- most common when?
- physical exam
Most often in pts in 30s-40s
Happens when performing activities needing axial loading and rotation
- pt feels a pop followed by pain
- joint swelling following 12-24 hrs
- joint line tenderness
- decreased ROM
- McMurray’s test
MRI to dx
Meniscal vs. ligamentous injuries
Meniscal injuries joint swelling over 12-24 hrs
Ligamentous injuries are REALLY RAPID swelling b/c hemarthrosis
- ligaments have more blood supply than menisci
- ex: ACL tear
From chronic overuse (like strenuous athletic activities)
Point tenderness over proximal patellar tendon
Anserine bursa = under conjoined tendons of gracilis and semitendinosus muscles
- separates theses muscles from head of tibia
Bursitis –> tenderness over MEDIAL knee
- usually in atheletes and obese middle age –> elderly women
- what happens?
Tearing of tunica albuginea which invests the corpus cavernosum
Hematoma rapidly forms at site of injury –> bends shaft of penis at fracture site
- emergent urethrogram to look for urethral injury
- then emergent surgery to evacuate hematoma and mend torn albuginea
Organs lacerated in blunt abdominal trauma
How to evaluate blunt ab trauma
Hemodynamilcaly unstable + unresponsive to fluids –> exlap
Responds to fluids: CT scan is next best step
- assess for intraperitoneal free fluid or hemorrhage
- use US
+ eval pericardium = focused assessment w/ sonography for trauma (FAST) exam
- Exploratory laprotomy if diagnostic peritoneal lavage or FAST is +
- Ab CT to see if need ex lap if hemodynamically stable and (-) FAST
Focused assessment w/ Sonography for trauma (FAST) exam
US to detect free intraperitoneal fluid + evaluate pericardium
High sensitivity + specificity to detect hemoperitoneum, pericardial effusion, intraperitoneal fluid
Response to an infection
= SIRS w/ known infection
Systemic inflammatory response syndrome (SIRS)
Response to NONinfectious cause
Need at least 2/4 criteria
Temp > 101.3 or < 95
Pulse > 90
Respiration > 90
WBC > 12,000, < 4000, or > 10% bands
Major cause of morbidity and mortality in patients w/ total body surface burns?
Usually 2/2 sepsis and septic shock
Who do you use the following for?
- orotracheal intubation
- laryngeal mask placement
- nasotracheal intubation
- needle cricothyroidotomy
OT intubation = unstable, apneic pts
Laryngeal mask = temporary if OT intubation fails and need to figure out what to do next
NT intubation = blind procedure, pt needs to be breathing SPONTANEOUSLY
Needle CT = good for children in field. Not for adults b/c risk CO2 retention
+ psoas sign
no guarding, rigidity, rebound
What could be likely?
- usually staph aureus
from furuncles on leg, heme spread of bacteria, etc
Not appendicitis b/c - guarding, rigidity, rebound
CT scan to confirm
Steps in diagnosing peripheral artery disease
Usually due to atherosclerosis
1 is normal
1) Ankle-brachial index via Doppler
- ratio < 0.9 (nl = 1-1.3) is very sensitive and specific for > 50% occlusion in major vessel
2) If normal ABI…
- Exercise test w/ repeat ABI
Tx peripheral artery disease
Aspirin + cilostazol
Verapamil can improve walking distance but change ABI
Tight glucose control doesn’t have significant impact on PAD
Most important goal in management of rib fracture?
Ensure proper analgesia
Rib fracture very painful and may cause hypoventilation —> atelectasis or pneumonia
- intercostal nerve block (some risk pneumothorax)
DO NOT NEED TO DO MECH STABILIZATION OF CHEST WALL
Acute febrile nonhemolytic transfusion reaction
- how happen?
Happens after blood transfusions
Increase 1C + rigors
Ab bind donor cells –> activate complement –> release inflammatory cytokines
- stop blood transfusion
- give antipyretics
Thigh abduction at hip
Superior gluteal N
Palsy: Trendelenburg gait
Hip abduction (assists) Knee extension (maintains)
Tensor fascia lata
Iliac crest –> fascia lata
Flex and laterally rotate thigh
Psoas major muscle
Transverse processes of lumbar vertebrae –> lesser trochanter of femur
Lateral flexion of trunk
Rib cage fixation
Iliac crest –> 12th rib and transverse processes of L1-L4
Leg extension at knee
Most common cause of sepsis in splenectomy patients?
If suspect child abuse…
1) Perform thorough PE + skeletal survey to document abuse
2) Report case to child protective services
3) admit pt for safety
How do you manage splenic trauma if patient is
- hemodynamically unstable + responds to fluids
- hemodynamically unstable + unresponsive to fluid administration?
If responds to fluids (SBP > 100
- abdmoinal CT scan
- ex lap
Compartment syndrome signs
Deep pain out of proportion to injury
PULSES present DO NOT rule out compartment syndromeage in an unstable trauma patient if FAST exam is inconclusive
Firm necrotic tissue formed on exposed tissue following burn wounds
If circumferentially on extremity, can restrict outward expansion of compartment as edema builds –> vascular flow compromised –> compartment syndrome
Need to do escharotomy
Also do escharotomy if muscle compartment pressure > 30 mmHg
Abdominal bleeding - diagnostics?
Hemodynamically stable –> abdominal CT
Hemodynamically unstable –> FAST US, then DPL
Rupture of tendon of long head of biceps
Biceps muscle belly becomes prominent in mid upper arm
Weakness in supination
Forearm flexion OK
+ drop arm sign in shoulder injury
Rotator cuff tear
Better to dx diffuse axonal injury
CT will show many minute punctate hemorrhages w/ blurring of grey white interface
Nasal septum surgery - complications
Difficult to heal b/c septum poorly perfused cartilage
Can result in septal perforation = whistling noise during repisration
From staph folliculitis
Usually after nose picking or nasal hair plucking
Can be life threatening if spreads to cavernous sinus
Pain, tenderness, erythema in nasal vestibule
Best for animal bites
Unasyn (ampicillin + sulbactam)
How are hip fractures classified?
By anatomic location and fracture type
- femoral neck and head
- —-> higher chance of avascular necrosis
- intertrochanteric and subtrochanteric
- —–> greater need for implant devices (eg nails and rods)
Risk factors for VTE
Thrombophilic disorder or previous DVT
Can you infuse vanco fast into blood? Why not?
Will cause thrombophlebitis
What to do for hydrocele in newborn?
Most will resolve by age of 12 months
- can be safely observed during that period
Communicating hydrocele needs surgery
L shoulder pain referred from splenic hemorrhage irritating phrenic N and diaphragm
Signs of necrotizing infection
Intense pain in wound
Fever, hypotension, tachy
Decreased sensitivity at edges of wound
Tense edema outside involved skin
SubQ gas w/ crepitus
of midline sacrococcygeal skin + subQ tissues
Infection of pilonidal cyst
Most common in young males w/ larger amts of body hair
Can spread to form abscess
Drain abscess and excise sinus tracts
Nerve entrapment features
Not reproducible usually with palpation
Central cord syndrome
Classical w/ hyperextension injuries in elderly w/ degen changes in cervical spine
Selective damage to central portion of anterior spinal cord
Weakness more pronounced in upper extremities than in lower extremities
- arm motor fibers nearer to central part of corticospinal tract
Tx scaphoid bone fractures
If nondisplaced, wrist immobilization for 6-10 wks
If displaced (>2mm), open reduction and internal fixation
Most common peripheral artery aneurysms
Popliteal > femoral
Hemodynamically unstable victim of MVA w/ suspected blunt ab trauma (BAT), management?
Hemodynamically stable victim of MVA w/ suspected BAT, management?
CT scan of abdomen w/ contrast
Quantify amt of blood
Surgeon selects laparotomy or admission and observation based on CT result
Drugs increasing cAMP
Increases heart contractility
Relaxes smooth muscle of arteries
Drugs increase cGMP
Next steps in management after a fall showing a hip fracture
1) Stabilization, treatment for pain control, DVT ppx
2) Figure out cause of fall and assess preop risk
In elderly, commonly:
- syncope (arrhythmia, valves)
- Heart failure
- CNS pathology (TIA, stroke)
- infection (PNA)
- metabolic (Hypoglycemia)
LE venous valvular incompetence —>
Pooling of venous blood and increased P in postcapillary venules —>
Damages capillaries w/ increased P —>
Lose fluid, plasma proteins, RBC into tissue –>
RBC extravasation causes hemosidering deposition –>
get classic color of stasis dermatitis
Xerosis is most common early finding
Transient unilateral weakness after tonic-clonic seizure that usually resolves
What’s a common physical sequelae after grand mal seizure?
Posterior dislocations of shoulder
Pt holds arm addudcted and internally rotated
Anterior urethra injuries
- where is the injury?
- how does it happen?
Injury to urethra distal to urogenital diaphragm
Usually due to blunt trauma to perineum (straddle injuries) OR instrumentation of urethra
- perineal tenderness/hematoma
- normal prostate
- bleeding from urethra
- may not complain of inability to urinate
- delayed presentation can be complicated by sepsis 2/2 to extravasation of urine into scrotum, abdominal wall
- immediate surgical repair
Posterior urethra injuries
- where is the injury?
- how does it happen?
Injury to prostatic and membranous urethra
Usually assoc w/ fractures of pelvis
- blood at urethral meatus
- high riding prostate (b/c displaced by pelvic hematoma)
- scrotal hematoma
- pelvic fracture
- suprapubic pain
- inability to void following major trauma
Tx step 1:
- retrograde urethrogram
Where are most clavicular fractures?
In middle 1/3 of bone
Shoulder of affected side is displaced inferiorly and posteriorly
Clavicular fracture ID’d - what do next?
Careful neurovascular exam b/c clavicle close to subclavian A and brachial plexus
Angiogram if hear bruit in clavicle area
Fixing clavicle fractures
middle 1/3 –> nonoperative w/ brace, rest, ice
distal 1/3 –> open reduction + internal fixation
Pain or locking w/ internal and external rotation of knee while standing on 1 leg w/ knee flexed to 20 degrees
Painful clock w/ passive flexion and extension of knee w/ examiner’s thumb and index finger placed on medial and lateral joint lines
Pain w/ pressing heel toward floor while internally and externally rotating foot w/ knee flexed to 90 degrees
What to use to dx meniscal injuries?
Manage traumatic spinal cord injuries
1) Hemodynamically stabilized
2) proper airway management
3) stabilize neck until spine injury r/o
4) Urinary catheter placement to assess urinary retention and prevent bladder distention and damage
Fat embolism signs
Severe respiratory distress - increasing diffuse b/l pulm infiltrates on serial CXR Petechial rash Subconj hemorrhage Tachycardia Tachypnea Fever
Dx w/ fat droplets in urine or intraarterial fat flobules on fundoscopy
Happens 12-72 hrs after fracture injrueis
Tx fat embolism
- LMW dexxtran
Kidney stones in Chrons disease?
Usually Ca binds oxalate in gut and prevents absorption
In fat malabsorb from Crohns, Ca bound by fat and oxalate is unbound and free to absorb in blood
ALSO, failure of reabsorb bile salts can damage colonic mucosa and cause more oxalate absorption
What kinds of catheters have higher rate of infection?
Femoral > subclavian
Usually due to Staph but femoral catheters can also be due to Gm - bacteria
Dx ACL tears?
Lachman’s test (like anterior drawer but 30 degree flexion)
Anterior drawer test
Pivot shift test
What is GCS used for?
Predicts prognosis of coma and other medical conditions (bacterial meningitis, TBI, subarachnoid hemorrahage)
NOT used to diagnose coma
Findings used to dx coma
Impaired brainstem activity (disruption of pupillary light, Extraocular, and corneal reflexes)
Motor dysfunction (decorticate or decerebrate posturing)
Impaired level of consciousness
Slipped capital femoral epiphysis
Displacement of femoral head on femoral neck b/c disrupt proximal femoral growth plate
Usually seen in obese adolescent boys
- obesity increases shear stress and physis (physical junction b/n femoral head and neck) fractures and femoral head slips POSTERIORLY + MEDIALLY relative to neck
- loss of abduction and internal rotation
- external rotation of thigh while hip flexed
Tx: surgical pinning of slipped epiphysis to lessen risks of avascular necrosis or chondrolysis
Most common carpal bone fracture
ON radial side of wrist
Usually get max pain in anatomic snuffbox, min dec ROM, decreased grip strength, possible swelling
Suspected scapohid fracture but not present on xray - what do you do?
Can take up to 10 days to show abnormalities on xrays
Immobilize wrist w/ thumb spica cast for 7-10 days followed by repeating xrays
CT or MRI of wrist can distinguish b/n fracture and ligament injries
Needle shaped crystals on urinalysis + ileus - what do you do next/
CT scan of abdomen or intravenous pyelography
Probably have uric acid stones, not seen on xray
Ileus probably due to vagal rxn from ureteral colic - ileus over when ureterolithiasis is treated
Part of bladder that is covered by peritoneum and is most susceptible to rupture
Dome of bladder
Can get irritation of peritonitis and irritation of diaphragm
Most common site of extraperitoneal bladder rupture
Rapidly progressive bilateral cellulitis of submandibular and sublingual spaces
Usually from infected 2nd or 3rd mandibular molar
Usually Strep and anaerobes
Sx: Fever Dysphagia Odynophagia Drooling --> due to swelling of submandibular space + posterior displacement of tongue
How does hearing loss happen in Paget’s?
Cochelar N damage
- enlargement of temporal bone –> impinge on internal auditory meatus
Carcinomas that love to spread hematogenously
RCC HCC Follicular thyroid carcinoma Choriocarcionma Prostate adenocarcionma
Activate all 3 receptors
Mixed: Butorphanol, nalbuphine, pentazocine
- block mu but activate kappa receptor
- block kappa, weak mu receptor activator
Antagonist at mu receptors
Cancers w/ osteolytic lesions (and hypercalcemia of malignancy as a result!)
BLT with a Kosher Pickle, Mustard & Mayo
B = breast cancer L = lymphoma, lung cancer T = thyroid cancer K = kidney cancer P = prostate cancer M & M = multiple myeloma
How are opioids (morphine, hydromorphone, fentanyl) eliminated?
Hydromorphone is metabolized via glucuronidation (not lost as much w/ age) so can have inactive metabolite (vs morphine and fentanyl which are CYP metabolized so may have accumulation if CYP enzymes lost)
Acute limb ischemia
3 layers of blood vessel
Adventitia is strongest
Time before acute limb ischemia causes necrosis of tissue
1/2 life of heparin
If rutherford classification I, what do you do?
Time to work up
+ heparin ASAP
If rutherford classification IIa, what do you do?
still have some time but need to be quicker than I
+ heparin asap
If rutherford classification IIb, what do you do?
Now have only 6 hrs before necrosis of tissue
- ASAP emergency
- very acute emergency
Urgency need to tx acute limb ischemia
o I = No pulse, OK sensory and motor
o IIa = No pulse, no sensory, OK motor
o IIb = No pulse, no sensory, no motor
o III = Rigor (dead extremity)
If rutherford classification III, what do you do?
DO NOT reperfuse! Will get reperfusion injury from all the dead cell released products
Get an amputation
1st sign of compartment syndrome
paresthesia in 1st web space
- deep peroneal N innervates this and is in ANTERIOR compartment
REMEMBER: compartment syndrome is a clinical diagnosis
Compartment of leg most susceptible to compartment syndrome
Risks after vascular surgery after acute limb ischemia blood flow restoration?
Pulse volume recording
BP cuffs on whole leg (Thigh, calf, foot)
Increase cuff pressure to 60 mmHg to obstruct venous flow
Will give tracing of pulses
Height of tracing will tell you amount of blood flow going through.
Can tell you ~where obstruction is
What is utility of PVR?
Ex: if diabetic, can have falsely elevated ABI b/c not compressible vessels (they are calcified)
PVR will eliminate that problem with ABI
When do surgery on claudication of leg?
If have extreme impact on lifestyle (QOL) if there is relatively low risk
What are the components of a duplex ultrasound?
B mode imaging (architecture of vessels)
• Can see stenotic area
Color flow (velocities), in cm/s
• Will have increased velocity in stenotic areas
• Want to compare the increased velocity area with areas before and after – how hemodynamically unstable is this area based on how much increase in velocity?
Glasgow Coma Scale (GCS)
Eyes (4) 1 - No eye opening 2 - Eye opening in response to pain stimulus 3 - Eye opening to speech 4 - Eyes opening spontaneously
**if awaken sleeping pt w/ speech, this is a 4, not a 3
1 - No motor response
2 - Decerebrate
3 - Decorticate
4 - Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5 - Localizes to pain.
6 - Obeys commands (thumbs up, wiggle toes)
1 - No verbal response
2 - Incomprehensible sounds. (Moaning but no words.)
3 - Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4 - Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5 - Oriented. (AAOx3)
extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist
flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist
MAP - ICP
CPP should be > 50
If CPP too high, increase risk of HTN hemorrhage
- cerebral blood flow vs. CPP should be constant ratio
What happens when you have too much CO2 in brain?
Increase blood flow for O2 delivery, increase pressure in brain
What’s the most sensitive test for weakness?
Supinator muscle is smallest muscle in arm –> if have weakness, will pronate drift down
Flick middle finger, thumb will move up and down
How can you grossly test urinary function?
Why is blood hyperdense on CT?
Because of the iron! that’s why it will become hypodense when the iron gets out of the blood in the brain on CT
Why is dura hyperdense on CT?
B/c it is very vascularized
CSF drainage path
Choroid plexus Lateral ventricle Interventricular foramen of Monro 3rd ventricle Aqueduct of sylvius 4th ventricle Foramen of Luschka and Magendie Subarachnoid space around spinal cord Arachnoid granulations Venous sinuses
Why should you hyperventilate in brain injury?
Will decrease CO2
Brain will think it has too much blood perfusion
Will decrease arterial blood flow to brain
This will decrease ICP
Happens in runners
Mechanically induced neuropathic degen w/ sx of numbness, burning of toes, achin and burning in distal forefoot radiating forward from metatarsals to 3rd and 4th toes
- pain b/n 3rd and 4th toes, plantar surface
- clicking sensation (mulder sign) w/ palpating space and squeezing metatarsal joints
metatarsal support w/ padded shoe inserts
- surgery if conservative tx fails
Tarsal tunnel syndrome
Compression of tibial N as passes through ankle
- caused by fracture of bones around ankle
Malignancy on chronically wounded, scarred or inflamed skin
Squamous cell carcionma
Is Marjolin ulcer if SCC arises in burn wounds
Where should central venous catheters be to avoid myocardial perf?
Tip should be proximal to cardiac silhouette
Angle b/n trachae and R mainstem bronchus
Catheter should be in SVC
Always do CXR after get catheterized
Effect of + pressure mech ventilation
Increases Intrathoracic P –>
Inc R atrial pressure –>
Decrease systemic venous return
Can cause circulatory failure and death
Diffuse axonal injury
Result of traumatic acceleration/deceleration-shearing forces
Damage axons in brain
Head CT: nl or diffuse small bleeds at grey-white matter junctions
Arterial occlusion @ bifurcation of aorta into common iliacs
Bilateral hip, thigh, and buttock claudication
passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip
The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues
Volkmann’s ischemic contracture
Final sequel of compartment syndrome
Dead muscle replaced w/ fibrous tissue
Causes of hypocalcemia
HYPERcitrate (eg blood transfusion)
1st physio signs of hemorrhage
Peripheral vascular constriction
High PTH, normal Ca — what does person have?
Vitamin D deficiency if getting Ca supplements
Dx urinary stones
non-contast sprial CT of ab + pelvis
Most commonly injured metatarsal in hairline fractures of metatarsals
Tx: rest, analgesia, hard-soled shoe
Valgus vs varus
Valgus = abducion at knee
Varus = adduction at knee
Tx MCL tears
Surgery rarely necessary
Bracing and early ambulation preferred
When is brachial artery usually injured
supracondylar fracture of humerus (esp in children)
Can get ischemia - pain, pallor, pulselesness, pressure, paresthesia
Tx subluxation of head of radius
Extend and distract elbow
Hyperflex elbow w /thumb over radial head to feel reduction as it occurs
Artery of adamkieqicz spans…
Nasopharyngeal carcinoma associations
Chronic nitrosamine consumption
Idiopathic avascular necrosis of femoral capital epiphysis
Usually in boys 4-10yo
Sx: Unilateral subacute hip pain Antalgic gait thigh muscle atrophy dec ROM Collapse of ipsilateral femoral head on plain pelvic xrays
Observation + bracing
What are these? abl cmyc bcl2 Her2/neu ras L--myc N-myc ret c-kit
abl = CML
cmyc = Burkitts lymphoma
bcl2 = follicular lymphoma
Her2/neu = breast, ovarian, gastric
ras = colon carcinoma
L–myc = Lung tumor
N-myc = Neuroblastoma
ret = Men 2A and 2B
c-kit = GIST
What are these? Rb p53 BRCA1 BRCA2 p16 BRAF APC WTf NF1 NF2 DPC4 DCC
Tumor suppressor genes
- lose function, increase cancer risk
Rb = retinoblastoma, osteosarcoma
p53 = li-fraumeni, most human cancers
BRCA1 = breast + ovarian BRCA2 = breast + ovarian
p16 = Melanoma BRAF = Melanoma
APC = Colorectal cancer
WTf = Wilms Tumor
NF1 = NF-1 NF2 = NF-2
DPC4 = Pancreatic cancer
DCC = Colorectal cancer
Use BP cuff to cut off brachial A flow
In the absence of blood flow, the patient’s hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm.
The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia with resultant hyperexcitability of nerves
Will get spasm of obicularis muscle
Can also happen w/ hypoMg
What do you watch out for in P vera surgical pt?
Usually are thrombocytosis but have hemorrhagic tendency b/c qualitative deficiency of platelets
Can use busulfan or chlorambucil to decrease Hct levels
1/2 life of FFP
b/c factor 7 is most stable 1/2 life at 4-6 hrs
Body water distribution
40% ICF (2/3 of TBW)
20% ECF (1/3 of TBW)
50% TBW —> 2/3 ICF, 1/3 ECF –> 1/4 plasma volume, 3/4 interstitial volume
Plasma volume measured by albumin
Extracellular volume measured by albumin
Serum osmolality =
BUN / 2.8 +
Glucose / 18
If you give normal saline in huge amounts for resuscitation, what can happen?
Hyperchloremic metabolic acidosis
What is in lactate ringers?
Less Na, Cl
BUT also has K, Ca, Bicarb
Be careful with hyperkalemia!
Good for hyperchloremic metabolic acidosis
Replacement strategies for losses in: sweat gastric biliary/pancreatic small bowel s/p NGT colon 3rd space losses
Sweat - D5 1/2 NS + KCl Gastric - D5 1/2 NS + KCl Biliary/pancreatic - LR Small bowel - LR Colon - LR 3rd space losses - LR
Indicators of successful resuscitation
Clearance of lactate
Resolution of base deficit
SvO2 = 70%
- [ O2] at pulmonary A port and is most deO2 blood in body
BP IS BAD INDICATOR!
Major drawbacks of general anesthesia
Increase incidence of pulm complications
Mild cardiodepression from anesthetic
Effect on platelets of aspirin and NSAIDs?
Aspirin = irreversible on plt aggregation for 7-10 days
NSAIDs = reversible
D/c aspirin for 7-10 days before surgery
D/c NSAIDs 2 days before surgery
Should hypercholesterolemia alone postpone surgery?
w/ PAD, how do you do a stress test?
Persantine thallium stress test
Specific to kidney transplant
In same family as JC virus
Will attack kidney
Does platelet transfusion in a pt w/ plt dysfunction due to uremia help?
Conjugated estrogens (slower)
Most common physio cause of hypoxemia is
Ventillation perfusion inequality
What to do after hemolytic reaction caused by ABO incompatability happens?
Put in foley catheter and monitor UO hourly
Give mannitol + alkalinze urine to prevent precipitation in kidneys
Restrict fluids and K in presence of severe oliguria or anuria
Which anesthetic has low solubility and fills air spaces during prolonged anesthesia?
Dopamine actions on receptors
Low doses –> D receptor –> increase renal flow, slight increase
Med dose –> B1 receptor –> inotropic effect on heart to increase CO and BP
High dose –> a1-receptor –> periph vasoconstriction, decreased kidney fxn, HTN
In blood, where is CMV?
Blood products not routinely tested for CMV
Most common viral transfusion in blood transfusion?
non A non B hepatitis (usually hep C)
CAn cause chronic hepatitis in ~16% of pts
Foster Kennedy syndrome
refers to a constellation of findings associated with tumors of the frontal lobe.
Early phase of shock, what is
Mild hypoxia –> low O2
Compensatory hyperventilation –> low CO2
Respiratory alkalosis –> high pH
What does epi in lidocaine do for the drug?
Double duration of infiltration anesthesia
Increases max safe total dose by decreasing rate of absorption of drug into bloodstream
DO NOT INJECT into finger, nose, toes, hose (penis), ears
Transfusions of blood through
- hypotonic solutions
- ringers lactate
Hypotonic (D5W / NS)
- swelling of erythrocytes and lysis
- has Ca and causes clotting in IV line –> PE can happen
Hypokalemic metabolic alkalosis
- kidneys excrete H+ to try and save K+
Oxygen demanding organs
Kidney is not as metabolically active as brain and heart but gets lots of blood for filtration
Coronary V lowest O2 content in blood because heart really extracts O2
S/E: anesthetic causing seizures
HaLi MeKid EnCon
Halothane = liver
Enflurane = Convulsant
decreased peripheral vascular resistance
nephrotoxicity due to free F ions released during biodegradation
Carotid body innervated by
CN 9 - nerve of Herring
Factors: 2 5 7 10 Fibrinogen
Factors: 8 9 11 12
Bleeding time measures
Interaction of plt and formation of plt plug
Qualitative and quantitative defect in plt fxn
Thrombin time measures
Qualitative abnormalities in fibrinogen and presence of inhibitors to fibrin polymerization
Lymphangitic inflammatory streaking up a person’s limb - what is it caused by?
Penicillin to tx!
Early wound management….
Early excision of areas of devitalized tissue with exception of deep wounds of palms soles genitals face
Staged excision of deep partial thickness or full thickness burns happen 3-7 days after injury
Carpal tunnel syndrome
- surgery - what do you do?
Assoc w/ pregnancy b/c have fluid retention
Surgery will release adhesions of median N and divide transverse carpal ligament
Extensor retinaculum is on DORSUM of the wrist and has extensor tendons – NOT FOR CARPAL TUNNEL
How often is leukoplakia develping into cancer?
Mass of lymphatic vessels in the head and neck region
Hypocapnia and preggers
Caused by direct stim effect of progesterone on central respiratory center
–> leads to increased resp drive and exaggerated resp effort –> primary resp alkalosis w/ metabolic compensation
- where do they come from?
Liver! All do except 8 (come from endothelium too)
Vit K dependent: 2, 7, 9, 10, C, S
Anion Gap =
Na - (HCO3 + Cl)
Increased AG met acidosis: Methanol Uremia DKA Phenacetin INH Lactic acidosis Ethylene Glycol Salicylates
Electolyte abnormalities in chronic EtOH
hypo Mg will cause refractory hypo K
Reactive leukocytosis after surgery - causes
What test is best to eval bladder?
Good markers for ischemia
- A base deficit (a below-normal base excess), thus metabolic acidosis, usually involves either excretion of bicarbonate or neutralization of bicarbonate by excess organic acids
If need an airway but intubation can’t be done for some reason, what do we do?
Usually don’t do before 12 yo b/c of possible need for future laryngeal reconstruction
Trauma - Airway
- how do you know it is there?
- when do you secure one
- how do you secure one?
OK - pt is conscious and speaking in nl tone of voice
- pt unconscious
- breathing noisy or gurgly
- inhalation injury
Get airway BEFORE securing cervical spine injury
Secure w/ orotracheal intubation or nasotracheal intubation
Use fiberoptic bronchoscope if there is subQ emphysema in neck –> sign of major traumatic disruption of tracheobronchial tree
Trauma - Breathing
- how do you know it is ok?
breath sounds b/l
ok pulse ox
Trauma - Circulation
- signs of shock
- causes of shock
- tx hemorrhagic shock
- low bp
- fast pulse
- low UO
- pale, cold, shivering, sweating, thirsty, apprehensive
- bleeding (CVP low)
- pericardial tamponode (CVP high)
- tension pneumo (CVP high, resp distress)
- if big trauma center nearby surgery 1st, then vol replacement
- if not, vol replacement (2L Ringer lactate w/o sugar) + blood until UO = 0.5 mL/kg/hr and CVP not more than 15 mmHg
Ways to do fluid resuscitation
2 peripheral IV lines, 16 gauge
Percutaneous femoral vein catheter
Intraosseous cannulation of proximal tibia
Tx linear skull fracture
If closed –> leave alone
Open –> wound closure
Comminuted or depressed –> OR
Signs of fx @ base of skull
Ecchymosis behind ear
CT scan to see
DO NOT do nasal endotracheal intubation
Penetrating neck traumas - tx for:
- upper zone
- middle zone
- base of neck
- when do surgical exploration?
Surgical exploration in all cases where there is an expanding hematoma, deteriorating vital signs or clear signs of esophageal or tracheal injury
Upper = arteriographic dx
Middle = surgery if symptomatic
Base = arteriography, esophogram (barium), esophagoscopy, bronchoscopy to help decide surgery
Central cord syndrome
Usually in elderly
Forced hyperextension of neck (ear end collision)
Tx rib fracture
Nerve block + epidural catheter
Rare potential sequelae of injuries affecting renal pedicle in blunt trauma..
AV fistula –> CHF
Extent of burns in adult
Rule of 9’s
9 = Head, each of upper extremities 18 = each LE 36 = trunk
Fluid replacement in burns
Aim for hourly UP of 1-2 mL/kg/hr while avoiding CVP > 15 mmHg
Usually 1000 cc/hr Ringer lactate (w/o sugar) if burns > 20%
- don’t use sugar b/c will induce osmotic diuresis from glycosuria which would invalidate the UO measurement
Extent of burns in babies
18 = head 27 = both lower extremities
Clean burn areas
- silver sulfadiazine
- mafenide acetate (for deep penetration)
- triple abx if burns near eyes
2-3 wks wound care – >if not regen, grafting needed
When do you graft asap for burns?
Limited burns that are obviously 3rd degree
- dosage of antivenin?
- first aid at site?
Dosage relates to size of envenomation, not size of pts
First aid = splint extremity during transport
DO NOT suck out venom, wrap with ice, touniquet, or make cruciate cuts
Tx black widow bite
IV calcium gluconate
Tx brown recluse spider bites
Surgical excision may be needed- tx
Developmental dysplasia of hip
- uneven gluteal folds
- hops easily dislocated posteriorly w/ jerk and click
Dx: US (NO Xray as babies hips are not calcified)
Tx: abduction splinting w/ Pavlik harness for 6 mo
Osgood Schlatter disease
IN teens w/ persisten pain over tibial tubercle
- aggravated by contraction of quads
No knee swelling
Tx: Rest, Ice, compression, elevation (RICE)
extension or cylinder cast if RICE doesn’t work
Thoracic spines curve towards right
Colles = wrist fracture, usually on old women
Monteggia = direct blow to ulna (protect yourself from cop with stick) –> fx proximal ulna, anterior dislocation of radial head
Galeazzi = Hit distal radial
Open fx treatment
Cleaning in OR
suitable reduction w/in 6 hrs of injury
Usually in women w/ babies
Pain along radial side of wrist and first dorsal compartment
Get pain w/ thumb inside closed fist and forcing wrist into ulnar deviation
Tx w/ steroid injection best
Jersey finger vs Mallet finger
Jersey = injured flexor tendon; can’t flex
“Jersey can’t flex”
Mallet = injured extensor tendon
Tx amputated fingers
clean w/ steroile saline
wrap in saline gauze
put in sealed plastic bag on icee
DO NOT allow to freeze, do not put antiseptic solutions on
Lumbar disk herniation usually…
+ Straight leg test
MRI to dx
What is a sign of sepsis in babies?
Rapidly dropping platelet count
Branchial cleft cyst
Along anterior edge of SCM
at base of neck as large, mushy ill definied mass
Usually takes up entire supraclavicular area and can extend deeper into chest
CT scan before surgery is best so know how far lesion goes
Epistaxis in juvenile - what do you suspect?
Cocaine abuse or juvenile nasopharyngeal angiofibroma
WIll be posterior septum problem (vs anterior septum in nosepicker).
Resect the angiofibroma b/c it is benign but can eat away at nearby structures
Dizziness 2/2 inner ear vs brain
Inner ear = room is spinning around them
- tx w/ meclizine, Phenergan or diazepam
Brain = room is steady but pt is unsteady
Tx reflex sympathetic dystrophy (causalgia)
Sympathetic block is diagnostic
Surgical sympathetctomy to cure
TEsticular torsion vs. acute epididymitis
Very similar in presentation
Torsion - no imaging needed. Surgery + orchiopexy to tx
Epididymitis - fever + pyuria, testis in normal position
- use sonogram to r/o torsion just in case
IV pyelogram used to be in favor but limitations include allergic rxn and contraindication if Cr > 2
CT for renal tumors
US for obstruction in kidney
Cystoscopy for cancers in blader mucosa
1 cause for newborn boy not to urinate in 1st day of life
Posterior urethral valves
Voiding cystourethrogram is dx
Tx: endoscopic fulguration or resection
urethral opening on ventral side (underside) of penis
DO NOT do circumcision as will need tissue for plastic reconstruction
Workup of hematuria
Whn do you not work up?
Cystoscopy (r/o bladder ca)
Dont work up if hematuria (trace) after significant trauma
Tx bladder ca
F/u closely b/c local recurrence is high
When does a man w/ urinary retention get worse?
During a cold
W/ use of antihhistamines adn nasal drops + abundant fluid intake
What is a contraindication to organ donation
HIV status is only absolute contraindication
Severe nutritional depletion signs
- can you have surgery?
Loss of 20% of body wt
Albumin < 3
Anergy to skin antigens
transferrin < 200
Very high risk surgery but can undergo if get 7-10 days (optimal) of TPN
tx penetrating urologic injuries
Surgical exploration - do for all!
When can femoral fractures cause shock?
If bilateral and comminuted (smashed into a million pieces!)
What happens when a person trying to pass a stone (kidney) spikes a fever or white count?
Put in stent or nephrostomy tube asap to decompress! This is emergency and kidneys could fail in a few hrs
Will aorta look bigger or smaller on lateral xray?
subtract 20% from size
Easiest method to evaluate ab aorta
5mm error in measurement
Most accurate to assess ab aortic aneurysm
F/u s/p endovascular repair of AAA
Annual CT and US exams
Need to make sure no endograft leak (~20% do)
If have hematoma s/p carotid endartectomy, what do you do first?
Open up wound at bedside
DO NOT intubate first
CN injury in CEA
- soft palate dysfunction
- nasal regurg
- ipsilateral tongue deviation
INITIAL trauma series is usually
an AP (supine) CXR on a trauma board
an AP pelvis radiograph
a cross-table lateral c-spine radiograph
Eval aortic arch injury without contrast media
MRI is a great means of studying the aorta, but it is a much longer examination and may not be suitable for unstable patients. We also cannot allow any ferromagnetic metal into the MRI scanner and it can be very difficult to be sure there is no metal in or on a trauma emergency patient.
Transesophageal echo would probably be the next choice in this situation - this can be performed in the ED or the operating room, but may require sedation or anesthesia.
Transthoracic ultrasound is not a good option to evaluate Mr. Roger’s aorta. Although it may show the lower portion of the ascending aorta well, it does not display the arch and descending aorta adequately due to the overlying lung.
Contraindications to CT contrast
Contraindications to CT IV contrast media:
- Previous allergic reaction to IV iodinated contrast
- Renal failure
- Glucophage/Metformin - Metformin is discontinued for 48 hours after the contrast enhanced CT and reinstated after confirming that the creatinine is normal.
- Multiple myeloma
- Thyroid disease
- Seafood allergy - This allergy is to a protein in seafood not the iodine. Actually the ‘allergy’ to contrast is to the compound that the iodine attaches, not the iodine
ivp first then cystoscopy if normal
Flank mass eval
do ivp and ct to eval for rcc
Asymptomatic prostatic cancer not treated after age..
Rock hard testicle
- what to suspect
- what do you do?
Do not bx. Do orhiectomy ASAP
Complicated UTI in men
start with ivp and sonogram instead of cystoscopy as you risk septic shock with instrumenting an infected bladder
- what do you do?
will be due to a colovesicular fistula
need to do ct scan to rule out cancer in sigmoid
Psychogrnic impotence tx
needs psychotherapy ASAP. Will be reversible after 2 yrs
Perioperative risk of stroke for CEA
Most common site of lower body arterial occlusion 2/2 arterial emboli
Common femoral artery (45%)
Tx arterial embolism in lower periphery
ballroon cathete embolectomy
Most common site for claudication occlusion (long trm process)
superficial femoral artery
rest pain ABI
Why will BP / ABI measurements be incorrect in diabetics?
B/c usually ahve calcified vessels preventing arterial occlusion w/ BP cuff
Reverse flow component can be lost
What does it mean that the Doppler waveform is triphasic?
1- rapid systolic flow
2- brief reverse flow 2/2 elastic recoil of vesel
3 - long diastolic outflow
If severe atherosclerosis, wafeform can become monophasic as may lose 2 and 3 phases
Tx for patiens with claudication in distal lower extremity (peripheral artery disease)?
Mostly don’t perform surgery
Tx claudication causing absence of femoral pulse
This is suggestive of aortoiliac occlusive diseae
Surgery is considered b/c more progressive than periph occlusive diseas
What is a pt with peripheral artery disease likely to die of?
coronary artery disease / MI
When do you get an artetriogram for claudication?
If you decide to proceed with surgery
Does LVEF predict myocardium at risk for ischemia perioperatively?
Good indicator of postop heart failure but does not adequatly predict myocardium at risk for ischemia
Complications of AAA repair
Ischemia to colon - IMA is disrupted
- sigmoidoscopy to est dx
Anteror spnal syndrome
- vascular graft infection
- aortoenteric fistula (aorta + duodenum)
Tx aortic dissection
- type 1
- type 2
- type 3
Type 1 = ascending + descending aorta
- surgery ASAP
Type 2 = ascending aorta
- surgery ASAP
Type 3 = descending aorta
- beta blockers
- CONTROL HTN!
DVT outpatient treatment
Warfarin for 3-6 months
Popping in knee + rapid onset of pain and swelling with hemarthrosis - what happened?
Most common cause of hypotension adn distended neck veins in trauma pts
–> Other less likely = cardiac tamponade
Pregnant women in trauma - how to evaluate
At basline because of preggers, can have increased HR and hypotension 2/2 uterine compression on vena cava
Evaluate preggers on her left side
Findings in fresh spinal cord injury
loss of anal sphincter tone
loss of vasomotor tone
What can DPL miss?
Retroperitoneal structure injury
Most common nephropaathy assoc w/ carcionma
Most common nephropathy assoc w/ hodgkin’s
Carcinoma - membranous nephropathy
Hodgkins - minimal change disease
Selenium deficiency feature
Zinc deficiency feature
Bullous, pustulous lesions around body orifices and/or extremities
Impaired wound healing
Places LARGE amt of blood could hide in body
Thigh (femoral fracture)
Intraoperative development of coagulopathy
If tehre is hypothermia and acidosis too, need to stop laparotomy and pack bleeding surfances + temporary closure
Resume op after pt warmed and coagulopathy treated
Best for human bites
Amoxicillin + clavulanate