Lavage with large volumes of water

Apply direct pressure to the wound

Deflate ET tube cuff and pull back 23cm at teeth,

If local wound exploration reveals NO fascial prez, admit pt 24hrs observe

Increased Lactate, Increased peak airway pressure if on vent, Decreased CO, Increased PVR, Acidosis, Decreased UOP

Supplemental oxygen and continued observation

Observation and oxygen, further treatment may not be needed

Listen to the patient’s breath sounds

Most blunt abdominal trauma is managed conservatively

Urgent echocardiogram (US) at the bedside

abdominal hollow viscous injury

Same 43yo patient, next step?

Urgent general surgery consult for decompressive laparotomy

Which of the following findings demonstrates a need for an emergent laparotomy?

Lack of response to initial fluid therapy

What’s the underlying cause of the opacity found on radiograph?

V/Q mismatch secondary to pulmonary contusion

Asia Impairment Scale? Cord Syndrome?

Asia score D with central cord syndrome

Immediate endotracheal intubation

Decreased right-sided tactile fremitus

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Surgery Block 3 Exam

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Questions 55

Answers

1
Q
Lavage with large volumes of water
apply an antimicrobial agent
Treat with a weak acid
Treat with calcium glucinate gel
Cover the skin with skin substitute
2
Q
Apply a tourniquet distal to the wound
Begin large volume isotonic fluid resuscitation
Reverse his anticoagulation
Irrigate the wound
Apply direct pressure to the wound
3
This patient GCS of 6 and head CT shows a bleed. What ICP monitor would be appropriate for this patient?
Richmond Bolt
Brain Tissue Oxygen Probe
Decompressive Craniotomy
Fiberoptic Intraparenchymal
Ventriculostomy
4
Which solid organ is most frequently injured in blunt trauma?
Sigmoid Colon
Stomach
Duodenum
Spleen
Liver
5
Q
Maturation
Migration
Proliferation
Inflammatory
6
At what ICP level would you drain the CSF when an intraventricular ICP monitor is placed?
20
10
30
40
50
7
Q
Three view abdominal plain film
Diagnostic Peritoneal Lavage
Ultrasound
Serum amylase and lipase
CT abdomen
8
Q
Exploratory Laparotomy
Placement of bilateral chest tubes
Median Sternotomy
CT of chest and ABD
Diagnostic Peritoneal Lavage (DPL)
9
Same 23yo TBI
Perform an immediate compressive craniotomy
3% Hypertonic Saline
Hyperventilate
Perform evacuation of scalp hematoma
Give 1 unit of whole blood
10
What triage category is this patient?
Minimal
Immediate
Delayed
Expectant
11
Q
Diagnostic peritoneal lavage
Exploratory laparotomy
Observation
Abdominal CT scan
Local wound exploration
12
What do you want to do for this guy?
Continue Observation
Fasciotomy
Splint and immobilize the leg
Administration of additional CroFab doses
Provide adequate analgesia
13
Q
Hypertension
Hypoglycemia
Sustained SaO2 of 92%
ETCO2 of 35mmHg
Hypotension
14
Next Step?
Order CXR
Perform a tube thoracostomy
Call the burn center
Perform NCD
Deflate ET tube cuff and pull back 23cm at teeth,
15
Q
Diagnostic peritoneal lavage
Formal ultrasound to rule out rupture of an abdominal aortic aneurysm
C-spine X-rays
Contrast enhanced computed tomography of the chest, abdomen and pelvis
Exploratory laparotomy
16
Which of the following CXR findings is most likely suggestive of traumatic rupture of the aorta (TRA)?
Right-sided diaphragmatic rupture
Pneumomediastinum
Enlarged cardiac silhouette
Widened mediastinum
Sternal fracture
17
What would be an appropriate IVF admin volume for this guy who is 60kg with a TBSA of 60%?
800ml/hr
600ml/hr
500ml/hr
400ml/hr
700ml/hr
18
Q
Urgent CT of the chest
Chest x-ray
Cardiac enzymes and EKG
Urgent pericardiocentesis
Transesophageal echocardiography
19
Q
Active Massive Transfusion Protocol
Apply a C-Collar
Emergent Thoracotomy
Apply BVM
Needle Thoracostomy
20
Q
If local wound exploration reveals fascia = absolute indication to explore
If local wound exploration reveals NO fascial prez, admit pt 24hrs observe
ABD CT is sensitive in detecting injury to diaphragm
Intra-ABD injury is highly unlikely in this pt
FAST exam reliably rules out intra-ABD injury in this pt
21
Q
Venous oozing
History of hemorrhage at the scene
Peripheral nerve deficit
Expanding hematoma
Non-pulsatile hematoma
22
Q
Increased Lactate
Increased peak airway pressure if on vent
Decreased CO, Increased PVR
Acidosis
Decreased UOP
23
Next step?
Elevate the leg
Emergent referral to orthopedics
Perform an urgent Escharotomy
Pull traction on the leg
Perform an urgent Fasciotomy
24
Q
Perform an emergent laparotomy
perform a cross-table lateral radiograph of the cervical spine
Head & ABD CT scan
Perform a Tube thoracostomy of the L chest
Supine and Lateral Decubitus Radiograph of the ABD
25
Q
Hyperbaric treatment
Left chest tube placement
Supplemental oxygen and continued observation
Thoracoscopic repair of lung injury
Left chest needle catheter placement
26
?
Cervical Vertebral Burst Fracture
Cervical Vertebral Compression Fracture
Pleural Effusion
Large Bowel Rupture
Pneumothorax
27
Q
Immediate tube thoracostomy
Observation and oxygen, further treatment may not be needed
Immediate endotracheal intubation
CT scan of the chest, abdomen and pelvis
Immediate needle decompression
28
Next best fluid choice
Plasmalyte
Lactated Ringers
1:1 (plasma:RBC)
Component Therapy 1:1:1
RBCs
29
Q
Tertiary Intention
Delayed Primary Intention
Secondary Intention
Primary intention
30
Now that you have completed the secondary survey what is next appropriate step to confirm the likely diagnosis?
CT w/ contrast
Lumbar Puncture
CT w/out contrast
MRI
Cervical AP & Lateral Radiograph
31
Q
Listen to the patient’s breath sounds
Perform a CT scan of the abdomen and thorax
Place a right chest tube
Perform a FAST
Obtain an upright CXR
32
Next step?
Tube Thoracostomy
Extubation and replace ET tube
CXR
CT scan
Massive Transfusion Protocol
33
Q
No Tx options that can be done outside the OR
Immobilization to a long backboard
Placement of a pelvic binder
Intravenous access with fluid resuscitation
34
26yo F MVC
Resuscitative Thorocotomy
Tube Thoracostomy of the L chest
Pericardiocentesis
Sternotomy
CT of the chest
35
Q
Most blunt abdominal trauma is managed conservatively
Blunt abdominal injuries are will not cause hematoma in the duodenum
Blunt abdominal injuries cannot result in rupture of a hollow viscus
Penetrating trauma causes more diaphragmatic injuries than blunt injuries
36
Q
Urgent pericardiocentesis
Urgent echocardiogram (US) at the bedside
Needle decompression of the right lung
Emergent left thoracotomy
Continue aggressive fluid administration
37
During the initial management of the patient with blunt thoracic trauma, which of the following is the first priority?
Determine Glasgow coma score
AP chest radiograph
Airway management
Central line placement
Immobilization of the pelvis
38
Suspect?
L-spine compression fracture
cervical vertebral compression fracture
abdominal hollow viscous injury
Cervical vertebral burst fracture
Pneumothorax
39
Same 43yo patient, next step?
increase IVF administration
Urgent urology consult for suprapubic catheter placement
Administer diuretics
Remove the Foley catheter
Urgent general surgery consult for decompressive laparotomy
40
Q
Topical anibiotics
Fasciotomy of the LUE
Cardiac monitoring
Escharatomy of the LUE
STSG over third degree burns
41
Which of the following findings demonstrates a need for an emergent laparotomy?
Obvious anatomical deformities of the extremities
GCS < 7
Lack of audible peristalsis
Lack of response to initial fluid therapy
Rapid and shallow breathing
42
Q
Left pulmonary contusion
Pneumomediastinum
Multiple R sided rib fractures
Left pneumothorax
Widened Mediastinum
43
What’s the underlying cause of the opacity found on radiograph?
V/Q mismatch secondary to pulmonary contusion
Widened mediastinum secondary to a great vessel injury
Pulmonary Edema secondary to volume overload
Cardiac Tamponade secondary to sternal fracture
Sepsis secondary to pneumonia
44
Q
Abnormal Head CT
GCS 3-8
Unilateral Pupil Dilation
Hypotension
SPO2 < 90%
45
Which of the following is the best interpretation of the patients CXR?
Normal CXR
Left sided pneumothorax
Nasogastric tube
Pneumoperitoneum
Right sided thoracostomy tube
46
TBSA % ???
60%
40%
90%
10%
30%
47
Asia Impairment Scale? Cord Syndrome?
Asia C with Brown-Sequard syndrome
Asia E with anterior cord syndrome
Asia cord C with anterior cord syndrome
Asia A with complete cord transection
Asia score D with central cord syndrome
48
Q
Determine GCS
Immediate transfer to the ICU
Insert two large bore IVs
Immediate endotracheal intubation
49
Q
Determine GCS
Endotracheal Intubation
Hyperventilate
Immediate transfer to ICU
Insert two large bore IV lines
50
Q
Caffeine-induced arrhythmia
Anxiety disorder
Pain
Fat embolism
Blunt cardiac injury
51
Q
Tracheal shift to the right side
Decreased right-sided tactile fremitus
Mediastinal shift to the right side
Left-sided hyper-resonance
52
Q
Immobilize the C-Spine
Check for pulses
Abdominal exam
Unclothe the patient
Check GCS
53
Which of the following statements is accurate regarding the use of the decision to get a CT scan?
Get a CT with contrast for suspicion of acute bleeds
CT should be reserved for operative planning by NSGY
CT takes precedence over neurosurgical consultation
Get a CT without contrast for suspicion of acute bleeds
Get a CTA of the neck in all cases of head injuries
54
Next step?
Emergent placement of a second Thoracostomy tube
Continue Observation
Urgent Thoracotomy
Emergency Angiography
Elective Video-Assisted Thoracoscopic Surgery
55
Q
Pulmonary contusion
Atelectasis
ICU psychosis
Occult pneumothorax
Fat embolism

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