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USMLE STEP 2

Airway

Present if patient: conscious with normal voice tone
Needed if: Patient is unconscious, expanding hematoma or emphysema in neck. * Secure airway before spine

Done : Intubation
Cervical Injury - Intubation with head secured or fiber optic bronchoscope. Cricothyroidotomy in pts with facial injuries.

Breathing

B/L breath sounds and normal pulse ox

Hemorrhagic Shock

- Decrease in BP, Increase in pulse, Pale cold pt
CVP is low, the pt is bleeding (hemorrhagic shock). In urban setting start with surgical intervention, all other places start with fluid replacement (2L Ringer Lactate), then PRBCs, until U/o = .5 - 2 ml/kg/h, maintain CVP below 15

Cardiac Tamponade

Caused by trauma
Decrease in BP, Increase in pulse, Pale cold pt
CVP is high
Based on clinical dx, sonogram if unclear)
TX- Pericardiocentesis or window, can also replace fluid

Tension Pneumothorax

Chest trauma
Patient is respiratory distress
Decrease in BP, Increase in pulse, Pale cold pt
CVP is high
based on clinical dx, no x rays or abgs
TX - Big needle catheter in affected pleural space followed by chest tube with underwater seal

Non Trauma shock

Hypovolemic - Burns, Diarrhea (decreased CVP)
Cardiogenic - MI, Myocarditis (increaed CVP) treat with circulatory support (fluid would be dangerous)
Vasomotor- Spinal cord transection. Patient warm and flushed, CVP decreased, restore TPR

Fluid Resuscitation

-2 16 gauge peripheral IV lines (best)
-Percutaneous femoral vein catheter/ saphenous vein cut down
-In children Intraosseous cannulation of tibia

Head Injuries

-Penetrating - Surgery/repair
-Linear fractures- Open (close wound). Closed (Leave alone)
If Pt Unconscious - Head CT
-Base injury - Racoon eyes, epistaxis, ecchymosis. --Expectant mgmt, CT spine for integrity.
-Neurological trauma- Caused by : Blow, Hematoma (surgery), or ICP increase (medication to prevent)
-Epidural Hematoma - MMA damaged in trauma to side of head. Present with trauma-unconscious-lucid interval-coma-dilated pupil on side of hematoma-contralateral hemipariesis. Treat with craniotomy
-Subdural Hematoma - More severe, crescent shaped, craniotomy only helps if midline structures are deviated, montior ICP. Give mannitol or furosemide, hyperventilate (35 pco2)- Chronic pts are old, or alchoholics, shrunken brain tears venous sinuses. Mental function deteriorates, CT scan dx, tx with surgery.
-Diffuse axonal injury- Blur of gray and white matter interface, and multiple punctuate hemorrhages, prevent further damage by dec ICP.

Neck Trauma

- Surgical Exploration in penetrating injuries if there is an expanding hematoma, vital signs deteriorating, or esophageal/tracheal injury. Strong tradition of surgical exp in gunshot wounds to the middle zone becoming more selective
-Selective Approach:
Gunshot to UpperZone (arteriographic dx + mgmt)
Gunshot to base (arteriography, esophagogram, esophagoscopy, bronchoscopy)
Stab wounds to Upper and Middle - safely observed
-Blunt trauma: CT Neck (spinal integrity)

Hemisection of spinal cord

Brown Sequard

Ipsilateral proprioception and paralyisis
Contralateral loss of pain and temp

Anterior Cord Syndrome

Burst fracture of vertebral body
Loss of motor function and pain and temp on both sides distal to injury

Central Cord Syndrome

Elderly with forced hyperextension of neck
Paralysis and burning pain in upper extremities
Preservation of motor function in lower extremities
* Mgmt of spinal cord inj- MRI best for dx
* some say corticosteroids good immediately after.

rib fracture

can be deadly in the elderly because of hypoventilation can cause pneumonia. treatment local nerve block

plain pneumothorax

results from penetrating trauma. Moderate shortness of breath affected side has no breath sounds and is hyper resonant to percussion get chest x-ray place chest tube and connect to underwater seal

hemothorax

penetrating trauma affected side will be dull to percussion. Diagnosed by chest x-ray blood needs to be evacuated to prevent to empyema chest tube placed low. No need for surgery most of the time low-pressure system if blood is more than 1500 ML when the chest tube is inserted or collects 600 ML over the ensuing six hours then thoracotomy should be considered

severe blunt trauma to the chest

hidden injuries are possible. Monitor blood gases and chest x-ray cardiac enzymes and ecg possible plmonary and cardiac and contusion. check for transection of the aorta

sucking chest wounds

flap that sucks air with inspiration closed with expiration.
treat with 3 sided gauze

flail chest

multiple rib fractures cause paradoxical breathing chest wall caves and during inspiration bulge out during expiration. problem is underlying pulmonary contusion treatment is fluid restriction and use of diuretics. monitor blood gases Bilateral chest tubes are advised if respirator is needed. check for transection of aorta because of the amount of trauma.

Pulmonary Contusion

Needs to be checked for after after chest trauma. Signs are deteriorating blood gases and white out on xray

myocardial contusion

should be suspected in sterno fractures ECG monitoring will detect it. treatment is focused on complications such as arrhythmias

traumatic rupture the diaphragm

shows up with bowel in the chest always on the left side

traumatic rupture the aorta

ultimate hidden injury. happens at the junction of the arch and the descending aorta usually caused by a big deceleration injury usually asymptomatic until the hematoma ruptures. Should be suspicious with big injuries are hard to break bones TE E, spiral CT scan, MRI angiography are noninvasive diagnostic tests most practical is spiral CT

differential diagnosis of subcutaneous emphysema

include rupture of the esophagus and tension pneumothorax

air embolism

should be suspected when sudden death occurs in chest, patient who is intubated and on a respirator. it can happen in supraclavicular node biopsies or central line placement.leading to sudden collapse in cardiac arrest immediate management is cardiac massage prevention includes trendelenburg position

fat embolism

typical setting patient with multiple trauma including long bone fractures develops particular rash in the axilla and neck fever and tachycardia low platelet count. Respiratory distress . precise diagnosis is fat droplets in urine. therapy is respiratory support

gunshot wounds to the abdomen

require exploratory laparotomy for repair of intra-abdominal injuries any entrance or exit wound below level of the nipple line is considered to involve the abdomen. In select cases low caliber gunshot wounds involved in the right upper quadrant conservative therapy may be used

stab wounds

more individualized approach. If it is clear penetration that has occurred with the protruding viscera exploratory laparotomy is mandatory. It is also mandatory with signs and hemodynamic instability or peritonial irritation. In the absence of the above digital exploration and observation may be sufficient CT scan is diagnostic

blunt trauma to the abdomen

requires exploratory laparotomy if signs of peritoneal irritation develops. Otherwise in blunt, one must determine whether they are internal injuries, bleeding into the peritoneal cavity, and whether the bleeding is likely to stop by itself or require surgical intervention. For example signed internal bleeding shock low CVP

signs of internal bleeding in a patient with blunt trauma

include a drop in blood pressure with a fast pulse, low CVP, and low urinary output, in a cold pale anxious who is shivering and thirsty and sweating. these signs of shock occur in 25 to 30% of blood loss.thus there are few places that this much blood could be hidden without a gross deformity. For example blood the pericardial sac would cause tamponade. That leaves the abdomen, pelvis and thighs the only 3 places that 1500 ml of blood can hide. pelvis and thighs which showed fractures on x-ray so patient would be suspected intra-abdominal bleeding. if Shock no obvious reason

diagnosis of intra-abdominal bleeding

most accurately withCT scan. Will show presence of blood and injury most frequently liver and spleen. main limitation CT scan is patient has to be hemodynamically stable, unless there is a fast ct scan present (newer technology) so if the patient is unstable you can do a sonogram for a diagnostic peritoneal lavage if positive exploratory laparotomy required

ruptured spleen

is the most common source of significant bleeding in the abdomen in blunt trauma fractures of the lower ribs is a hint.if removal is unavoidable post operative immunization against encapsulated bacteria is mandatory

intraoperative development of coagulopathy

during prolonged abdominal surgery there can be multiple transfusions platelet packs and fresh frozen plasma if patient develops coagulopathy acidosis and hypothermia the laparotomy has to be promptly terminated with temporary closure

abdominal compartment syndrome

occurs when lots of fluid has been given in prolonged laparotomy so that by the time of closure of the abdomen can not be closed temporary cover is placed

any pelvic fracture

associated injuries have to be ruled out. for rectum do rectal exam and proctoscopy. For bladder do pelvic exam or retrograde urethrogram for males

in pelvic fractures with ongoing bleeding

hypovolemic shock in patients with pelvic fracture negative sonogram or CT scan and pelvic hematoma. Patient is in need of blood replacement. Most commonly external fixation. Arteriographic embolization for arterial bleeding. no easy answer

Hallmark of urologic injuries

Blood in urine in patient with bunt trauma. Gross hematuria must be evaluated. In children microscopic should be evaluated for congenital anomalies.

Penetrating urologic injuires

Must be explored surgically

Blunt urologic injuries

May affect kidneys (lower rib fracture) Or bladder or urethra (pelvic fracture)

Urethral injury

occurs almost exclusively in men. May present with blood at the meatus. clinical picture may include scrotal hematoma, for sensation of wanting to void but cant in post erior injuries, and a high riding prostate on rectal exam. Do not insert Foley, do a retrograde urethrogram.

Bladder injury

Can occur in either sex, usually assc with pelvic fractures.
Dx by retrograde cystograms. X ray studies must include post void films to see extra peritoneal leaks. surgical repair is done and protected by suprapubic cystotomy

Renal injuries

assesed by CT scan, can be managed without surgical intervention most of the time. Rare sequela of injury affecting peduncle can devlop av fistula leading to CHF. also renovascular hypetension can develop.

scrotal hematomas

Can become really big but do not need specifin intervention unless testicle ruptures

Fracture of penis

Fracture of corpora cavernosa, fracture of tunica albuginea occurs when practicing vigorous sex. Sudden pain and developement of large penile shaft hematoma with normal appearing glans. emergency surgical repair is required. If not av shunts and impotence will ensue

Penetrating injuries to extremities

Main issue is whether avascular injury has occurred or not. Anatomic location provide the first clue. When there are no major vessels in the vicinity only tetanus prophylaxis is required. If penetration is near major vessels patient is asymptomatic, Doppler studies or ct angio are done. There is an obvious vascular injury surgical exploration and repair

combined injuries of arteries nerves and bone

bone first then vascular repair leave nerve for last. could also do fasciotomy

high velocity gun shot wound

large cone of destruction. requires extensive debridement and potential amputation

crushing injury

posed a hazard of hyperkalemia, myoglobinemia, myoglobinuria and renal failure,as well as development of compartment syndrome. Vigorous fluid administration osmotic diuretics alkalinatization of the urine and fasciotomy are done.

chemical Burns

require massive irrigation to remove agent

high-voltage electrical burns

always worse than they appear. Massive debridement or amputations may be required.give fluids and diuretics and alkalinize the urine. orthopedic injuries secondary to massive muscle contraction for example posterior dislocation of the shoulder or compression fractures of the vertebral bodies can occur and late development of cataracts for demyelinization syndromes are possible.

respiratory burns

occur with flame burns in enclosed spaces they are chemical injuries caused by smoke inhalation. Diagnosis is confirmed by fiber optic bronchoscopy blood gases help determine whether respiratory support is needed if carboxy hemoglobin is elevated hundred percent therapy of oxygen can be given

circumferential burns

can lead to cut off of the blood supply as the edema accumulates underneath the eschar. Esharotomies can provide relief

scalding burns and children

should raise awareness of abuse

fluid needs in the first 48 hours after burn

first you estimate the extent of the burn. The rule of nine the head and each of the upper extremities are assigned 9% of body surface each each lower extremity is assigned two 9% unitsand the trunk is given four units of 9%. This adds up to 99%.

formula is kilograms x % Burns x 4ml = amount of ringer lactate required for first 24 hours. (half in first 8 hours 2nd half in the next 16) Day two give half the the amount given in day 1.

and also give 2000 ml due to the fact patient is npo.
Aim for urinary output of 1-2 ml/kg/hour and do not exceed cvp of 15.

formula for babies is different 2 9s for the head 3 for both legs, four for the trunk and one for each upper limb.

other aspects of burn care

include tetanus prophylaxis, cleaning of the burned areas, and topical agents. silver sulfadiazine is common. For deeper penetration mafenide acetate is the choice. Burns near the eyes, use triple antibiotic. After 2 - 3 weeks areas that have not regrown are grafted.

Early excision and grafting

For very limited burns

tetanus prophylaxis

wound care for all bites

dog bites

considered provoked if the dog was petted while eating or teased. No rabies prophylaxis required. But observe dog to see if it might have rabies. If bite is to the face, give rabies prophylaxis then see if the dogs behavior is reassuring then deiscontinue

If unprovoked (dog or any wild animal) then the available animal is killed to see if it has rabies. If not available, prophylaxis required.

snakebite

signs of venom are severe local pain.swelling and discoloration developing within 30 min of the bite. If present draw blood for typing and crossmach, coagulation studies, Liver and renal function tests. Do not follow boy scout measures. Dosage and antivenin depend on size and type of envenomation

Bee stings

Kill more people than snake bites because of the anyphylactic reaction. epinephrine is drug of choice .3 - .5 ml per 1000 ml of solution. remove stinger without squeezing

Black widow bite

antidote is IV calcium gluconate. Patients get nausea vomiting and muscle cramps

Brown recluse spider

Patient develops skin ulcer with necrotic center an halo of erythema the day after. Dapsone is helpful, surgery can be done but after a week to asses full damage.

Human Bites

Require massive irrigation and debridement.

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