that is attached to the outer surface of the brain.
85
what is the brain composed of?
the cerebrum, the cerebellum and the brainstem
86
what is within the brainstem?
the midbrain and the pons and medulla.
87
what is the midbrain?
part of the brainstem which contains the reticular activating system responsible for the awake state.
88
what is the pons and medulla?
part of the brainstem that contains the cardiorespiratory control centres.
89
what is the tentorium?
part of the brain. it is a fold of the duramater that separates the cerebral hemispheres from the cerebellum and the brainstem.
90
what major drug from control of major haemorrhage is an antifibrinolytic agent?
txa
91
what are immediate indications of hypoperfusion?
thirst, cold extremities, poor peripheral pulses and impaired cap refill.
92
a patient with inadequate global perfusion will often presentwith one or more of these?
tachypnoea, tachycardia, confusion, altered skin perfusion, oliguria
93
oliguria
low urine output
94
hypoperfusion
reduced blood flow to vital organs.
95
a pt complaining of ischaemic chest pain is indicating what?
an imbalance between myocardial oxygen supply and demand.
96
skin mottling usually starts where and is scored how and can independantly predict what?
starts at the knees, scored according to a mottlng score out of 5 (how far its spread from the knee, the further out it is and up the thigh, the higher the score out of 5) it can independently predict mortality.
97
what can make skin mottling worse? and what can it lead to?
high doses of vasosupressors can make skin mottling worse and lead to purpuric changes
98
what is happening when skin is mottled?
blood flow to small blood vessels is disrupted
99
what does a prolonged cap refill indicate?
may indicate circulatory shock
100
causes of prolonged cap refil?
peripheral vascular disease.
hypothermia
cold ambient temp
poor lighting
old age
101
what does a weak thready pulse indicate?
low cardiac output and most likely hypovolaemia.
102
what does a strong bounding pulse indicate?
vasodilation associated with sepsis or anaphylaxis.
103
what does the MAP need to be to maintain good organ perfusion?
above 65
104
MAP calculation?
SBP + DBP + DBP / 3
105
generally the SBP will not reduce untill approximately how much of the circulating blood volume has depleted? what also happens?
one third and heart begins to fail.
106
PP?
pulse pressure
107
how to calculate PP?
SBP - DBP = PP
108
what is a normal PP?
30 - 50mmHg
109
what is a narrowed or decreasing (low) PP suggestive of?
(vasoconstriction) hypovolaemia or cardiogenic shock.
110
what is a widening (higher but in range) pp suggestive of?
(vasodilation) sepsis or early stages of anaphylaxis.
111
what is a widened (high) PP suggestive of?
often seen in pts with aortic valve regurgitation.
112
when should internal catastrophic haemorrhage and external haemorrhage be identified?
external haemorrhage should be identified and treated during of primary survey and internal during C
113
methods to control a cat haem?
direct pressure
haemostatic dressing
extremity torniquets
truncal and junctional tourniquets
tissue clamps
113
what are the three main mechanisms that promote clotting in haemostatic dressings?
factor concentrate
procoagulant supplementers
mucoadhesive agents
113
what does the factor concentrate in haemostatic dressing do?
promote clot formation by concentrating clotting factors at the site of injury through the absorbtion of water from plasma.
they rely on the pts intrinsic clotting mechanism for clot formation an are therefore less effective when clotting is impaired due to hypothermia or anticoagulant drugs.
113
what does the procoagulant supplementers do in hemostatic dressings?
these agents function by delivering procoagulant factors to the bleeding wound to promote blood clotting.
113
what do the mucoadhesive agent do in haemostatic gauze?
the agents are chitosan-based dressings which adhere quickly to and physically seal bleeding wounds.
because it is positively charged it rapidly cross links with negatively charged red cells and adheres to the wound surface.
the process is independant of intrinsic clotting mechanisms and so is unaffected by hypothermia, anticoag drugs, antiplatelet agents or the acute coagulopathy of trauma.
113
what is the most common symptom of limb trauma in a conscious pt?
complaint of pain
113
what should you do when inspecting a possible limb injury?
examine for open wounds and previous op scars. limb deformities and signs of a crush injury.
113
what should you do before covering an open fracture?
photograph before covering with a sterile dressing.
113
what should you feel for in a limb trauma pt?
tenderness, crepitus. important to feel at site of commonly missed injuries. pulse and sensation
113
what are some commonly missed limb trauma injuries?
clavicle, isolated fibula, hands, feet and forearm.
113
what is an essential exam to do for a blunt or penetrating trauma?
neuro examas can damage peripheral nerves.
114
what are the three groups of peripheral nerve damage?
neuropraxia, axonotmesis and neurotmesis.
114
neuropraxia
a type of peripheral nerve damage as a result from trauma, usually secondary to compression (blunt). characterised by local myelin damage. axon continuity is preserved and nerve does not undergo distal degeneration, nerves are concussed or bruised, good chance of recovery.
114
axonotmesis?
a type of peripheral nerve damage usually following a crush or stretch injury. defined as a loss of continuity of axons (some divisions of the nerve fibres), with variable preservation of the connective tissue elements of the nerve (nerve sheath intact). good chance of recovery.
114
neurotmesis?
most severe peripheral nerve damage usually from penetrating injury or severe blunt force. physiological disruption of the nerve, which may or may not include nerve transmission. needs surgery.
115
what is the management of an open frac?
all effort to avoid inf
remove gross contamination
photograph wound to avoid repeated examinations and removal of bandages or splints
antibiotics asap ideally under and hour.
gentle antiseptic irrigation prior to dressing cosidered
avoid further inj and vascular inj by splinting
116
what are the benefits of splinting?
pt comfort
reduced blood loss
relocation of periosteum prevents release of ongoing inflam mediators
reduces risk of fat embolism
117
what happens in crush injuries?
muscle protien if release if it is severely injuered. (myoglobin). myoglobin released into systemic circulation. then filtered in kidneys damaging the glomerular filtration system. cn cause renal failure, resulting in rhabdomyolysis, dark urine containing blood.
118
management of a crush injury?
iv fluid - prior to release of limb
renal support as req.
cathetar
strict fluid balance
119
compartment syndrome?
occurs when there is increased pressure in a limited space of a muscle compartment. can reduce blood flow to the tissue below.
120
injuries at risk of developing compartment syndrome?
severe crush inj
vascular inj
severe contusions
a swollen limb under cast or splint
121
6 Ps of compartment syndrome?
pain (10/10)
Pressure
Parasthesia (loss of sensation)
Paralysis (loss of movement)
Pallor (late stage)
Pulses (present until very late stages when pressure is too high)
122
management of compartment syndrome?
dressing release and supportive therapies (if occlusive dressing on)
fasciotomy and supportive therapies
amputation and supportive therapies
continued hydration
123
what are the 4 pevic fracture forces in blunt force trauma?
anteroposterior compression
lateral compression
vertical sheer
complex or compound pelvic fractures
124
what is an Anteroposterior compression of the pelvis?
results in open book or sprung pelvis fractures, may cause disruption to the symphysis pubis joint. risk of instability too pelvis if so. especially if posterior ligaments have been injured. disruption to SI joints may occur suggesting inj to illiac vessels and haemorrhage.
125
what is a lateral compression pelvic injury?
result is a wideswept pelvis. force or impact from the side. causes internal rotation or compressed of one side of the hemi pelvis (or both). avoid log roll onto affected side. risk of structural damage to underlying organs such as bladder, urethra and uterus.
126
what is a vertical shear pelvic traumatic inj?
result is malgaigne fracture or bucket handle frac. high energy shearing force causing major disruption to bony ring, the si joints, stabilising ligaments and illiac vessels. leads to major pelvic instability and life threatening haemorrhage. can cause significant damage to underlying organs, causing rectal, urethral and vaginall bleeding.
127
what is a complex or compound pelvic frac?
two or more types of pelvic injury.
128
what are the phases of mortality and morbidity associated with abdominal trauma?
early phase - rapid uncontrolled or unrecognised haemorrhage causing hypovolaemia and death
later phase - death occurs from sepsis, dic,multi organ failure and abdo compartment syndrome.
129
what should be considered as a possible injury when a trauma pt has unexplained shock?
abdo injuries
130
what are the organs most frequently injured in abdo blunt trauma?
spleen, liver and small bowel and retroperitoneal structures.
131
what is the most common organ injured in a penetrating abdo trauma?
liver.
132
what happens when abdominal tauma is located at the intraperitoneal area?
blood collects in the peritoneal cavity. structures that may be injured could be diaphragm, liver, spleen, gall bladder, small bowel, transverse and sigmoid colon.
133
what happens when abdo trauma is located at the retroperitoneal area?
more difficult to recognise as it has fewer physical signs. structures that could be injured may be the aorta, inferior vena cava, most of duodenum, pancreas, ascending and descending colon and upper urinary tract.
134
clinical signs of liver injury in abdo trauma?
abrasions, bruising and/or wounds in the RUQ
pain in RUQ or upper abdo
right lower rib fractures
signs of hypovolaemic shock or haemodynamic instability.
135
clinical signs of a sleen injury following abdo trauma?
abrasions, bruising and/or wounds in the left upper quadrant
pain in LUQ or radiating up to the left shoulder
left lowere rib fractures
signs of hypovolaemic shock or haemodynamic instability.
136
what are the main signs of a blunt kidney injury in trauma?
haematuria, may be no overt signs, bruising over back or abdo where kidneys are
137
what are the main signs of a penetrating trauma injuring kidneys?
wounds may be hard to find, small oor distant to the kidneys.
138
kidney injuries clinical signs in abdo trauma
abrasions, contusions and/or wound in the loin region
loin pain
flank tenderness
haematuria
139
physiological shock occurs when?
there iis inadequate organ perfusion and cellular oxygen utilisation.
140
what does physiological shock result in at a cellular level?
imbalance in oxygen supply and demand results in a critical reduction in o2 availability in mitochondria.
141
what follows physiological shock?
anaerobic respiration, lactic acidosis and organ dysfunction.
142
what are the different types of shock?
hypovolaemic shock
cardiogenic shock
distrubutive shock
obstructive shock
143
coagulopathy associated with trauma may occur due to the activation of what?
protein C, endothelial glycocalyx disruption, consumption of fibrinogen and platelet dysfunction.
144
what is normal coagulation a balance of?
haemostatic and fibrinolytic processes
145
large injuries to chest wall that remain open can result in what?
open pneumothorax aka a sucking chest wound
146
why does an open pneumothorax happen?
because the intrathoracic pressure and atmospheric pressure equillibrium is immediate (the pressure of air in the lungs and the pressure of air out of the lungs want to be equal) and air tends to follow path of least resistance (easiest route). if opening in chest wall is approx 2/3s of the diameter of trachea or bigger, air will go through there as its the least resistive route.
147
what is the management of associated resp distress from open pneumothorax?
mechanical ventilation
chest drain
application of a one way valve dressing.
148
what is the aim of a needle thoracentesis?
to remove air or fluid from around the lung. fix a tension pneumothorax.
149
why does a tension pneumothorax happen?
occurs when plueral damag allows more air into the plueral space during inspiration than escapes during expiration. leads to abuild up of air in the plueral space with an increase in intrathoracic preassure.
150
what is the result of a tension pneumothorax?
increase in intrathoracic pressure which leads to a further collapse of the lungand pushing of the diaphragm down, ribs outwards and mediastinum acroos to the other hemithorax. pt will compensate as best they can but ultimately if not treated will result in a cardiac arrest.
151
TOM CAT
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Cardiac tamponade
Airway obstruction
Tracheal tree injury
(Flail segment)
152
clinical features of a tension pneumothorax?
resp distress
low o2 sats on air
ipsilateral hyper-expansion and reduced movement
absent breath sounds
tachycardia
tracheal deviation (late)
high inflation pressures
distended neck veins (hypovolaemia)
153
indications for a thoracotomy?
penetrating chest trauma within the cardiac box
signs of life within the past 5 mins
cpr should be ongoing
154
massive haemothorax?
over 1500 ml of blood in hamithorax.
155
clinical features of a massive haemothorax?
haemmorhagic shock
ipsilateral chest signs; hypomobility, hypoinflation, reduced breath sounds, dullness to percussion.
resp distress (pot. only mild)
156
cardiac tamponade?
blood flows into pericardial space after pentrating trauma to chest.
157
clinical features of a cardiac tamponade?
tachycardia
hypotension
presence of injury
distended neck veins
muffled heart sounds
becks triad
158
management of a cardiac tamponade?
needle pericardiocentesis
thorocotomy and repair of the myocardial defect
159
TWELVE?
Tracheal deviation
Wounds
Emphysema
Larynx
Veins
Exposure
160
TTJI?
Trans-Tracheal Jet Insufflation
- a ventilation method where you cover port with thumb to deliver o2 for 1 second and then take thumb off for 4 seconds to allow for recoil. used when a needle cricothyroidotomy has been done.
161
duckworth suggests what pneumonic for assessing etco2?
PQRSTwh
162
what does PQRST stand for in relation to end tidal?
Proper, Quantity, Rate, Shape, Trend
163
contraindications of an igel?
responsive pt w aw in tact
known eosophageal disease
caustic ingestions
upper aw obstructions due to foreign bodies or pathology
trismus, limited mouth opening, aw abscess, trauma or mass
164
