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82 Cards in this Set
- Front
- Back
75% of mortality occurs in the hospital from trauma with in ____ hours
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48 hours,
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Possible contraindications to cricothyroidotomy
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include age younger than 12 years and suspected laryngeal trauma; permanent laryngeal damage may result in the former, and uncorrectable airway obstruction may occur in the latter situation.
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Induction agent contraindicated in brain and major vascular injuries?
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Ketamine due to increased ICP and BP, HR
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Indicators of spine injury in awake patients
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neck pain, tenderness, and extremity paresthesias
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C-spine clearance for awake patient
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(1) no midline cervical tenderness, (2) no focal neurologic deficit, (3) normally alert, (4) not intoxicated, and (5) no distracting painful injury
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The Canadian C-Spine Rule for Radiography after Trauma
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(1) Is there any high-risk factor mandating radiography? (2) Are there low-risk factors that permit safe evaluation of the range of motion of the neck? (3) Can the patient rotate the neck laterally for 45 degrees in each direction without pain? Comparison of these two sets of criteria showed that the Canadian Rule is more reliable than NEXUS in diagnosing cervical spine injury in responsive patients.
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The Eastern Association for the Surgery of Trauma (EAST) guidelines for radiographic clearance of c-spine for patients w/ risk factors for injury
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3 views AP, lateral and open mouth and head CT
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Stable fractures of the c-spine
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Stable fractures of the spine are spinous process fractures; isolated osteophyte, trabecular, transverse process, and avulsion fractures without ligament injury; and wedge compression fractures with loss of ≤25% of vertebral body heigh
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Standard measure of diganosing ligmentous injury
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flexion and extension series
however, MRI is more accurate |
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Nasothracheal intubation risks in trauma patients
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epistaxis, failure of intubation, and the possibility of entry of the endotracheal tube into the cranial vault or the orbit if there is damage to the cranial base or the maxillofacial complex.
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increased possibility of cranial injury w/ the following
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midface fractures involving the frontal sinus, as well as the orbitozygomatic and orbitoethmoid complexes.
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Clinical signs of penetrating cervical airway trauma
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escape of air, hemoptysis, and coughing are present in almost all patients
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major blunt laryngotracheal damage signs on presentation
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includes hoarseness, muffled voice, dyspnea, stridor, dysphagia, odynophagia, cervical pain and tenderness, ecchymosis, subcutaneous emphysema, and flattening of the thyroid cartilage protuberance (Adam's apple).
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blunt laryngeal trauma patients may also have which condition?
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cervical spine injury, in 70%
no cricothroidotomy or blind intubation! |
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signs of thoracic airway injuries
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Pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema, and a continuous air leak from the chest tube are the usual signs of this injury; they occur frequently but are not specific for thoracic airway damage. In patients intubated without the suspicion of a tracheal injury, difficulty in obtaining a seal around the endotracheal tube or the presence on a chest radiograph of a large radiolucent area in the trachea corresponding to the cuff suggests a perforated airway.
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Complications of thoracic airway injury repair
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suboptimal and complicated by stump leak and empyema, suture line stenosis, or the need for tracheostomy or pneumonectomy.
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Which patients should be managed surgically for thoracic airway injury
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Patients with lesions larger than 4 cm, cartilaginous rather than membranous injuries, concomitant esophageal trauma, progressive subcutaneous emphysema, severe dyspnea requiring intubation and ventilation, difficulty with mechanical ventilation, pneumothorax with an air leak through the chest drains, and/or mediastinitis are still managed surgically. Those without these problems may be treated nonoperatively with a reasonable outcome.
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Signs of flail chest
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Coexisting hemopneumothorax, paradoxical chest wall movement, and/or pain-induced splinting, history of trauma
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what is predictive of development of ARDS in patient w/ flail chest?
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once the contusion volume exceeds 20% of total lung volume
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Management of flail chest w/o gas abnormalities
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conservative - epidural analgesia w/ local and opioids, no need for resp support until pt can't exchange gasses, otherwise increase in morbidity and mortality.
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which patient's should get intubated for flail chest
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pulmonary contusion, respiratory insufficiency, or failure despite adequate analgesia, clinical evidence of severe shock, associated severe head injury, or injury requiring surgery, airway obstruction, and significant pre-existing chronic pulmonary disease
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Ventilation settings for trauma patients
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. Positive end-expiratory pressure (PEEP) with low tidal volumes (6 to 8 mL/kg) and low inspiratory alveolar or plateau pressures should be used to decrease the likelihood of ARDS if ventilation is controlled
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ventilation settings in severe bilateral pulmonary contusion patients
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differential lung ventilation via a double-lumen endobronchial tube, or high-frequency jet ventilation may enhance oxygenation and cardiac function, which may be compromised by concomitant myocardial contusion or ischemia
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Base deficit in shock for mild, mod and severe trauma.
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A base deficit between 2 and 5 mmol/L suggests mild shock, between 6 and 14 mmol/L indicates moderate shock, whereas >14 mmol/L is a sign of severe shock. An admission base deficit in excess of 5 to 8 mmol/L correlates with increased mortality
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Class I trauma
blood loss HR BP RR Urine output mental status fluid replacement |
<750 ml
<15% <100 HR normal BP 14-20 RR > 30 ml urine Slightly anxious crystaloid |
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Class II trauma
blood loss HR BP RR Urine output mental status fluid replacement |
750-1500
15-30 % >100 HR normal BP 20-30 RR urine output of 20-30 ml/hr mildly anxious crystaloid |
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Class III trauma
blood loss HR BP RR Urine output mental status fluid replacement |
1500-2000
30-40% >120 HR decreased BP 30-40 RR urine 5-15 anxious and confused crystaolloid + blood |
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Class IV trauma
blood loss HR BP RR Urine output mental status fluid replacement |
> 2L blood
> 40 % > 140 HR Decreased BP > 35 RR urine output negligible confused and lethargic crystalloid + blood |
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transfusion threshold in trauma
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hematocrit <25% for young, healthy patients and <30% for older patients or those with coronary or cerebrovascular disease
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vicious cycle or lethal triad of trauma
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acidosis, hypothermia and coagulopathy
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fluid therapy for severe trauma
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liquid plasma replacement along with fluids and PRBCs as soon as the patient arrives in the emergency department, and continuing it throughout surgery.
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what is liquid plasma and how does it differ from FFP
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Liquid plasma differs from fresh-frozen plasma (FFP) in that it is frozen at -180°C within 8 to 24 hours, whereas FFP is frozen within 8 hours. It contains all of the stable proteins found in FFP, although in slightly lower concentrations. The major difference is a 25% reduction of factor VIII. One unit of FFP contains approximately 7% of the coagulation factor activity of a 70-kg man.
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most important cause of death in head-injury patients?
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hypotension
a single episode of systolic blood pressure <90 mm Hg is associated with a 50% increase in mortality, and subsequent episodes or lower pressures78 increase mortality even further. |
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most appropriate thearpeutic interventions for head trauma
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normalization of the systemic blood pressure (mean blood pressure >80) and maintaining the Pao2 >95, the ICP <20 to 25 mm Hg, and the CPP 50 to 70 mm Hg. 30 degrees head elevation, sedation and neuromuscular blockers are given as necessary, and cerebrospinal fluid is drained through a ventriculostomy catheter, if available. Rapid and adequate restoration of the intravascular volume with isotonic crystalloid and, if necessary, with colloid solutions should be aimed at maintaining the CPP between 50 and 70 mm Hg while attempting to minimize further brain swelling.
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crystaloid of choice for brain trauma
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NS, since LR is slightly hypotonic
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diuretic of choice for head trauma
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mannitol
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mannitol toxicity and adverse effects
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hyponatremia, high serum osmolality, and a gap between calculated and measured serum osmolality >10 mOsm/L, may result when the drug is given in large doses (2 to 3 g/kg) or to patients with renal failure. Mannitol should be used with great care in the presence of hypotension, sepsis, nephrotoxic drugs, or pre-existing renal disease as these may also precipitate renal failure. the effects of mannitol result from its activity in regions of the brain where the blood–brain barrier is intact. It may exacerbate edema in injured areas in which it may easily enter the tissues.
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what is AVDo2
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1.34 · Hgb · (Sao2 – Sjvo2), with the saturations expressed as decimal values, and normally is approximately 6. An increase in this value is a sign of insufficient blood flow, whereas a subnormal level indicates hyperemia. A reduction in ICP with elevation of CPP during treatment is reflected by a rise in Sjvo2 and a narrowing of the AVDo2, presumably reflecting an improvement in the circulation to the brain.
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criticism of use of AVDO2 in brain injured patient
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reflects global 02 consumption, not in the ischemic area
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when one should use barbiturates to decrease ICP in head injured patients?
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only for refractory high ICP
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predictors of spine injury
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a history of a motor vehicle, industrial, or athletic accident, an act of violence, or a fall; penetrating trauma resulting in a neurologic deficit below a specific spinal level; or pain and tenderness over the involved vertebrae
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does spinal pain always localize to the level of injury?
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No
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signs of spinal injury in comatose patients
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flaccid areflexia, loss of rectal sphincter tone, paradoxical respiration, and bradycardia in a hypovolemic patient suggest the diagnosis
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harmful side-effects of steroid therapy for spinal cord patients
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increased rate of sepsis, pneumonia, and days of intensive care and positive-pressure ventilation, and is also associated with increased mortality in the 36 to 74% of patients with spine injuries who also have head injuries
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at which C-spine level will a patient need ventilatory assistance?
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C 4 and above
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neuromuscular blockade in quadriplegic patients
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avoid succinylcholine , may use Roc to intubate if RSI is desired
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indication for thoracotomy in patients w/ hemothorax
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Initial drainage of 1,000 mL of blood, or collection of >200 mL/hr for several hours, a “white lung” appearance on the anteroposterior chest radiograph, or a continuous major air leak from the chest tube
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What is VATS? when does it need to be performed?
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Hemodynamically stable patients with persistent bleeding of <150 mL/hr are managed with video-assisted thoracoscopic surgery (VATS) to control bleeding. This procedure requires placement of a double-lumen tube to collapse the lung on the involved side; it can also be useful in diagnosis of suspected diaphragmatic, cardiac, or mediastinal injuries; evaluation of some bronchopleural fistulas; and evacuation of clotted blood or an empyema that does not drain with a chest tube. Use of VATS decreases the need for open thoracotomy and the number of negative explorations in stable trauma patients
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consequences of penetrating cardiac trauma?
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Pericardial tamponade, cardiac chamber perforation, and fistula formation between the cardiac chambers and the great vessels
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classic findings of cardiac tamponade?
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tachycardia, hypotension, distant heart sounds, distended neck veins, pulsus paradoxus, or pulsus alternans
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findings in cardiac injury? after blunt trauma
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angina, sometimes responding to nitroglycerin, dyspnea, chest wall ecchymosis and/or fractures; dysrhythmias of any type; and right-sided or left-sided congestive heart failurea
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diagnosis of cardiac injury? after blunt trauma
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The diagnosis is based on the 12-lead ECG, troponin I level, and echocardiography. The ECG is very sensitive, although not specific. A normal trace cannot rule out the diagnosis, but it is the best screening test. Common ECG abnormalities include almost any type of dysrhythmia, ST or T-wave changes, and conduction delays.
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Clinical sings of aortic injury?
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Increased arterial pressure and pulse amplitude in upper extremities
Decreased arterial pressure and pulse amplitude in lower extremities Absent or weak left radial artery pulse Osler's sign: discrepancy between left and right arm blood pressure Retrosternal or interscapular pain Hoarseness Systolic flow murmur over the precordium or medial to the left scapula Neurologic deficits in the lower extremities |
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radiographic features of aortic injury?
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Widened mediastinum
Blurring of the aortic contours Widened paraspinal interfaces Left apical cap Opacified aortopulmonary window Broadened paratracheal stripe Displacement of the left main-stem bronchus Displaced SVC Rightward deviation of the esophagus and trachea Nasogastric tube shift Left hemothorax Sternal and/or upper rib fractures Lung contusion Pneumothorax |
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ct findings in aortic injury
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Mediastinal hematoma
Aortic wall irregularity Intimal flap False aneurysm Pseudocoarctation Intramural hematoma Intraluminal clot or medial flap |
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ultrasound findings for aortic injury
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Intimal flap
Turbulent flow Dilated aortic isthmus Acute false aneurysm Intraluminal medial flap Hemothorax Hemomediastinum |
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at which anatomical point does thoracic aortic injury mostlikely appear?
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at the isthmus—the junction between the free and fixed portions of the descending aorta—in 90% of cases, and carries an 80% mortality in the first hour following injury.
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classification of thoracic aortic injuries with TEE?
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grade 1 injury consists of an intramural hematoma, limited intimal flap and/or mural thrombus; grade 2 injury consists of subadventitial rupture, injury to the media, altered aortic geometry and/or small hemomediastinum; grade 3 injury consists of transsection with massive blood extravasation, intraluminal obstruction causing pseudocoarctation, and ischemia
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which class based on TEE for thoracic aortic injuries could be treated w/ observation?
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class 1: intramural hematoma, limited intimal flap and/or mural thrombus
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Pelvic fractures, management of bleeding
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external fixation and extraperitoneal packing of the pelvis in the OR followed by angiography and possible embolization is more beneficial than only external fixation and angiography
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Delayed fracture repair is associated with?
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an increased risk of deep vein thrombosis (DVT), pneumonia, sepsis, and the pulmonary and cerebral complications of fat embolism. In open fractures, an additional important concern is infection. Wounds left unrepaired for more than 6 hours are likely to become septic.
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sings of vascular trauma in patients w/ extremity fractures
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pain, pulselessness, pallor, paresthesias, and paresis
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Indication for surgery in patients w/ compartment syndrome?
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A pressure exceeding 40 cm H2O is an indication for immediate surgery.
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partial-thickness burn
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is red, blanches to touch, and is sensitive to painful stimuli and heat.
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Superficial burns ( first degree) involve the :
and heal? |
burns involve the epidermis and upper dermis, and heal spontaneously
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Deep partial-thickness (second-degree) involve?
and how are they managed? |
deep dermis and require excision and grafting to ensure rapid return of function
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Deep burns ( third degree), what does it look like?
management? |
does not blanch even with deep pressure and is insensate
Complete destruction of the dermis requires wound excision and grafting to prevent wound infection that may lead to local sepsis and systemic inflammation |
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Fourth degree burns involve....
management? |
involve muscle, fascia, and bone, necessitating complete excision and leaving the patient with limited function.
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systemic effects of a severe burn
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stimulates the release of mediators such as interleukins, tumor necrosis factor, and neopterins, locally—producing wound edema—and into the circulation, resulting in immune suppression, hypermetabolism, protein catabolism, sepsis, and multisystem organ failure. Burns >40% TBSA consistently develop catabolism and weight loss that may last up to 1 year
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which pharmacological agents can decrases the catabolism in severe burns?
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low-dose insulin infusion, beta-blockade, and the synthetic testosterone analogue oxandrolone
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following a burn, how long does it take to develop parenchymal lung injury?
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1-5 days to ARDS
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Late lung complications of burns?
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pneumonia and PE, take longer than 5 days to develop
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ventialtory support in intubated burn patients?
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low levels of PEEP will prevent the pulmonary edema that may develop secondary to loss of laryngeal auto-PEEP in patients with significant airway obstruction before intubation. Airway humidification, bronchial toilet, and bronchodilators if needed for bronchospasm are also indicated.
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how does CO poisoning cause tissue hypoxia
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by its 200-fold greater affinity for hemoglobin than oxygen and by its ability to shift the hemoglobin dissociation curve to the left, impairing O2 unloading to the tissues. It also interferes with mitochondrial function, uncoupling oxidative phosphorylation and reducing adenosine triphosphate production, thus causing metabolic acidosis. CO can be a direct myocardial toxin, preventing survival in patients who suffer cardiac arrest
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does normal pulse ox reading exclude CO poisoning?
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No, although arterial gas w/ co-oxymeter does
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at which CO concentration does blood turn cherry-red?
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> 40%
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List symptoms for the following COHbc level?
< 15-20 20-40 40-60 >60 |
1. headache, dizziness, and occas confusion
2. nausea, vomiting, disorientation, visual impairment 3. agitation, combativeness, hallucinations, coma, shock 4. death |
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at which COHb level is hyperbaric oxygen recommended
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> 30 %
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Other cause of hypoxia in burned patients than CO toxicity?
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Cyanide toxicity
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cyanide toxicity presentation
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unexplained metabolic acidosis, neuro symptoms, agitation, confusion, coma, elevated plasma lactate
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what is the toxic level of cyanide?
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0.2 mg/L and lethal leve is above 1 mg/ L
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management of cyanide toxicity victim?
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oxygen at high flows. the ion has short half life and pharmacological therapies - thiosulfate, amyl nitrate, sodium nitrate- offer no additional benefit.
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