Surgery Surgical Recall Flashcards

chest tube
Terms Definitions
What are the three main elements of the ATLS protocol?
1. Primary survey/resuscitation
2. Secondary survey
3. Definitive care
How and when should the patient history be obtained?
Obtained while completing the primary survey; often the rescue squad, witnesses, and family members must be relied upon
What are the 5 steps of the primary survey?
Think: "ABCDEs"
Airway (and C-spine stabilization)
Breathing
Circulation
Disability
Exposure and Environment
What principles are followed in completing the primary survey?
Life-threatening problems discovered during the primary survey are always addressed before proceeding to the next step
What are the goals during assessment of the airway?
Securing the airway and protecting the spinal cord
In addition to the airway, what MUST be considered during the airway step?
Spinal immobilization
What comprises Spinal immobilization?
Use of a full backboard and rigid cervical collar
In an alert pt, what is the quickest test for an adequate airway?
Ask a question; if the pt can speak, the airway is intact
What is the first maneuver to establish an airway?
Chin lift, jaw thrust, or both; if successful, often an oral or nasal airway can be used temporarily maintain the airway
If Chin lift, jaw thrust, or both are unsuccessful, what is the next maneuver to establish an airway?
Endotracheal intubation, either nasal or oral (oral if the pt is not breathing with inline C-spine traction)
When is nasotracheal intubation contraindicated?
In pts w/ maxillofacial fracture or apnea
If all other methods are unsuccessful, what is the definitive airway?
Cricothyroidotomy, A.K.A. "surgical airway": incise the cricothyroid membrane b/w the cricoid cartilage inferiorly and the thyroid cartilage superiorly and place an endotracheal or tracheostomy tube into the trachea
What must always be kept in mind during difficult attempts at establishing an airway?
Spinal immobilization and adequate oxygenation; if at all possible, pts must be adequately ventilated with 100% oxygen using a bag and mask before any attempt at establishing an airway
What are the goals in assessing breathing?
Securing oxygenation and ventilation
Treating life-threatening thoracic injuries
What comprises adequate assessment of breathing?
Inspection - for air movement, respiration rate, cyanosis, tracheal shift, jugular venous distension, asymmetric chest expansion, use of accessory muscles of respiration, open chest wounds
Auscultation - for breath sounds
Percussin - for hyperresonance or dullness over either lung field
Palpation - for presence of sucutaneous emphysema, flail segments
What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step?
Tension pneumothorax
Open pneumothorax
Massive hemothorax
What is a pneumothorax?
Imjury to the lung, resulting in release of air into the pleural space b/w the normally apposed parietal and visceral pleura
How is pneumothorax diagnosed?
Tension pneumothorax is a clinical diagnosis: dyspnea, JVD, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side
What is the treatment of a tension pneumothorax?
Immediate decompression by needle thoracostomy in the second intercostal space midclavicular line, followed by tube thoracostomy placed in the anterior/midaxillary line in the fourth intercostal space (level of the nipple in men)
What is the medical term for a "sucking chest wound"?
Open pneumothorax
How is an open pneumothorax diagnosed and treated?
Diagnosis: usually obvious, with air movement through a chest wall defect and pneumothorax on CXR
Treatment in the ER: +/- intubation w/ positive-pressure ventilation, tube thoracostomy (chest tube), occlusive dressing over chest wall defect
What does a pneumothorax look like in CXR?
Loss of lung markings; lung-air interface
What is flail chest?
Two separate fractures in 3 or more consecutive ribs
How is flail chest diagnosed?
A flail segment of chest wall that moves paradoxically (sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall)
What is the major cause of respiratory compromise with flail chest?
Underlying pulmonary contusion!
What is the treatment of flail chest?
Intubation with positive pressure ventilation and PEEP PRN (let ribs heal on their own)
What is cardiac tamponade?
Bleeding into the pericardial sac, resulting in constriction of heart, decreasing inflow and resulting in decreased cardiac output (the pericardium does not stretch!)
What are the signs and symptoms of cardiac tamponade?
Tachycardia/shock with Beck's triad, pulsus paradoxus, Kussmaul's sign
What is Beck's triad?
1. Hypotension
2. Muffled heart sounds
3. JVD
What is Kussmaul's sign?
JVD with inspiration
How is cardiac tamponade definitely diagnosed?
Ultrasound (echocardiogram)
What is the treatment of cardiac tamponade?
Immediate IV fluid bolus; with pericardiocentesis, subsequent surgical exploration is mandatory (pericardiocentesis is a temporizing option; rare)
How is massive hemothorax diagnosed?
Hypotension; unilaterally decreased or absent breath sounds; dullness to percussion; CXR, CT scan, chest tube output
What is the treatment of massive hemothorax?
Volume replacement
Tube thoracostomy (chest tube)
Use of cell saver, if available
Removal of the blood (which will allow apposition of the parietal and visceral pleura, sealing the defect and slowing the bleeding)
What are indications for emergent thoracotomy for hemothorax?
Massive hemothorax =
1. >1500 cc of blood on initial placement of chest tube
2. Persistent > 200 cc of bleeding via chest tube per hour x 4 hours
What are the goals in assessing circulation?
Securing adequate tissue perfusion; treatment of external bleeding
What is the initial test for adequate circulation?
Palpation of pulses; As a rough guide, if a radial pulse is palpable, then systolic pressure is at least 80 mmHg; if a femoral or carotid pulse is palpable, then systolic pressure is at least 60 mmHg
What comprises adequate assessment of circulation?
HR, BP, Peripheral perfusion, urinary output, mental status, capillary refill (nml <2 seconds), exam of skin: cold, clammy = hypovolemia
Who can be hypovolemic with normal BP?
The young; autonomic tone can maintain BP until CV collapse is imminent
Which pts may not mount a tachycardic response to hypovolemic shock?
Those with concomitant spinal cord injuries
Those on beta-blockers
Well-conditioned athletes
How are sites of external bleeding treated?
By direct pressure; +/- tourniquets
What is the best and preferred IV access in the trauma pt?
"Two large-bore IV's" (14-16 gauge), IV catheters in the upper extremities (peripheral IV access)
What are alternate sites of IV access?
Percutaneous and cutdown catheters in the lower leg saphenous; central access into femoral, jugular, subclavian veins
For a femoral vein catheter, how can the anatomy of the right groin be remembered?
Lateral to medial "NAVEL":
Nerve
Artery
Vein
Extralymphatic material
Lymphatics
thus, the vein is medial to the femoral artery pulse (or think "venous close to penis")
What is the trauma resuscitation fluid of choice?
Lactated Ringer's (LR) solution (isotonic, and the lactate helps buffer the hypovolemia-induced metabolic acidosis)
What types of decompression do trauma pts receive?
Gastric decompression with an NG tube and Foley catheter bladder decompression after normal rectal exam
What are the contraindications to placement of a Foley?
Signs of urethral injury
Severe pelvic Fx in men
Blood at the urethral meatus
"High-riding" "ballotable" prostate (loss of urethral tethering)
Scrotal/perineal injury/ ecchymosis
What test should be obtained prior to placing a Foley catheter if urethral injury is fearing?
A retrograde urethrogram (RUG; dye in penis retrograde to the bladder and x-ray looking for extravasation of dye)
How is gastric decompression achieved with a maxillofacial fracture?
Not with an NG tube b/c the tube may perforate through the cribiform plate into the brain; place an oral-gastric tube (OGT), not an NG tube
What are the goals in assessing disability?
Determination of neurologic injury

(think: neurologic disability)
What comprises adequate assessment of disability?
Mental status - GCS
Pupils - a blown pupil suggests ipsilateral brain mass (blood) as herniation of the brain compresses CN III
Motor/sensory - screening exam for lateralizing extremity movement, sensory deficits
Describe the GCS scoring system
Eye opening (E)
4 - opens spontaneously
3 - opens to voice (command)
2 - opens to painful simtulus
1 - does not open eyes
think: eyes = "four eyes"
Motor response (M)
6 - obeys commands
5 - localizes painful stimulus
4 - withdraws from pain
3 - decorticate posture
2 - decerebrate posture
1 - no movement
(think: motor = "6-cylinder motor"
Verbal response (V)
5 - appropriate and oriented
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1 - no sounds
(think: verbal = "Jackson 5")
What is the GSC score for a dead man?
GCS 3
What is the GSC score for a patient in a "coma"?
GCS less then or equal to 8
How does scoring differ if the patient is intubated?
The verbal evaluation is omitted and replaced with a "T"; thus, the highest score for an intubated pt is 11 T
What are the goals in obtaining adequate exposure?
Complete disrobing to allow a thorough visual inspection and digital palpation of the patient during the secondary survey
What is the "environment" of the E?
Keep a warm Environment (i.e., keep the pt warm; a hypothermic pt can become coagulopathic).
What principle is followed in completing the secondary survey?
Complete PE, including all orifices: ears, nose, mouth, vagina, rectum
Why look in the ears during the secondary survey?
Hemotympanum is a sign of basilar skull fracture; otorrhea is a sign of basilar skull fracture
Examination of what part of the trauma pt's body is often forgotten?
The pt's back (logroll the pt and examine!)
What are typical signs of basilar skull fracture?
Raccoon eyes, Battle's sign, clear otorrhea or rhinorrhea, hemotympanum
What diagnosis in the anterior chamber must not be missed on the eye exam?
Traumatic hyphema = blood in the anterior chamber of the eye
What potentially destructive lesion must not be missed on the nasal exam?
Nasal septal hematoma; the hematoma must evacuated; not, it can result in pressure necrosis of the septum
What is the best indication of a mandibular fracture?
Dental malocclusion; tell the pt to "bite down" and ask: "Does that feel nml to you?"
What signs of thoracic trauma are often found on the neck exam?
Crepitus or subcutaneous emphysema from tracheobronchial disruption/PTX; tracheal deviation from tension pneumothorax; JVD from cardiac tamponade; carotid bruit heard with seatbelt neck injury resulting in carotid artery injury
What is the best PE for broken ribs or sternum?
Lateral and anterior-posterior compression of the thorax to elicit pain/instability
What physical signs are diagnostic for thoracic great vessel injury?
None; diagnosis of great vessel injury requires a high index of suspicion based on the mechanism of injury; associated injuries, and CXR/radiographic findings (e.g., widened mediastinum)
What must be considered in every penetrating injury of the thorax at or below the level of the nipple?
Concomitant injury to the abdomen; remember, the diaphragm extends to the level of the nipples in the male on full expiration
What is the significance of subcutaneous air?
Indicates PTX, until proven otherwise
What is the proper technique for examing the thoracic and lumbar spine?
Logrolling the pt to allow complete visualization of the back and palpation of the spin to elicit pain over fractures, step off (spine deformity)
What conditions must exist to pronouce an abdominal PE negative?
An alert pt w/o evidence of head/spinal cord injury or drug/EtOH intoxication (even then, the abdominal exam in not 100% accurate)
What physical signs may indicate intra-abdominal injury?
Tenderness; guarding, peritoneal signs; progressive distention (always uses a gastric tube for decompression of air); seatbelt sign
What is the seatbelt sign?
Ecchymosis on lower abdomen from wearing a seatbelt (approx 10% of pts w/ this sign have a small bowel perforation)
What must be documented from the rectal exam?
Sphincter tone (as an indication of spinal cord injury);
Presence of blood (as an indication of colon or rectal injury);
Prostate position (as an indication of urethral injury)
What is the best PE technique to test for pelvic fractures?
Lateral compression of the iliac creasts and greater trochanter and anterior-posterior compression of the symphysis pubis to elicit pain/instability
What is the "halo" sign?
CSF from nose/ear will form a clear "halo" around the blood on a cloth
What physical signs indicate possile urethral injury thus contraindicating placement of a foley catheter?
High-riding ballotable prostate on rectal exam; presence of blood at the meatus; scrotal or perineal ecchymosis
What must be documented from the extremity exam?
Any Fx or joint injuries; any open wounds; motor and sensory exam, particularly distal to any Fx; distal pulses; peripheral perfusion
What complication after prolonged ischemia to the lower extremity must be treated immediately?
Compartment syndrome
What is the treatment for compartment syndrome?
Fasciotomy (four-compartment below the knee)
What injuries must be suspected in a trauma pt with a progressive decline in mental status?
Epidural hematoma, subdural hematoma, brain swelling w/ rising ICP

but hypoxia/hypotension must be ruled out!
What are the classic blunt trauma ER x-rays?
1. AP chest film
2. AP pelvis film
What are the common trauma labs?
Blood for CBC, chemistries, amylase, LFTs, lactic acid, coagulation studies, and type and crossmatch; urine for U/A
Will the hematocrit be low after an acute massive hemorrhage?
No (no time to equilibrate)
How can a C-spine be evaluated?
1. Clinically by PE
2. Radiographically
What pts can have their C-spines cleared by a physical exam?
No neck pain on palpation with full range of motion with no neurologic injury (GCS 15), no EtOH/drugs, no distracting injury, no pain meds
Ho do you rule out a C-spine bony fracture?
With a CT scan of the C-spine
What do you do if no bony C-spine Fx is apparent on CT scan and you cannot obtain an MRI in a COMATOSE pt?
This is controversial; the easiest answer is to leave the pt in a cervical collar
What x-rays are used for evaluation of cervical spine LIGAMENTOUS injury?
MRI, lateral flexion and extension C-spine films
What findings on chest film are suggestive of thoracic aortic injury?
Widened mediastinum (most common finding), apical pleural capping, loss of aortic contour/KNOB/AP window, depression of left main stem bronchus, nasogastric tube//tracheal deviation, pleural fluid, elevation of right mainstem bronchus, clinical suspicion, high-speed mechanism
What study is used to rule out thoracic aortic injury?
Spiral CT of mediastinum looking for mediastinal hematoma w/ CTA
Thoracic arch aortogram (gold standard)
What percentage of thoracic aortograms will reveal an aortic injury?
Only about 10% of studies are positive
What is the most common site of thoracic aortic traumatic tear?
Just distal to take off of the left subclavian artery
What studies are available to evaluate for intra-abdominal injury?
FAST, CT< DPL
What is a FAST exam?
Ultrasound:
Focused Assessment with Sonography for Trauma = FAST
What does the FAST exam look for?
Blood in the peritoneal cavity looking at Morison's pouch, bladder, spleen, and pericardial sac
What does DPL stand for?
Diagnostic Peritoneal Lavage
What diagnostic test is the test of choice for evaluation of the unstable pt with blunt abdominal trauma?
FAST
What is the indication for abdominal CT in blunt trauma?
Normal vital signs with abdominal pain/tenderness
What is the indication for DPL or FAST in blunt trauma?
Unstable vital signs (hypotension)
How is a DPL performed?
Place a catheter below the umbilicus (in pts w/o a pelvic fracture) into the peritoneal cavity
Aspirate for blood and if less than 10 cc are aspirated, infuse 1 L of saline or LR
Drain the fluid (by gravity) and analyze
What is a "grossly positive" DPL?
> 10 cc blood aspirated
Where should the DPL catheter be placed in a pt with a pelvic fracture?
Above the umbilicus
A common error- if you go below the umbilicus, you may get into a pelvic hematoma tracking b/w the fascia layers and thus obtain a false-positive DPL
What constitutes a positive peritoneal tap?
Prior to starting a peritoneal lavage, the DPL catheter should be aspirated. If more than 10 mL of blood or enteric contents are aspirated, then this constitutes a positive tap and requires laparotomy
What are the indications of a positive peritoneal lavage in blunt trauma?
Classic: inability to read newprint through lavaged fluid
RBCs > 100,000/ mm^3
WBCs > 500/mm^3
Lavage Fluid (LR/NS) drained from chest tube, Foley, NG tube

Less common:
Bile present
Bacteria present
Feces present
Vegetable matter present
Elevated amylase level
What must be in place before a DPL is performed?
NG tube and Foley catheter (to remove the stomach and bladder from the firing line)
What injuries does CT miss?
Small bowel injuries and diaphragm injuries
What injuries does DPL miss?
Retroperitoneal injuries
What study is used to evaluate the urethra in cases of possible disruption due to blunt trauma?
Retrograde urethrogram (RUG)
What are the most emergent orthopaedic injuries?
1. Hip dislocation - must be reduced immediately
2. Exsanguinating pelvic fracture (binder or external fixator)
What findings would require a celiotomy in a blunt trauma victim?
Peritoneal signs, free air on CXR/CT, unstable pt with positive FAST exam or positive DPL results
What is the treatment of a GSW to the belly?
Exploratory laparotomy
What is the evaluation of a stab wound to the belly?
If there are peritoneal signs, heavy bleeding, shock, unstable vital signs, perform exploratory laparotomy. Otherwise, many surgeons either observe the asymptomatic stab wound pt closely, use local wound exploration to rule out fascial penetration, or use DPL
What depth of neck injury must be further evaluated?
Penetrating injury through the platysma
Define the anatomy of the neck by trauma zone: Zone III
Angle of the mandible and up
Define the anatomy of the neck by trauma zone: Zone II
Angle of the mandible to the cricoid cartilage
Define the anatomy of the neck by trauma zone: Zone I
Below the cricoid cartilage
Note: the zones are in the same anatomic order as the LeFort facial fractures (III, II, I) (or I, II, III following carotid blood flow)
How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone:
Zone III
Selective exploration
How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone:
Zone II
Surgical exploration vs. Selective exploration
How do most surgeons treat penetrating neck injuries (those that penetrate the platysma) by neck zone:
Zone I
Selective exploration
What is Selective exploration?
Selective exploration is basd on diagnostic studies that include A-gramor CT A-gram, bronchoscopy, esophagoscopy
What are the indications for surgical exploration in all penetrating neck wounds (Zone I, II, III)?
"Hard signs" of significant neck damage: shock, exsanguinating hemorrhage, expanding hematoma, pulsatile hematoma, neurologic injury, SUBQ emphysema
What is the "3-for-1" rule?
The trauma pt in hypovolemic shock acutely requires 3 L of crystalloid (LR) for every 1 L of blood loss
What is the minimal urine output for an adult trauma pt?
50 mL/hr
How much blood can be lost into the thigh with a closed femur fracture?
Up to 1.5 L of blood
Can an adult lose enough blood in the "closed" skull from a brain injury to cause hypovolemic shock?
Absolutely not! But infants can lose enough blood from a brain injury to cause shock
Can a pt be hypotensive after an isolated head injury?
Yes, but rule out hemorrhagic shock!
What is the breif ATLS history?
An "AMPLE" history:
Allergies
Medications
PMH
Last meal (when)
Events (of injury, etc)
In what population is a surgical cricothyroidotomy not recommended?
Any pt younger than 12 years; instead perform needle cricothyroidotomy
What are the signs of a laryngeal fracture?
Subcutaneous emphysema in neck
Altered voice
Palpable laryngeal fracture
What is the treatment of rectal penetrating injury?
Diverting proximal colostomy; closure of perforation (if easy, and definetly if intraperitoneal); and presacral drainage
What is the treatment of extraperitoneal minor bladder rupture?
"Bladder catheter" (Foley) drainage and observation; intraperitoneal or large bladder rupture requires operative closure
What intra-abdominal injury is associated with seatbelt use?
Small bowel injuries (L2 fracture, pancreatic injury)
What is the treatment of a pelvic fracture?
+/- pelvic binder until the external fixator is placed;
IVF/blood; +/- A-gram to embolize bleeding pelvic vessels
Bleeding from pelvic fractures is most commonly caused by arterial or venous bleeding?
Venous (approximately 90%)
If a pt has a laceration through an eyebrow, should you shave the eyebrow prior to suturing it closed?
No - 20% of the time, the eyebrow will not grow back if shaved!
What is the treatment of extensive irreparable biliary, duodenal, and pancreatic head injury?
Trauma whipple
What is the most common intra-abdominal organ injured with penetrating trauma?
Small bowel
How high up do the diaphragms go?
To the nipples (intercostal space #4); thus, intra-abdominal injury with penetrating injury below the nipples must be ruled out
Classic trauma question: "If you have only one vial of blood from a trauma victim to send to the lab, what test should be ordered?"
Type and cross (for blood transfusion)
What is the treatment of penetrating injury to the colon?
If the pt is in shock, resection and colostomy
If the pt is stable, the trend is primary anastomosis/repair
What is the treatment of small bowel injury?
Primary closure or resection and primary anastomosis
What is the treatment of minor pancreatic injury?
Drainage (e.g., JP drains)
What is the most commonly injured abdominal organ with blunt trauma?
Liver (in recent studies)
What is the treatment for significant duodenal injury?
Pyloric Exclusion:
1. Close duodenal injury
2. Staple off pylorus
3. Gastrojejunostomy
What is the treatment for massive tail of pancreas injury?
Distal pancreatectomy (usually perform splenectomy also)
What is "damage control" surgery?
Stop major hemorrhage and GI soilage. Pack and get out of the OR ASAP to bring the pt to the ICU to warm, correct coags, and resuscitate. Return pt to OR when stable, warm, and not acidotic
What is the "lethal triad"?
ACHe
1. Acidosis
2. Coagulopathy
3. Hypothermia

(think: ACHe = Acidosis, Coagulopathy, Hypothermia)
What comprises the workup/treatment of a stable parasternal chest gunshot/stab wound?
1. CXR
2. FAST, chest tube, +/- OR for sub xiphoid window; if blood returns, then sternotomy to assess for cardiac injury
What is the diagnosis with NGT in chest on CXR?
Ruptured diaphragm with stomach in pleural cavity
What films are typically obtained to evaluate extremity fractures?
Complete views of the involved extremity, including the joints above and below the fracture
What lab tests are used to look for intra-abdominal injury in children?
Liver function tests (LFTs) = increased AST and/or increased ALT
What is the only real indication for MAST trousers?
Prehospitalization, pelvic fracture
What is the treatment for human and dog bites?
Leave wound open, irrigation, antibiotics
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