Surgical Critical Care: A Comprehensive Guide for Trauma Management, Exams of General Surgery

Download Surgical Critical Care: A Comprehensive Guide for Trauma Management and more Exams General Surgery in PDF only on Docsity! surgery exam 5 what is used for the evaluation and resuscitation at the scene of a traumatic injury? - ATLS most critical concept of ATLS - treat the greatest threat to life first primary survey - •Prioritizes & identifies most acute life-threatening issues •ABCDE mneumonic •Interventions occur as soon as identified •Resuscitation typically performed simultaneously as team approach most common cause of preventable post-injury death - hemorrhage PEA potential causes: - -trauma -tamponade, cardiac -toxins -thrombosis, coronary -thrombosis, pulmonary -tension PTX -hypovolemia -hypothermia -hypoxia -hyper/hypokalemia -hyper/hypoglycemia -hydrogen ions (acidosis) most important measure in resuscitation of intravascular volume deficit - early assessment of pt's response to fluid admin most common type of shock following injury - hypovolemic shock -mostly from hemorrhage positive FAST in unstable pt - -represents hemorrhage -mandates operative exploration positive FAST in stable pt - CT with contrast abd/pelvis C-spine clearance using NEXUS - <60yo + all of the following: •Absence of posterior midline cervical tenderness •Normal level of alertness •No evidence of intoxication •No abnormal neurologic findings •No painful distracting injuries - don't need imaging if met diagnostic modality of choice for pts not meeting NEXUS criteria - CT of c-spine •Zone II evaluated operatively or nonoperatively •Unstable patients require exploration for all zones management of penetrating abd trauma - •Most require exploratory laparotomy •Stab wounds: plain abd film to exclude retained FB •GSW: chest, abd, & pelvic x-ray to identify retained bullets & determine trajectory (GSWs + bullets should = even number) management of blunt abd trauma - •Objective eval to exclude intra-abdominal injury •Serial abdominal exams, serial US, FAST, CT, and/or DPL trauma laparotomy - •Tetanus updated & preoperative broad-spectrum antibiotics •NGT, Foley catheter, & calf compression boots •Skin prep & drape from chin to knees •Typical midline incision from xiphoid to pubis •Systematic packing of cavity & zones explored •Active hemorrhage controlled immediately management of thoracic injuries - •Dictated by clinical presentation •> 85% managed nonoperatively (analgesia, pulmonary toilet, tube thoracostomy, & selective endotracheal intubation) •Initial eval & treatment for imminently lethal chest injuries •Subsequent eval to identify or exclude "hidden" causes of death •Emergency department (EDT) or surgical thoracotomy •EDT goals: •Relieve pericardial tamponade •Temporize bleeding •Improve perfusion to coronary arteries & brain by temporarily occluding descending aorta most commonly injured organ in blunt trauma - liver management of liver trauma - •Most commonly injured organ in blunt injury •Majority of hemorrhage venous & generally self-limited •Most isolated hepatic injuries managed nonoperatively (if stable) & require ICU admission •Laparotomy: most injuries controlled with suture ligation, cautery, or topical hemostatic agents •Opening peritoneum may release tamponade in massive hemoperitoneum from hepatic hemorrhage Pringle maneuver for severe liver trauma management of splenic injuries - •Isolated blunt injury managed nonoperatively (if stable) •Grades I-III without active bleeding managed with bed rest, serial abdominal exams, close VS monitoring, & serial Hgb •Grades IV & V + active bleeding: angioembolization considered •If needed, safest operative approach is splenectomy via midline laparotomy what is the safest operative approach to splenic injuries? - splenectomy management of extremity injuries - •Signs of vascular injury ("hard signs") require angiogram or operative exploration: pulsatile bleeding, expanding hematoma, palpable thrill, audible bruit, regional ischemia, diminished or absent pulses •Further work up (ie, angiography, DUS) to exclude vascular injury for "soft signs": history of active bleeding, stable & non-pulsatile hematoma, neuro deficit due to primary nerve injury, proximity of wound to major vascular structures management of damage control - •During exsanguinating hemorrhage patients die from coagulopathy, hypothermia, & metabolic acidosis •Process often intractable & terminal •Early termination of operative procedures •Retreat to ICU for physiologic & metabolic recovery •Once stable, return for staged operative repair of injuries management of trauma in pregnant pts - •Testing considered in all women of childbearing age (10-50) •Priority is to save mother (thereby saving fetus) •Initially evaluated in same manner as non-pregnant patients •Early obstetrics consultation in pregnancies > 20 weeks gestation encouraged •Secondary testing should be utilized as needed (missed maternal injuries more detrimental to fetus than theoretical risk of moderate radiation exposure) •Indications for operative intervention do not differ from non-pregnant trauma patients criteria for declaring pts dead on arrival - -blunt trauma: CPR >5min, >12yo, no pulse -penetrating trauma- head, neck, abd, groin: CPR >5min, >12yo, no pulse -penetrating trauma-chest: CPR >15min, >12yo, no pulse -child with any of the above + CPR>15min, no pulse most adults require fluid resuscitation with burns of what TBSA - >15% TBSA tibial nerve - -posterior compartments of lower leg -ankle plantar flexion strength -sensation: bottom of foot -terminal branches: medial and lateral plantar nerves femoral nerve - -sensation: medial ankle -branch: saphenous what is the only part of the ankle not innervated by sciatic nerve branches? - medial ankle obturator nerve - -decreased sensation over upper medial thigh detailed cervical, thoracic, and lumbar spine exam for who? - all trauma pts -performed with log roll in secondary survey clinical outcome of pt with SCI is based on what? - initial functional level -accurate documentation is necessary complete evaluation of spinal cord function includes what? - detailed motor and sensory exam of BILAT upper and lower extremities muscle strength: 5 - •Muscle contracts normally against full resistance muscle strength: 4 - •Muscle strength is reduced, but muscle contraction can still move joint against resistance muscle strength: 3 - •Muscle strength is further reduced, such that joint can be moved only against gravity with examiner's resistance completely removed muscle strength: 2 - •Muscle can move only if the resistance of gravity is removed muscle strength: 1 - •Only a trace or flicker of movement is seen or felt in muscle, or fasciculations are observed in muscle muscle strength: 0 - •No movement is observed signs suggesting upper motor neuron lesion: - -babinski -hoffman what is required if concern for SCI? - rectal exam •sensory & motor simultaneously (perineal sensation & Bulbocavernosus reflex) •Absence of reflex indicates spinal shock (lasts up to 48 hours) •Neurologic exam not reliable while pt in spinal shock •Repeat exam at 48 hours to eval for restored reflex description of fractures - -skin -bone -pattern -alignment -orientation initial tx of closed fractures - •Immobilization (stabilize joint above & below fx) with splint or cast •NV exam •Non-weight bearing •Appropriate referral to orthopedics initial tx of open fractures - 1.Prophylactic antibiotics (depends on type of injury) •Ex. Cefazolin + gentamicin ( + PCN if "barnyard" injury to cover for Clostridium) 2.NV exam 3.Lavage wound < 6 hrs post-incident with sterile irrigation and splint 4.Surgical debridement w/in 24hrs 5.Open reduction of fracture & stabilization (ie. use of external fixator) 6.Inoculation against tetanus (if >5yrs) Gustilla-Anderson Classification of Open Fractures - •Type I injuries: low energy and wounds are usually less than 1 cm. •Type II injuries: wound length of 2 to 10 cm with moderate soft tissue damage and wound contamination. •Type III injuries: high-energy wounds usually greater than 10 cm in length with extensive muscle devitalization smith fracture displacement - volar jones fracture surgical tx - percutaneous screw fixation or ORIF boxer's fracture tx - •Nondisplaced: ulnar gutter splint x 3-4wks •Unstable/Unacceptable criteria: •Surgical fixation with perc pins/ORIF afterfailure of closed reduction & casting or splinting how are most hangman's fractures treated? - non operatively Monteggia fracture treatment: - •Adults/unstable: require ORIF of ulna & closed reduction of radial head •Peds: may simply require CR & casting ifradiocapitellar joint remains stable external fixation indications - •segmental bone loss, crush injury, severe swelling, injuries associated with vascular injuries •used in multiply injured pt with extremity injuries & in hemodynamically unstable pt what is the most versatile method of fracture fixation? - internal fixation bone tumor imaging - •XR to start •MRI: most accurate for definition of tumor size, & intra- and extraosseous extent •CT: best to evaluate thorax for metastatic disease •CT chest, abdomen, & pelvis for suspected malignant bone tumor where do malignant bone tumors most commonly metastasize? - lungs osteosarcoma imaging - •amorphous "cloud-like" character •"sunburst" pattern how do you confirm osteosarcoma? - bone bx what is a necessary component of curative therapy for osteosarcoma? - surgery what is the only option for cure for Chondrosarcoma? - surgical treatment Ewing sarcoma imaging - "permeative" or "moth-eaten" pattern "onion pee/skinl" appearance Ewing sarcoma treatment - •Localized: most use neoadjuvant chemo, limb salvage surgical resection or RT (or combo), then additional chemo +/- RT •Metastatic: aggressive multimodality therapy (chemo, surgical resection, RT) benign bone tumor treatment - •Most: referral & follow-up with orthopedic surgeon •Some: reassurance & no routine follow-up imaging •Others: observation: serial exams & radiographs •Symptomatic or aggressive tumors: •curettage and bone grafting or excision Dequervain's tenosynovitis affects what tendons - APL and EPB common s/sx of Dequervain's tenosynovitis - pain with holding or gripping objects what maneuver can be used to dx Dequervain's tenosynovitis? - Finkelstein maneuver -Pain at radial styloid with active or passive stretch the thumb tendons over radial styloid in thumb flexion non-operative methods for Dequervain's tenosynovitis - •1. forearm-based thumb spica splint with the interphalangeal joint free, NSAIDs, & application of ice •2. Local glucocorticoid injection into the sheath: trial in patients failing nonoperative measures •Worry about fat atrophy surgical option for Dequervain's tenosynovitis - opening (cutting, releasing) first extensor (dorsal) compartment(outpatient surgical procedure using local or regional anesthesia) "no mans land" of the hand - •From distal palmar crease to just beyond the PIP joint •Location where flexor tendon injuries have a poor prognosis due to high rate of adhesions and stiffness •New rehab protocols surgical tx of carpel tunnel syndrome - •release of transverse carpal ligament •Initial for severe disease •Failure of non-surgical therapy most common imaging modality for intracranial hematomas - non-contrast CT mainstay of surgical tx for EDH - •standard craniotomy over EDH for hematoma evacuation SAH are most commonly due to what? - trauma Cushing triad - -severely increase ICP may result in Cushings triad -HTN, bradycardia, respiratory irregularity -Can occur in setting of herniation syndromes secondary to severely elevated ICP and/or lateralizing mass lesions why is NG suctioning used in SCI? - ileus is common in SCI most common intracranial tumors in adults - metastases 5 most common primary cancers that metastasize to CNS - •Lung (20%) •Melanoma (7%) •Renal cell carcinoma (7%) •Breast (5%) •Colorectal (2%) diffuse glioma tx - •a combination of watchful waiting, surgery, and/or chemotherapy (survival rates ~5-20 yrs) glioblastoma tx - •maximal surgical resection followed by radiation, temozolomide, & tumor-treating fields meningioma tx - surgical resection +/- RT brain metastases tx - combination of surgery, stereotactic radiation, whole-brain radiation therapy, and/or chemotherapy most frequent early complication of emergency cric - •incorrect performance of the procedure resulting in damage to the cartilaginous structures or failure to achieve airway access