Textbooks: Essentials of Surgery, Abernathy Surgical Secrets, First Aid for Surgery Clerkship
Free Practice Suturing Board: ETHICON 1-800-255-2500 (Registered Nurse Services, Johnson & Johnson) --- Common Problems in Surgery
General: Shock, Trauma, Acute Abdomen and Appendicitis, Hernia, Gastrointestinal Hemorrhage, Peptic Ulcer Disease, Biliary Tract Disease, Pancreatitis, Abdominal Masses, Colonic and Ano-rectal Disease, Arterial Occlusive Disease, Breast Masses
Endocrine: Thyroid, Parathyroid, Adrenal, Pancreas, Testicle, Ovary Cancer: Breast, Colon, Gastric, Pancreatic, Lung, Skin
--- Procedures: NEJM Videos In Clinical Medicine: http://www.nejm.org/multimedia/videosinclinicalmedicine Sterile Gloving by Jennifer Baler, RN, MSN, CCRN: http://www.youtube.com/watch?v=pAKZ3mdFIj4 Gowning & Surgical Scrub by Valencia Cardiovascular Technology: http://preview.tinyurl.com/348vkpn
--- Some Tips For Your First Day In The Operating Room (From Clerkship Students)
Scrub Cap Rule: You cannot enter an O.R., regardless of what is happening, without a scrub cap (hair cover) on. Mask Rule: If a patient is in the O.R., you have to wear a mask in the room.
Fogging: You may find no matter what type of mask you use in the O.R., whether it be a combined shield or with separate safety goggles, that your vision still fogs up. This is difficult to control due to the heat of your breath and the cool O.R. air. One trick is to put some tape over your nose and the nose-bridge of your mask, sealing your mask to your face. The latex-free brown tape works very well and doesn’t leave residue on your face.
Handling Tools: Learn the correct way to hold a scissor and needle holder (not between your thumb and pointer/middle finger). Watch how the doctors hold tools.
Measurements: It’s good to know what 1mm and 1cm look like. 1cm is about the width of your pinky nail. Scrub Nurse: They will save you; they know all the ins and out of the O.R. and can help you correctly gown, know where to stand, how to hold tools, and what the names of the tools are.
Safe Spot: “Surgery is a hands-on sport…if your hands are not on something, you’re not in the game.” When you are standing at the table observing, your hands should be placed on the patient, not at your waist or crossed/folded. Note that many patients will have warming devices on (Bair Hugger) or Sequential Compression Devices (SCDs), which inflate and deflate. So, you may feel this move under you if you’re at the patient’s legs; it’s not the patient moving. Knots: Don’t tie any knots unless you are absolutely certain you know how to tie them as square knots.
Other Details: You will learn the names of tools as you go, details of instrument handling, and techniques. Basic Surgical Skills textbooks (e.g. Mayo Clinic) provide pictures and further explanations if needed.
Rules of Surgery: Eat when you can, sleep when you can, don’t mess with the pancreas.
--- How To Succeed In Clerkship – First Aid For The Surgery Clerkship (Kaufman, Stead, & Stead)
In The OR: Eat before you begin the case. Pay attention and do a good job, even if you are just holding the retractor. Some students get light-headed from standing in one position, so make sure to shift your weight and bend your knees from time to time. This will keep you from fainting. Try to get a list of the cases for the coming day and study the basics the night before. Find out who you are working with and do a quick bibliography search on the surgeon. Assess the mood in the OR. Some surgeons will engage students while others will pretend you aren’t there. If your questions and comments reflect that you have read about the procedure and disease, things will go well. Keep a log of all surgeries you have attended, scrubbed on, or assisted with.
On The Wards: Most surgical ward teams begin rounding between 6 and 7am. Give yourself at least 10minutes per patient you are seeing to learn about the events that occurred overnight. Do not make scrubs your uniform unless specifically told to; dress professionally. The surgical rotation is often difficult, stressful, and tiring. Smooth out your experience by being nice to be around. Smile a lot and learn everyone’s name. Learn the hierarchy; address questions about ward functioning to interns or residents and address medical questions to attendings. Address patients and staff in a respectful way. Take responsibility for your patients, knowing everything there is to know about them. Be self-propelled and self-motivated. Be a team player and help with tasks, but don’t steal the spotlight, steal a procedure, or make a fellow medical student look bad. Be honest and never document information that is false. Keep patient information handy, such s on a small notebook.
Present patient information in an organized manner: “This is a [age] your old [gender] with a history of [major history] who presented on [date] with [major symptoms], and was found to have [working diagnosis]. [Tests done] showed [results]. Yesterday the patient [important changes, new plan, new tests, new medications]. This morning the patient feels [in patient’s words], and physical exam is significant for [findings]. Plan is [state plan].”
Presenting the chest radiograph (CXR): “This is the CXR or Mr. Jones. The film is an AP view with good inspiratory effort. There is an isolated fracture of the 8th rib on the right. There is no tracheal deviation or mediastinal shift. There is no pneumo- or hemothorax. The cardiac silhouette appears to be of normal size. The diaphragm and heart borders on both sides are clear; no infiltrates are noted. There is a central venous catheter present, the tip of which is in the superior vena cava.”
Procedure note: “Under sterile conditions following anesthesia with 5cc of 2% lidocaine with epinephrine and negative wound exploration for foreign body, the laceration was closed with 3-0 Ethilon sutures. Wound edges were well approximated and no complications occurred. Wound was dressed with sterile gauze and triple antibiotic ointment.”
Operative Notes: It is also useful to learn how to write preoperative, operative, and postoperative notes. However, interns and residents will likely be writing these.
Your Rotation Grade: Inpatient evaluation includes ward time with residents and attendings, may be worth 50% of your grade, and is largely subjective. Ambulatory evaluation includes clinic performance and clinical notes. Written examination, such as NBME or “Shelf” exam. Objective structures clinical examination (OSCE) includes a student’s bedside manner and physical exam skills, which could comprise up to 25% of the grade.
Study: If you see a patient with a thyroid mass, read about Graves disease, Hashimoto’s, thyroid cancer, and the technique of needle aspiration.
Prepare a talk: You may be asked to give a small talk during your rotation. If not, you should volunteer. The ideal topic is slightly uncommon but not rare, for example: bariatric surgery.
Lights: Study in a bright room to help prevent you from falling asleep.
Eating: Make sure your meals are balanced, with lean protein, fruits and vegetables, and fiber. A sugar, high-carbohydrate meal will give you an initial burst of energy for 1 to 2 hours, but then you’ll drop.
--- Survival Guides – Netter Anatomy & Student Consult
Most frequently encountered cases: groin lumps (hernias), varicose veins, neck masses, breast lumps, jaundice, bowel obstruction. Other topics for attending quizzes include: anesthesia, analgesia, antibiotics, IV fluids. When studying a topic, organize as: Definitions, Classifications, Epidemiology, Etiology, Clinical Presentation, Differential Diagnosis, Investigations/Tests, and Management.
Be Safe: Assume a mature and professional role, know patient’s history/vital signs/investigation results, don’t do procedures you are unsure of, ask questions when in doubt, most important person in the room is the patient. Be Sensible: Admit you don’t know the answer, don’t rush, don’t argue.
Be Sharp: Dress smartly in respect of your patients and teachers, be accurate and brief when answering or asking a question (“speak up then shut up”).
Be Seen: Come early and leave late (but do get some sleep), ask if you can help, don’t ask “when can I go home?” Do’s & Don’ts: Attend ward rounds, check inpatients on the ward and present them on ward rounds, get to know the inpatients and follow their progress, make presentations at meetings or discussions, help out with ward duties, see outpatients at clinics (do history, examination, differential diagnosis, and decide on investigations), if possible see patients in the emergency department, attend surgeries to learn (not just to be present), spend your time wisely for your own gain, know the rules of the operating room (wear hat, mark, correct footwear, wear your ID badge, remove jewelry, know how to scrub in or ask someone with experience)
--- Top 100 Secrets – Abernathy Surgical Secrets (5th, Harken & Moore)
1) Clinical determinants of brain death are the loss of the papillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and respiratory reflexes for > 6 hours. The patient should also undergo an apnea test, in which the pCO2 is allowed to rise to at least 60 mmHg without coexistent hypoxia. The patient should be observed for the absence of spontaneous breathing.
2) The estimated risks of HBV, HCV, and HIV transmission by blood transfusion in the United States are 1 in 205,000 for HBV, 1 in 1,935,000 for HCV, and 1 in 2,135,000 for HIV.
3) The most common location of an undescended testicle is the inguinal canal.
4) Most common solid renal mass in infancy is congenital mesoblastic nephroma and in childhood Wilms' tumor. 5) Ogilvie's syndrome is acute massive dilatation of the cecum and the ascending and transverse colon without organic obstruction.
6) The best screening for prostate cancer is digital rectal exam combined with serum prostate-specific antigen. 7) The most common histologic type of bladder cancer is transitional cell carcinoma.
8) Carcinoma in situ of the bladder is treated with immunotherapy with intravesical bacillus Calmette-Guérin. 9) Localized renal cell carcinoma is treated with surgery (radical nephrectomy).
10) The most common cause of male infertility is varicocele.
11) The most common nonbacterial cause of pneumonia in transplant patients is cytomegalovirus. 12) Chimerism is leukocyte sharing between the graft and the recipient so that the graft becomes a genetic composite of both the donor and the recipient.
13) OKT3 is a mouse monoclonal antibody that binds to and blocks the T-cell CD3 receptor. 14) The most common disease requiring liver transplant is hepatitis C.
15) Cystic hygroma is a congenital malformation with a predilection for the neck. It is a benign lesion that usually presents as a soft mass in the lateral neck.
16) In neuroblastomas, age at presentation is the major prognostic factor. Children younger than 1 year have an overall survival rate > 70%, whereas the survival rate for children older than 1 year is < 35%.
17) The most feared complication of diaphragmatic hernia is persistent fetal circulation.
18) The three most common variants of tracheoesophageal fistula are (1) proximal esophageal atresia with distal tracheoesophageal fistula, (2) isolated esophageal atresia, and (3) tracheo-esophageal fistula with esophageal atresia. 19) Atresia can occur anywhere in the GI tract: duodenal (50%), jejunoileal (45%), or colonic (5%). Duodenal atresia arises from failure of recanalization during the 8th-10th week of gestation; jejunoileal and colonic atresia are caused by an in utero mesenteric vascular accident.
20) The types of aortic dissection are ascending (type A) dissection, which involves only the ascending or both the ascending and descending aorta, and descending dissection (type B), which involves only the descending aorta. 21) A solitary pulmonary nodule is < 3 cm and is discrete on chest radiograph. It is usually surrounded by lung parenchyma.
22) Mediastinal staging is indicated in patients with apparent or documented lung cancer who have (1) known lung cancer with mediastinal nodes > 1 cm accessible by cervical mediastinal exploration, as assessed by CT scan; (2) adenocarcinoma of the lung and multiple mediastinal lymph nodes < 1 cm; (3) central or large (> 5 cm) lung cancers with mediastinal lymph nodes < 1 cm; and (4) lung cancer with risk of thoracotomy and lung resection.
23) The most common causes of aortic stenosis are now congenital anomalies and calcific (degenerative) disease. 24) In mitral regurgitation, the left ventricle ejects blood via two routes: (1) antegrade, through the aortic valve, or (2) retrograde, through the mitral valve. The amount of each stroke volume ejected retrograde into the left atrium is the regurgitant fraction. To compensate for the regurgitant fraction, the left ventricle must increase its total stroke volume. This ultimately produces volume overload of the left ventricle and leads to ventricular dysfunction. 25) The indications for CABG are (1) left main coronary artery stenosis; (2) three-vessel coronary artery disease (70% stenosis) with depressed left ventricular (LV) function or two-vessel coronary artery disease (CAD) with proximal left anterior descending (LAD) involvement; and (3) angina despite aggressive medical therapy. 26) Hibernating myocardium is improved by CABG. Myocardial hibernation is reversible myocardial contractile function associated with a decrease in coronary flow in the setting of preserved myocardial viability. Some patients with global systolic dysfunction exhibit dramatic improvement in myocardial contractility after CABG.
27) The surgical treatment of ulcerative colitis is total colectomy with ileoanal pouch anastomosis.
28) Dieulafoy's ulcer is a gastric vascular malformation with an exposed submucosal artery, usually within 2-5 cm of the gastroesophageal junction. It presents with painless hematemesis, often massive.
29) The role of blind subtotal colectomy in the management of massive lower gastrointestinal bleeding is limited to a small group of patients in whom a specific bleeding source cannot be identified. The procedure is associated with a 16% mortality rate.
30) Colorectal polyps < 2 cm have a 2% risk of containing cancer, 2 cm polyps have a 10% risk, and polyps > 2 cm have a cancer risk of 40%. Sixty percent of villous polyps are > 2 cm, and 77% of tubular polyps are < 1 cm at the time of discovery.
31) Patients with colorectal cancer with lymph node involvement (Dukes' C) should receive chemotherapy postoperatively to treat micrometastases.
32) Goodsall's rule states the location of the internal opening of an anorectal fistula is based on the position of the external opening. An external opening posterior to a line drawn transversely across the perineum originates from an internal opening in the posterior midline. An external opening, anterior to this line, originates from the nearest anal crypt in a radial direction.
33) Incarcerated inguinal hernia: structures in the hernia sac still have a good blood supply but are stuck in the sac because of adhesions or a narrow neck of the hernia sac. Strangulated inguinal hernia: hernia structures have a compromised blood supply because of anatomic constriction at the neck of the hernia.
34) Chvostek's sign is spasm of the facial muscles caused by tapping the facial nerve trunk. Trousseau's sign is carpal spasm elicited by occlusion of the brachial artery for 3 minutes with a blood pressure cuff.
36) The only biochemical test that is routinely needed to identify patients with unsuspected hyperthyroidism is serum thyroid-stimulating hormone concentration.
37) The surgically correctable causes of hypertension are renovascular hypertension, pheochromocytoma, Cushing's syndrome, primary hyperaldosteronism, coarctation of the aorta, and unilateral renal parenchymal disease.
38) The "triple negative test" or "diagnostic triad" for diagnosing a palpable breast mass includes physical examination, breast imaging, and biopsy.
39) Chest wall radiation is indicated after mastectomy in patients with greater than 5 cm primary cancers, positive mastectomy margins, or more than four positive lymph nodes, all of which are associated with heightened locoregional recurrence rates.
40) Sentinel lymph nodes are the first stop for tumor cells metastasizing through lymphatics from the primary tumor. 41) The most common site of origin of subungual melanomas is the great toe. Amputation at or proximal to the metatarsal phalangeal joint and regional sentinel lymph node biopsy are advised by most authors.
42) Ramus marginalis mandibularis, the lowest branch of the nerve that innervates the depressor muscles of the lower lip, is the most commonly injured facial nerve branch during parotidectomy.
43) Waldeyer's ring is the mucosa of the posterior oropharynx covering a bed of lymphatic tissue that aggregates to form the palatine, lingual, pharyngeal, and tubal tonsils. These structures form a ring around the pharyngeal wall. This may be the site of primary or metastatic tumor.
44) A patient in whom the head and neck examination is completely normal but FNA of a cervical node reveals squamous cancer should have examination of the mouth, pharynx, larynx, esophagus, and tracheobronchial tree under anesthesia (triple endoscopy). If nothing is seen, blind biopsy of the nasopharynx, tonsils, base of tongue, and pyriform sinuses should be done at the same sitting.
45) The microorganisms implicated in atherosclerosis include Chlamydia pneumoniae, Helicobacter pylori, streptococci, and Bacillus typhosus.
46) The cumulative 10-year amputation rate for claudication is 10%.
47) The absolute reduction in risk of stroke is 6% over a 5-year period in asymptomatic patients with > 60% stenosis who undergo carotid endarterectomy plus aspirin versus patients treated with aspirin alone (5.1% versus 11%). 48) Abdominal aortic aneurysm's average expansion rate is 0.4 cm/year.
49) Heparin binds to antithrombin III, rendering it more active.
50) The patient with suspected intermittent claudication should initially be evaluated by obtaining ankle brachial index or segmental limb pressures at rest.
51) Shock is suboptimal consumption of O2 and excretion of CO2 at the cellular level.
52) Nitric oxide is synthesized in vascular endothelial cells by constitutive nitric oxide synthase and inducible NOS, using arginine as the substrate.
53) Saliva has the highest potassium concentration (20 mEq), followed by gastric secretions (10 mEq), then pancreatic and duodenal secretions (5 mEq).
54) Basal caloric expenditure = 25 kcal/kg/day with a requirement of approximately 1 g protein/kg/day. 55) 6.25 g of protein contains 1 g of nitrogen.
56) Dextrose has 3.4 kcal/g, protein 4 kcal/g, fat 9 kcal/g (20% lipid solution delivers 2 kcal/mL). 57) Maximal glucose infusion rates in parenteral formulas should not exceed 5 mg/kg/min.
58) Refeeding syndrome occurs in moderately to severely malnourished patients (e.g., chronic alcoholism or anorexia nervosa) who, upon presentation with a large nutrient load, develop clinically significant decreases in serum phosphorus, potassium, calcium, and magnesium levels. Hyperglycemia is common secondary to blunted insulin secretion. ATP production is mitigated, and the classic presentation is respiratory failure.
59) Glutamine is the most common amino acid found in muscle and plasma. Levels decrease after surgery and stress. Glutamine serves as a substrate for rapidly replicating cells (interestingly, it is also the number one metabolic substrate for neoplastic cells), maintains the integrity and function of the intestinal barrier, and protects against free radical damage by maintaining GSH levels. Glutamine is unstable in IV form unless linked as a dipeptide.
60) Fever is caused by activated macrophages that release interleukin-1, tumor necrosis factor, and interferon in response to bacteria and endotoxin. The result is a resetting of the hypothalamic thermoregulatory center. 61) Cardiac output = heart rate x stroke volume; normal CO is 5-6 L/min.
62) SVR = [(MAP - CVP)/CO] x 80; normal SVR is 800-1200 dyne.sec/cm-5. 63) Hypovolemic shock: low CVP and PCWP, low CO and SVO2, high SVR. 64) Cardiogenic shock: high CVP and PCWP, low CO and SVO2, variable SVR.
65) Septic shock: low or normal CVP and PCWP, high CO initially, high SVO2, low SVR.
66) Kehr's sign is concurrent LUQ and left shoulder pain, indicating diaphragmatic irritation from a ruptured spleen or subdiaphragmatic abscess. The diaphragm and the back of the left shoulder enjoy parallel innervation.
67) Rebound tenderness implies peritoneal inflammation and irritation not simply abdominal tenderness. 68) The 5 Ws of post-operative fever are wound (infection), water (UTI), wind (atelectasis, pneumonia), walking (thrombophlebitis), and wonder drugs (drug fevers).
69) Cricothyroidotomy should not be performed in patients < 12 years old or any patient with suspected direct laryngeal trauma or tracheal disruption.
70) The radial (wrist) pulse estimates SBP > 80 mmHg; femoral (groin) pulse estimates SBP > 70 mmHg; and carotid (neck) pulse estimates SBP > 60 mmHg.
71) A general rule for crystalloid infusion to replace blood loss is a 3:1 ratio of isotonic crystalloid to blood. 72) Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis) are clinical indicators of basilar skull fracture.
73) CPP = MAP - ICP. Some debate exists on the minimum allowable CPP, but consensus indicates that a cerebral perfusion pressure of 50-70 mmHg is necessary.
74) Violation of the platysma defines a penetrating neck wound.
75) Tension pneumothorax is air accumulation in the pleural space eliciting increased intrathoracic pressure and resulting in a kinking of the SVC and IVC that compromises venous return to heart.
76) Most common site of thoracic aortic injury in blunt trauma is distal to the take-off of the left subclavian artery. 77) The most common manifestation of blunt myocardial injury is arrhythmia.
78) Indications for thoracotomy in a stable patient with hemothorax include an immediate tube thoracostomy output of > 1500mL and ongoing bleeding of 250mL/h for 4 consecutive hours.
79) Beck's triad is hypotension, distended neck veins, and muffled heart sounds.
80) The hepatic artery supplies approximately 30% of blood flow to the liver while the portal vein supplies the remaining 70%. The oxygen delivery, however, is similar for both at 50%.
81) The Pringle maneuver is a manual occlusion of the hepatoduodenal ligament to interrupt blood flow to the liver. 82) Splenectomy significantly decreases IgM levels.
83) 90% of trauma fatalities due to pelvic fractures are due to venous bleeding and bone oozing; only 10% of fatal pelvic bleeding from blunt trauma is arterial (most common site is superior gluteal artery).
84) Intraperitoneal bladder rupture from blunt trauma: operative management. Extraperitoneal rupture: observant management.
85) Pseudoaneurysm is a disruption of the arterial wall leading to a pulsatile hematoma contained by fibrous connective tissue (but not all three arterial wall layers, which defines a true aneurysm).
86) The earliest sign of lower extremity compartment syndrome is neurologic in the distribution of the peroneal nerve with numbness in the first dorsal webspace and weak dorsiflexion.
87) Posterior knee dislocations are associated with popliteal artery injuries and are an indication for angiography. 88) Management of suspected navicular fracture despite negative radiography is short-arm cast and repeat x-ray in 2 weeks; at high risk for avascular necrosis.
89) Parkland formula: lactated Ringer's at 4mL/kg x %TBSA (second- and third-degree only) of burn. Infuse 50% of volume in first 8 hours and the remaining 50% over the subsequent 16 hours.
90) The metabolic rate peaks at 2.5 times the basal metabolic rate in severe burns > 50% TBSA. 91) Gallstones and alcohol abuse are the two main causes of acute pancreatitis.
92) Alcohol abuse accounts for 75% of cases of chronic pancreatitis.
93) Isolated gastric varices and hypersplenism indicate splenic vein thrombosis and are an indication for splenectomy.
94) The treatment for gallstone pancreatitis is cholecystectomy and intraoperative cholangiogram during the same hospital stay once the pancreatitis has subsided.
95) Proton pump inhibitors irreversibly inhibit the parietal cell hydrogen ion pump.
96) Definitive treatment of alkaline reflux gastritis after a Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm efferent jejunal limb.
97) Cushing's ulcer is a stress ulcer found in critically ill patients with central nervous system injury. It is typically single and deep, with a tendency to perforate.
98) Curling's ulcer is a stress ulcer found in critically ill patients with burn injuries.
99) Marginal ulcer is an ulcer found near the margin of gastroenteric anastomosis, usually on the small bowel side. 100) Most common cause of small bowel obstructions is adhesive disease. The second common cause is hernias. --- Suturing Basics – eMedicine Suturing Techniques (MacKay-Wiggan)
Lidocaine: 1% or 2% solution, lasts 30-60 minutes, preferred for vascular disease or immunocompromised. Lidocaine 2% with Epinephrine: Vasoconstriction, lasts 2-6 hours, not for fingers/toes/penis/nose/earlobes.
Bupivacaine (Marcaine): 0.25% or 0.5% solution, lasts up to 20 hours, cardiotoxic at high doses.
Local anesthetic max doses: Lidocaine is 4.5mg/kg (30cc for 70kg pt), Bupivacaine is 3mg/kg (50cc for 70kg pt). Anesthetic injection: Use smallest needle possible (25 or 30 gauge), injected through open wound, warming syringe by rolling in your hand may reduce injection pain, creams (EMLA, ethyl chloride) likely work via placebo effect. Irrigation: Clean wound with saline or Ringer lactate only, not Betadine or soap, do not shave hair or eyebrows. Scalpels: #10 for long straight cuts (abdomen), #11 for puncture cuts (central line), #15 for plastic surgery. Suture size: 4-0 nylon for general skin closure, 5-0 nylon for face, 10-0 is tiny, #5 larger than #1.
Suture needles: Cutting needle for skin, tapered needle for soft tissues, blunt needle for infection risk (e.g. HIV). Suture material: Absorbable for buried sutures, silk for homeostasis, nylon for general closure.
Needle Driver: Ring finger through loop, middle finger over loops, thumb is not through loop (just pressing it), index finger extends along the needle holder shaft, sewing is via pronation and supination of hand.
Arming needle: Grasp two-thirds to three-fourths distance from needle tip, needle point faces non-dominant hand. Simple interrupted stitch: Most common, 1cm gaps (width of pinky fingernail), enter at 90-degrees minimally to help evert skin edges, “build pyramids, not ditches”, for edges “approximate, don’t strangulate”, scar tissue will never expand to fix defects/gaps (myofibroblasts), all knots should be tied square, Surgeon knot may be used once.
Key structures to align: Center of laceration, vermillion border, lip philtrum, ear helix, eyebrow, eyelid, hairline. Signs of infection: Redness (rubor), heat (calor), pain (dolor), odor, purulent drainage.
Suture removal: Grasp knot, cut other side of suture close to skin, pull toward incision to reduce tension. Running stitch: Not common in the ED, provides even wound tension, one damaged stitch ruins entire suture. Horizontal mattress stitch: Helps evert edges and reduce wound tension.
Vertical mattress stitch: Helps evert edges and reduce dead space, does not significantly reduce tension. Half-buried mattress (corner) stitch: For stellate lacerations, preserves blood supply to skin tips.
Subcuticular stitch: Absorbable in healthy tissue, no external marks, minimizes scarring, cover with Steri-Strips. Deep sutures: Absorbable in healthy tissue, for multilayer closure.
Locking continuous stitch: For airtight or watertight closure, such as stomach, bowel, lung.
--- Mayo Clinic Basic Surgical Skills (1999, Sherris & Kern)
Tissue Injury: Wounding has three stages. Inflammation is 1-5 days and has increased erythema, lymphocytes, proteolytic enzymes causing debridement via leukocytes, and pain. Proliferation is 5-14 days and involves fibroblasts producing collagen, creating the scar (cicatrix). Scar maturation is 14 days onward and involves some wound contraction and 95% strength by week six.
Healing Factors: Healing affected by increasing age, increased weight, poor nutrition,
electrolyte imbalances, blood supply, immune responses, chronic illnesses, drugs (antineoplastic, radiation therapy), and smoking.
Intention: Healing by primary intention involves sutures. Healing by secondary intention involves natural processes (no sutures), where granulation tissue starts from deeper tissues and moves outward (4-8 weeks). Tertiary intention is recommended for dirty wounds, and involves secondary intention then suturing (delayed suturing).
Tension Lines: Incisions should be made parallel to relaxed skin tension lines to minimize
scarring. Undermining with scissors below the skin can help to relax the skin so that it is under less tension. Dead Space: Deep wounds should be fully closed to prevent dead-space, which causes dehiscence (breakdown). Kern’s Rule: Percent of anesthetic * 10 = mg of drug per mL. E.g. 2% lidocaine is 20mg lidocaine/cc.
Drawing Anesthetics: Since medication bottles are pressurized, you will need to inject air into the bottle in the amount of fluid you want to remove. So, to draw 3mL of lidocaine, you would attach the needle to the syringe, pull in 3cc of air, insert the syringe into the lidocaine bottle held upside down, inject 3cc into the bottle, then draw out 3cc of lidocaine. Use a small needle (27g or 30g) and inject slowly.
Pre-Scrubbing: Since you can’t touch your face after you scrub, you must have your cap, mask, and eye protection on before scrubbing. Tape over your nose and the mask edge can help prevent fogging.
Scrub Sinks: Sinks are usually activated by automatic sensor, a knee push, or a foot petal.
Drying: Post-scrub, enter the O.R. backwards with hands up. The scrub nurse should hand you a towel. Keep your hands held outward so the towel bottom doesn’t touch your scrubs. Dry from fingertips down to elbow.
Gloves: Common sizes range from 6 1/2 (small) to 8 (large). Ensure your thumbs will line up with the thumbs when you are putting them on. If your hands are not fully dry, this will be an annoying process.
Scalpels: A #10 blade is held like a violin bow with pointer finger on top for pressure, cutting so the belly of the blade is at 30-degrees from the skin. A #15 blade is held like a pencil at 45-degrees from the skin.
Tissue Scissors: Tissue (dissection) scissors have blunted tips that curve upward. They are held with the ring finger through a loop and the thumb through a loop. The middle finger rests for support and the pointer finger points. Common scissors are the straight Mayo, curved Mayo, and Metzenbaum (Metz).
Forceps: Held like chopsticks. Common forceps are the Adson, Bayonette Bipolar, Bonney, Debakey, Russian, and Sponge Stick.
Retractors: Pull tissue for visualization. Common retractors are the Army Navy, Baby Bennette, Deaver, Deep Gelpi, Mayo Body Wall, Nerve Root, Richardson, and Weitlaner.
Hemostat (Clamp): For grasping tissue and vessels. Common clamps are the Allis, Carmalt, Debakey, Jake, Kelly, Kocher, Mosquito, Right Angle, and Tonsil.
Suction: Some are continuous (no port) and some are intermittent (finger port).
Electrical: There are electrocautery devices and electrosurgical pencils (e.g. Bovie). Used for burning tissue to arrest bleeding as well as for cutting. Since they are electrical, they do not cut through rubber gloves.
Cutting Sutures: Usually a 3-4mm tail is recommended. Slide down to the knot with the scissors, rotate 90-degress, and cut. This will ensure you are not directly on the knot and are about 3mm above.
Absorbable Suture Materials:
Name Material Strength Tensile Reactivity Tissue Handling Security Knot Absorption
Collagen Beef Tendon Poor +2 Fair Poor 1 to 2 weeks
Plain gut Animal Collagen Poor +4 Fair Poor 1 to 2 weeks
Chromic gut Animal Collagen Poor +3 Fair Fair 1 to 2 weeks
Coated Vicryl
Polyglactin 910 Coated Polyglactin 370 and
Calcium Sterate
Good +1 Good Fair 3 months
Dixon "S" Polyglycolic Good +1 Fair Good 3 months
PDS Polydioxanone Good +1 Poor Poor 6 months
Monocryl Polyglicaprone 25 Fair +1 Good Good 3 months
Non-Absorbable Suture Materials:
Name Material Tissue
Reactivity Handling Knot Security
Silk Silk +4 Good Good
Ethilon Polyamide (Nylon) +2 Fair Fair
Dermalon Polyamide (Nylon) +2 Poor Poor
Surgamid Polyamide (Nylon) +2 Poor Poor
Nurolon Polyamide (Nylon) +2 Good Fair
Prolene Polyolefin (Polypropylene) +1 Poor Poor
Mersilene Polyester +2 Good Good
Dacron Polyester +2 Good Good
Ethibond Polyester (Coated Polybutilate) +2 Good Good
Surgical Steel Stainless Steel +1 Poor Good
Nurolon: May predispose to infection. Prolene: Low coefficient of friction. Stainless Steel: May kink. Square Knots: Use a resource such as the ETHICON Knot Tying Manual or the Conidian Knot Tying Manual. Practice until your muscle memory prevents you from tying anything but square knots. At one point during the square knot tie, your hands must cross.
Surgeon’s Knot: This may be used for the first throw. However, it should not be a substitute for good tension. Also, this knot is technically not square, so the number of throws needed increases by one.
Instrument Tie: Performed by placing the needle holder between the ends of the suture, over the injury line. The long end is looped over the needle holder and the short end is grasped and pulled through. The next step is repeated again, with the needle holder in midline and the long end (now on the other side of the wound) looping over the tool. Free Vessel Ligation: Free vessel end is held by hemostat and first part of square knot is tied and slid down the hemostat onto the vessel. At least 4 knots should be placed. The end is then cauterized before hemostat release. Figure-Of-8 Stick Tie: Useful for larger vessels. A needle is passed back and forth in a figure-of-8 fashion and then a knot is tied starting with a surgeon’s knot. The end is then cauterized before hemostat release.
Bone Wax: Bleeding areas of bone can be controlled with a soft, clay-like material called bone wax.
Halving: A cutaneous wound should be closed by halving. The first suture should divide the wound in half and each additional sutures should divide into halves as well. This helps keep edges lined up.
Subcutaneous Closure: For deeper wound to prevent dead space, absorbable sutures must be used. Subcuticular Closure: A buried technique that improves scar appearance.
Purse String: For closing holes. Do not enter the lumen with the suture.
Fusiform (Elliptical) Excision: When excising skin, it is good to have the length be 1.5 to 3 times the width of the incision. Anything closer to a 1:1 ration will prevent closure without puckering ends (“dog ears”).
Z-Plasty: useful for lengthening contracted scars and reorienting the direction of scars. Suture Removal: Clip near knot, close to skin, grasp knot, and pull through.
Staple Removal: Using a staple removal tool, put bottom part below staple on skin, then squeeze tool.
--- Suturing Basics – First Aid Surgery Clerkship (Stead, Stead, & Kaufman)
Location Suture Size/Type Suture Technique Removal
Scalp 3-0 or 4-0 nylon or polypropylene
Interrupted in galea, single tight layer in scalp,
horizontal mattress if bleeding not well controlled 7-12 days Pinna 5-0 Vicryl/Dexon in perichondrium Close perichondrium with interrupted Vicryl and close skin with interrupted nylon 3-5 days Eyebrow 4-0 or 5-0 Vicryl (SQ)
6-0 nylon for skin Layered closure 3-5 days
Eyelid 6-0 nylon Single-layer horizontal mattress or simple
interrupted 3-5 days
Lip
4-0 Vicryl (mucosa) 5-0 Vicryl (SQ or muscle) 6-0 nylon (skin)
If wound through lip, close three layers (mucosa,
muscle, skin); otherwise do two-layer closure 3-5 days Oral 4-0 Vicryl Simple interrupted or horizontal mattress if muscularis of tongue involved N/A Face 6-0 nylon (skin) 5-0 Vicryl (SQ) Simple interrupted for single layer, layered closure for full-thickness laceration 3-5 days Trunk 4-0 Vicryl (SQ, fat)
4-0 or 5-0 nylon (skin) Single or layered closure 7-12 days
Extremity 3-0 or 4-0 Vicryl (SQ, muscle) 4-0 or 5-0 nylon (skin)
Single-layer interrupted or vertical mattress; apply
splint if over a joint 10-14 days
Hands/Feet 4-0 or 5-0 nylon Single-layer closure with simple interrupted or horizontal mattress; apply splint if over a joint 7-12 days Nail bed 5-0 Vicryl Meticulous placement to obtain even edges, allow to dissolve N/A
--- Article – Benign Prostatic Hyperplasia (Barry & Roehrborn, BMJ 2001;323:1042–6)
Common symptoms: urinary frequency, urgency, a week and intermittent stream, needing to strain, a sense of incomplete emptying, and nocturia.
Beneficial interventions: Alpha-blockers, 5alpha reductase inhibitors, transurethral resection (TURP), transurethral microwave thermotherapy (TUMT), and transurethral needle ablation (TUNA).
Unknown effectiveness: TURP versus less invasive surgical techniques.
Alpha Blockers: May be more effective than 5alpha reductase inhibitors. May cause dizziness with withdrawal. 5alpha Reductase Inhibitors: May decrease libido (e.g. finasteride).
TURP: Better than watchful waiting and does not increase risk of erectile dysfunction or incontinence. Still, may cause bleeding, erectile dysfunction, and retrograde ejaculation.
TUMT: Limited evidence that TUMT is more effective than alpha blockers over six months. TUNA: Fewer side effects than TURP but less symptom improvement.
Saw Palmetto: One review found self-rated improvement was better in those taking saw palmetto. Beta Sitosterol: One review found improvement in lower urinary tract symptoms in the short term. Rye Grass: One review found self-rated improvement was better and reduced nocturia in the short term.
--- Article – Bowel Obstruction & Pseudo-Obstruction (Kahi & Rex, Gastroenterol N Am 2003;32:1229-47) Bowel obstruction is due to mechanical interruption of flow while pseudo-obstruction is characterized by dilation of the bowel in the absence of a causative anatomic lesion.
Small bowel obstructions are usually due to benign lesions while colonic obstruction is usually due to neoplasms. Peritoneal adhesions following laparotomy account for up to 75% of small bowel obstructions (SBOs).
SBO Symptoms: Abdominal distension, vomiting, constipation, crampy abdominal pain with paroxysms that occur every 4 to 5 minutes. Proximal obstructions tend to have more nausea and vomiting. Bowel sounds may be hyperactive and high-pitched (tinkling) initially, but may become hypoactive as motility decreases. The presence of peritoneal signs suggests strangulation, mandating urgent laparotomy.
Radiographs: Supine abdominal films can help estimate the degree of distension. Upright abdominal films can show distended loops of small bowel.
Managing SBO: IV fluids, NG tube, early surgical intervention due to low likelihood of spontaneous resolution. Adenocarcinoma accounts for the majority (60%) of large bowel obstructions (LBOs).
Managing LBO: IV fluids, NG tube, surgical intervention, endoluminal stents for nonresectable tumors.
Volvulus, or torsion, most commonly involves the cecum, followed by the sigmoid colon. Radiographs classically show a massively dilated, kidney-shaped cecum extending into the left upper quadrant.
Acute colonic pseudo-obstruction (ACPO) is synonymous with acute colonic ileus and Ogilvie’s syndrome. It is thought to be caused by hypersympathetic activation combined with suppressed parasympathetic activation. There are a wide variety of causes, such as narcotics, anticholinergics, alcoholism, trauma, and abdominal surgery. Managing ACPO: IV fluids, NG tube, assess underlying conditions such as medications or electrolyte imbalances. Ambulation helps; if non-ambulatory use prone or knee-chest position. Perform rectal exam every 6 hours. If conservative therapy fails, prokinetic agents may be used (e.g. erythromycin, cisapride, metoclopramide, and neostigmine). With neostigmine, symptomatic bradycardia may occur so atropine should be available. The
effectiveness of neostigmine may decrease the use of colonoscopic decompression. Surgical therapy is a last resort. --- Article – Management of Gallstones (Ahmed & Ramsey, Am Fam Physician 2000;61:1673-80)
Gallstones are a major cause of morbidity worldwide and cholecystectomy is the most commonly performed abdominal surgery. Up to 90% of stones are cholesterol with the rest being pigmented stones.
Biliary sludge (microlithiasis) is made of mucin, precipitates of cholesterol, and calcium bilirubinate. It usually precedes the formation of gallstones. Increasing age, female gender, and pregnancy increase risk.
Diabetics have a propensity for obesity, hypertriglyceridemia, and gallbladder hypomotility.
Common duct stones (choledocholithiasis) is most commonly caused by a stone from the gallbladder. Flukes and parasites (e.g. Asian population) increase risk for bile duct stones.
Differentiating Features of Gallstone-Induced Complications Feature Biliary colic Acute cholecystitis Chronic
cholecystitis Cholangitis Pancreatitis
Pain site Epigastrium RUQ RUQ RUQ Epigastric
Pain duration < 3 hours > 3 hours Variable Variable Variable
Mass No masses RUQ mass No masses +/- +/-
Fever x +/- +/- +/- +/-
Increased WBC x +/- +/- +/- +/-
Increased amylase Normal +/- x +/- +/-
Complications of gallstones occur 70-80% of the time with biliary colic, 12% with perforation of the gallbladder, 10% with acute cholecystitis, and the rest with disorders such as emphysematous cholecystitis, Mirizzi’s syndrome, and hydrops of the gallbladder.
Lab testing includes WBC count (leukocytosis with a “left shift”), serum aminotransferase, alkaline phosphatase, bilirubin, and amylase levels.
Ultrasonography should be a routine examination for the confirmation or exclusion of gallstone disease. Sensitivity and specificity is >95% for gallstones >2mm in diameter. Ultrasound is less sensitive for choledocholithiasis. A sonographic Murphy sign may be present.
Endoscopic retrograde cholangiopancreatography (ERCP) is the best method to diagnose choledocholithiasis. CT and MRI are now comparable to ERCP in terms of accuracy.
Hepatobiliary scintography (HBS) using Tc-99m-IDA, also known as a hepatobiliary iminodiacetic acid (HIDA) scan, can confirm or exclude acute cholecystitis with a high degree of sensitivity and specificity. Failure to image the gallbladder within 90 minutes despite adequate views of the liver, common bile duct, and small bowel, strongly suggests acute obstruction of the cystic duct. The use of cholecystokinin (CCK) during a scan may be helpful for imaging as well as useful in recreating the same pain symptoms.
Adult patients with silent or incidental gallstones should be observed and managed expectantly.
Non-operative therapies include:
Oral bile acid dissolution (ursodeoxycholic acid): 30-90% stone clearance with zero percent mortality. 50% recurrence of stones, most useful for stones < 5mm.
Contact solvents (methyl tert-butyl ether/n-propyl acetate): 50-90% stone clearance, 70% recurrence, experimental, may cause duodenitis, nephrotoxicity, and hemolysis.
Extracorporeal shock-wave lithotripsy (ESWL): 70-90% stone clearance, 70% recurrence, not approved by FDA, needs a center with expertise, may be costly.
Laprascopic cholecystectomy contraindications include: high risk for general anesthesia, morbid obesity, signs of gallbladder perforation, giant gallstones, end-stage liver disease with portal hypertension, suspected gallbladder malignancy, and last trimester of pregnancy.
--- Article – Pancreatitis (Mitchell, Byrne, & Baillie, Lancet 2003;361:1447-55)
Inappropriate activation of the proteolytic enzyme trypsin is thought to be the initial step in the development of pancreatitis. Most patients recover uneventfully, but up to 10-15% may develop systemic inflammatory response syndrome (SIRS), mediated by cytokines, immunocytes, and the complement system.
Gallstones are the leading cause of acute pancreatitis in developed countries. Alcohol abuse is a close second. Other causes include drugs, tumors, hypertriglyceridemia, trauma, iatrogenic, and scorpion stings.
Diagnosis of acute pancreatitis is difficult and many cases show at autopsy. Cullen and Grey-Turner signs
(periumbilical and flank bruising, respectively) are rare and non-specific. Increased serum amylase is expected, but not always seen. CT or ultrasound leads to a correct diagnosis in 81-95% of patients. Lipase estimation is more sensitive than amylase in alcohol-induced acute pancreatitis. Serum lipase rises within 4-8 hours of an episode, peaks at 24 hours, and returns to normal after 8-14 days.
An increase in lipase three times the upper limit normally excludes non-pancreatic causes.
Balthazar Scoring uses CT appearances to predict acute pancreatitis severity. The Atlanta Classification bases severe acute pancreatitis on a Ranson criteria score of 3 or more, or an APACHE II score of 8 or more. Urinary trypsinogen activation peptide can accurately predict severity of acute pancreatitis 24 hours after onset.
Treatment should include enteral nutrition via feeding tube and possibly starting antibiotics (e.g. imipenem), especially if necrosis is present. ERCP may be used for patients with progressive jaundice or acute cholangitis. If pseudocysts are presents and do not resolve, drainage is indicated and should be examined for amylase, CA19-9, and CEA. In gallstone pancreatitis, the gallbladder is often removed during pancreatic surgery.
CFTR gene mutations are associated with chronic pancreatitis.
ERCP remains the gold standard for diagnosis and staging of chronic pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) with or without secretin stimulation is a useful alternative to ERCP.
Some feel the gold standard test for pancreatic exocrine insufficiency is stimulation by secretin-cholecystokinin or a Lundh test meal.
Alcohol-induced pancreatitis may diminish over time. Patients with chronic pain may seek surgical resection, although there is no guarantee of pain relief, especially in those who are narcotic-dependent.
Narcotic-dependent patients will likely benefit from management in a dedicated pain clinic.
Chronic pancreatitis is a risk factor for pancreatic neoplasms (pancreatic intraepithelial neoplasms, PanIN). Pancreatic cancer is an almost 100% fatal cancer. CA-19-9 tumor marker may be elevated.
--- Kaplan Videos (2001) – Surgery with Carlos Pestana, MD, PhD
---Questions are usually high yield (most common) or high impact (misdiagnosis could seriously harm patient). ---Trauma: ABCs (Airway, Breathing, Circulation)
* Patient involved in a car accident is fully conscious and voice is normal. This implies the patient has a clear airway. If the vignette talks about shortness of breath, it is a breathing problem so airway is still intact. * Patient with multiple stab wounds is conscious with normal voice, has several stab wounds has an expanding hematoma in neck or subcutaneous emphysema. This patient needs an airway, such as intubation. This includes anesthetic with pulse oximetry as well as oral- or nasal-tracheal intubation. Subcutaneous emphysema implies tracheal-bronchial injury, so fiber optic bronchoscope intubation is needed.
* Severe car accident, multiple injuries, unconscious, spontaneous but gurgling/noisy breathing. Being unconscious alone is an indication for intubation in trauma.
* Unconscious, spontaneous with noisy/labored breathing. Neck pain at site, couldn’t move lower extremities, lost consciousness during ambulance ride. Attempted intubation during ride was failed. The neck cannot be moved due to possible cervical spine injury. Answer is always airway first (ABCs). The best answer is likely nasal tracheal intubation over a fiber optic scope.
* MVC, awake, facial fractures, bleeding into airway, voice masked by gurgling sounds. Face (nose or mouth) is smashed, so not oral tracheal intubation. Answer is also not an emergency tracheostomy, as this is for the operating room or ICU where patient already has airway. So correct answer is cricothyroidotomy.
* High speed MVC, smashed face, unconscious, head injury. Jet catheter in the trachea will likely not be enough. So, pick cricothyroidotomy.
* Unconscious trauma patient is rapidly intubated in the ED. Spontaneous breathing, bilateral breath sounds, SpO2 > 95%. This patient doesn’t need breathing help. Most breathing problems relate to chest trauma.
* 22yo gang member arrives in ED with multiple gunshot wounds to abdomen, diaphoretic, pale, anxious, wants blanket and drink of water. BP 60/40, pulse 150 barely present. So, patient is in shock (BP below 90, high pulse). Three conditions are responsible for shock in a trauma patient. Most common is bleeding (hypovolemic,
hemorrhagic), also pericardial tamponade or tension pneumothorax. Chest has to be involved for the last two, chest trauma is implied with blunt trauma like a car accident. Tension pneumothorax or pericardial tamponade would have distended neck veins (JVD), while bleeding shock has flat/empty neck veins. Tension pneumothorax interferes with both breathing and circulation, so gasping for breath and flaring nostrils. Other signs of tension pneumothorax are decrease breath sounds on one side, tympany on chest percussion on one side, and shifted mediastinum. Treatment of hypovolemic shock involves resuscitation phase of Lactate Ringer (LR) solution, however the current philosophy first step is to stop the bleeding. So, stop bleeding first if possible then fill the vascular tree with fluid. So, in the patient who was shot in the abdomen, they need an emergency laparotomy first before fluid resuscitation. The correct answer is not give fluid to attain a certain blood pressure or give blood to reach a hemodynamic stability with hemoglobin and hematocrit at a certain level.
* Bank robbery, innocent bystander shot in abdomen. Fully staffed trauma center is two miles from location. Patient is in shock. What should the EMTs on scene do? “Scoop and run.” Don’t waste time starting an IV or managing the patient on scene as the clock is ticking (golden hour). So the treatment is “diesel” (drive to the hospital).
* 19yo man shot in groin after drug deal gone bad, BP 90, pulse 105, bright red spurting blood from wound. First step is put a finger on bleeding and stop it with local pressure. Do not blindly put a clamp on (could injure other structures) and do not use a tourniquet.
* MVC, unconscious, BP 80/60, pulse 85, pale, no JVD. Anesthesia intubates patient, other team puts in a central line. So, we have to assume the patient is bleeding from somewhere. Since it’s blunt trauma and we don’t know where the bleeding is, we should fill the vascular tree first. Current philosophy is to use the peripheral veins for fluid resuscitation. Anesthesia is at the head, one team is at the neck, another at the chest, etc. So, use two large bore (16g) catheters at antecubital fossae in arms or cut-downs of the ankles. Use 1L or 2L of balanced electrolyte solution, such as Ringer lactate or Ringer acetate or Normal Saline (NS). Don’t use sugar, like D5W as it could create an osmotic diuresis and invalidate the fluid output measurement. Add blood as soon as it is available. Most important management parameters are urinary output and venous pressure.
* 4yo child shot in arm during drive-by shooting. Site of bleeding is controlled with local pressure, child is
hypotensive and tachycardia, unable to start IVs. Next step is intraosseous (IO) cannulation at proximal tibia. Bolus is 20ml/kg such as with NS.
* During a wilderness trek, man is attacked by bear, injuries to arms and leg, buddy stops bleeding but when EMTs arrive an hour later he is in shock. Transportation to hospital will take two hours. EMTs, in this situation, should spend time on site to start IVs and give fluid.
* 22yo gang member arrives in ED with multiple gunshot wounds to chest and abdomen, is diaphoretic, pale, cold, anxious, wants blanket and water. BP 60/40, pulse rate is 120. Since it’s chest, might think about pericardial tamponade or tension pneumothorax. If only given this information, have to assume bleeding (hypovolemia). Else the question would have to say JVD or high central venous pressure. The question may ask what else you need to make a decision, which would be neck vein status or ventral venous pressure.
* Multiple gunshot wounds to chest and abdomen, anxious, pale, BP 60/40, pulse is 150, diaphoretic. Large distended veins in neck and forehead. Breathing OK and bilateral breath sounds. Answer is pericardial tamponade. How do you manage this patient? Patient is dying, so don’t waste time with a chest x-ray. Don’t ask for blood gases. You have the diagnosis. So, do something that empties the pericardial sac, such as pericardial window, pericardial tube, pericardiocentesis, or median sternotomy. In the meantime, you can help the patient by giving them additional fluids. Adding intravascular volume seems counterintuitive, but it helps while waiting to empty the pericardial sac. * Domestic dispute, young woman stabbed in chest with 6” long butcher knife. Entry wound at 4th intercostal space, left of the sternal border, BP 80/50, pulse 110, cold, diaphoretic, JVD present, bilateral sounds present. So,
pericardial tamponade. Here, there is only one injury and it requires repair so the answer would be median sternotomy because it decompresses the sac and provides a means to repair the heart.
* 22yo gang member arrives in ED with multiple gunshot wounds to chest and abdomen. Has labored breathing, cyanotic, diaphoretic, cold, BP 60/40, pulse 150 weak, large JVD, trachea deviated to left, right-sided of chest is hyperresonant to percussion with no breath sounds. So, tension pneumothorax. Clinical diagnosis exists and patient is dying, so don’t order chest x-ray, CT scan, or blood gases. Immediately decompress the pleural space, needle decompression via 2nd intercostal space midclavicular then use a chest tube after. Eventually an exploratory laparotomy as this guy was shot in the chest and abdomen.
* 22yo man involved in high-speed head-on automobile collision. Arrive in ED in coma with fixed dilated pupils, fractures in both arms and right lower leg, BP 60/40, pulse 150. Implication of coma and pupils is closed head injury. Where is the bleeding causing the shock coming from? Answer is not acute subdural, acute subarachnoid, or any other head problem. Not enough room in head to bleed sufficient volume to go into hypovolemic shock. Need to lose 1.5L of blood for shock.
* Types of shock are hypovolemic, cardiogenic, and vasomotor (loss of peripheral vascular tone). * 72yo man lives alone, calls 911 for severe chest pain, cannot give coherent history. Arrives at ED, cold, diaphoretic, BP 80/65, pulse 130, JVD present, short of breath. Non-trauma, so most likely a massive myocardial infarction with cardiogenic shock (e.g. JVD present). This case is intrinsic cardiogenic shock so we treat the patient as a myocardial infarction, not like hypovolemic shock with fluid.
* Three cases: 17yo girl stung by swarm of bees, warm and flush, BP 75/20, pulse 150. CVP is low. 22 minutes after penicillin injection, man gets wheezes, BP 70/20, pulse 150, low CVP. Patient undergoing hernia repair has spinal anesthesia placed, anesthesia is higher than expected, BP 70/20, patient is warm and flush. All are vasomotor shock since patient is warm and flush rather than pale and cold. Treat patient with vasocontrictors to restore tone. Volume replacement would not hurt these patients, but vasocontrictors are needed such as antihistamines (pseudophedrine) or alpha-agonists like dopamine (beta1, alpha1), norepinephrine (alpha1, beta1), and phenylephrine (alpha1). ---Trauma: Head Injuries
* 22yo patient arrives to ED with axe implanted in head and based on size you can assume an intracranial wound has been sustained. Answer is do not remove an impaled foreign body until the patient is in the OR, as the object may be tamponading an injured vessel thus preventing bleeding.
* During a mugging, a man is hit over the head with a blunt instrument. Scalp laceration present and skull x-ray shower underlying linear skull fracture. No loss of consciousness and can remember events (grade I concussion). In this case, the wound can be cleaned and sutured in the ED. Loss of consciousness is grade III concussion.
* During a mugging, a man is hit over the head, scalp laceration, underlying comminuted depressed skull fracture. This patient needs to go to the operating room, not managed in the ED.
* Man hit by car, some laceration, normal neurologic examination. Crew reports loss of consciousness (LOC) at site but patient awakens in ambulance and is lucid. Every head trauma patient with LOC gets a CT scan. Negative CT scan, the patient can go home and the family should wake the patient up frequently over 24 hours.
* Three cases: Pedestrian hit by car, LOC, bruising around both eyes (raccoon eyes). Pedestrian hit by car, LOC, clear fluid from the nose or clear fluid from the ear. Pedestrian hit by car, LOC, ecchymoses behind ear (Battle sign). These are signs of basilar skull fracture. A nasal airway should not be used. Should get CT scan to help identify hematomas that need to be evacuated. No specific treatment is needed, usually, for basilar skull fracture. Basilar skull fracture implies massive trauma, so associated neck injury is possible. Must be in a cervical C-collar. Cervical plain radiographs (PR) should be three view, AP, lateral, and open-mouth odontoid. Also, these patients will need CT scan of neck so answer may be CT scan of head that includes the neck.
* 14yo boy hit over right side of head with baseball bat, loses consciousness for a few minutes, then continues to play. Is found unconscious one hour later, right eye fixed and dilated, contralateral palsy. This is acute epidural hematoma, which involves LOC, lucid phase, and LOC with dilated pupil. In acute subdural hematoma, the trauma is usually larger and the patient is usually sicker, such as elderly patient in high-speed car accident (>35mph combined impact). For acute epidural hematomas, 90% of them are ipsilateral to dilated pupil. Hemiparesis on opposite side. CT scan will show biconvex lens-shaped hematoma with deviation of ventricles/structures to other side. Emergency craniotomy is needed and prognosis is excellent (high impact disease).
* CNS damage with head trauma occurs in three ways: by initial trauma, by hematoma that develops, and by the swelling that frequently follows head trauma. Mostly medical measures are done for brain swelling.
* 32yo man involved in head-on high-speed automobile collision, unconscious at site, regains consciousness briefly during ambulance ride, then arrives in coma with dilated pupil and contralateral hemiparesis. Answer is acute subdural hematoma. Management is CT scan showing a biconcave semilunar crescent shaped hematoma. Next step is craniotomy and decompression. Prognosis is grim.
* Man involved in high-speed head-on automobile collision is in a coma. He has never had any lateralizing signs (unilateral dilated pupil, hemiparesis), CT scan shows small crescent-shaped hematoma without deviation of the midline structures. This is acute subdural hematoma. Management is not operative since hematoma is not pushing structures. Management is to control swelling, so minimize ICP via hyperventilation, avoid fluid overload, mannitol, furosemide. Don’t dehydrate to the point of hypotension of course. Monitoring ICP is helpful too.
* Head-on high-speed MVC in deep coma with bilateral fixed pupils, CT scan shows diffuse blurring of the gray-white mass and multiple small punctate hemorrhages, no single large hematoma. This is diffuse axonal injury (DAI). No operation is indicated, as there is no one single hematoma. Treatment centers on managing ICP.
* 77yo man becomes senile over a period of 3-4 weeks. He use to be active and managed all is financial affairs. Now he stares at the wall, barely talks, and sits all day. His daughter recalls he fell from a horse a few weeks ago. This is a chronic subdural hematoma. It is only seen in very old or alcoholics, as there is brain atrophy. The skull does not shrink (“size 7 brain, size 8 skull”). So brain moves more in head and can tear off a venous sinus. This disease could be easily missed, thinking it is Alzheimer or senility, but those do not occur over a short period. Management is to evacuate the hematoma and the patient can be back to managing their finances in a week.
* 45yo man involved in high-speed MVC, coma, fixed dilated pupil. He has multiple injuries including fractures, BP 70/50, 130bpm, what kind of intracranial bleeding is responsible? Answer is none. Blood loss source is elsewhere. ---Trauma: Neck Injuries
* Any penetrating trauma of the neck where the patient is rapidly deteriorating, answer is go to the OR. * All gunshot wounds to the middle part of the neck, regardless of vital signs, always go to the OR. * If patient is spitting up or coughing up blood, go to the OR.
* 42yo man shot once with 42-caliber revolver, shot is anterior middle of neck at level of thyroid cartilage, coughing up blood, expanding hematoma, BP responding to fluids. Answer is go to the OR.
* Young man shot in upper part of neck, trajectory is all above the level of the angle of the mandible, steady blood flows from wound, pressure does not completely control the bleeding. This injury is high in the neck with the base
of the skull close, so it is difficult to get both proximal and distal bleeding control. The preferred management of this type of injury is an emergency angiogram with bleeding vessel embolization.
* Gunshot wound to base of the neck, wound is above clavicle but below cricoid cartilage. The base of the neck is a boundary area, so the surgical approach may differ depending on location. So an arteriogram, esophagogram, and bronchoscopy are indicated first.
* Bar fight, stab once in neck in front of right sternocleidomastoid muscle, man is asymptomatic and normal vital signs. Here we can clinically observe the patient. If it were a gunshot wound to the middle of the neck, operate. * Unbelted man thrown from car going 30mph, hitting pole. Shows up in ED neurologically intact on backboard with multiple lacerations on face. Posterior midline of the neck has pain on palpation. Assume a bony injury to cervical spine. Answer is to look at cervical spine first, such as three-view x-ray (AP, lateral, odontoid), or CT scan of head and cervical spine.
* 18yo street fighter gets stabbed in back to the right of midline. Has paralysis and loss of proprioception distal to the injury on the right side and loss of pain sensation distal to the injury on the left side. This is a hemisection of the spinal cord (Brown-Séquard syndrome). Only way to get a hemisection is with a clean cut, so not a patient who dove into a shallow pool.
* Car accident, burst fracture of vertebral bodies, loss of motor function and pain/temperature sensation on both sides distal of injury, with preservation of vibratory sense and position. Spinal cord is behind vertebral bodies, so burst of the bodies affect the anterior part of the cord. Vibratory and position sense are in the posterior portion of the spinal cord. This injury is anterior cord syndrome. It can also be seen in anterior vascular injury.
* Rear-end collision with hyperextension of neck, has paralysis and burning pain of upper extremities. Has preservation of motor function in legs. This is central cord, as the ligamentum flavum buckles into the spinal cord bundle, affecting the middle fibers.
* Best method for examining the spinal cord and degree of damage is MRI. There is some controversy about giving high dose steroids in spinal cord injury, so it may be an answer choice before orthopedic surgeons get involved. ---Trauma: Chest Injuries
* 75yo man slips and falls at home, hitting chest on counter. Exquisite pain at 7th rib midaxillary line. Normally rib fractures and not a big deal, but in a 75yo it may be a problem. Patients don’t breath due to pain, they get atelectasis, then pneumonia, then can die. Management is to take away the pain in a way so the patient can breath. Answer is not to bind the chest, which alleviates pain but prevents breathing. Don’t pick the answer with a large dose of narcotic. Answer is a local anesthetic or nerve block that alleviates pain and allows for breathing.
* 25yo man stabbed in right chest, moderately short of breath, stable vital signs, no sounds on one side, tympanic on other side. This is a pneumothorax, without tension. First step of management is chest x-ray. If it were a tension pneumothorax, you wouldn’t waste time. Here you don’t rush for the needle decompression and chest tube. First step is x-ray, then if chest tube is needed you go high in the chest (2nd intercostal space).
* 25yo man stabbed in right chest, moderately short of breath, stable vital signs, no sounds at base on right, feint sounds at apex, dullness to percussion at base. This is suggestive of hemothorax. Next step is a chest x-ray to confirm hemothorax. Lung in not collapsed, bleeding is likely from low-pressure source like the atrium of the heart. Bottom line is the bleeding usually stops by itself. Contaminated blood in the pleural cavity is an invitation for infection and empyema. Management is to evacuate the blood in the pleural space with chest tube at base. * 25yo man stabbed in right chest, moderately short of breath, stable vital signs, no sounds at base on right, feint sounds at apex, dull to percussion at base, x-ray taken. Chest tube placed at right pleural space recovers 120cc of blood and another 10cc the next hour. This confirms blood is coming from lung as it is a small amount. Bleeding is stopping (<100cc/hour) so chest tube is all that was needed.
* 25yo man stabbed in right chest, moderately short of breath, BP 95/70, pulse 100, no breath sounds over right chest and is dull to percussion, chest tube at right base recovers 1200cc of blood. This patient is bleeding from systemic vessel, like an intercostal. The answer here is thoracotomy for control of bleeding.
* 25yo man stabbed in right chest, moderately short of breath, stable vital signs, no sounds at base of right chest, dull to percussion at base, chest tube at right base recovers 350cc of blood. Over the next four hours, he continues to drain 200-300cc per hour. So this is not from the lung and is from systemic vessel. Needs thoracotomy.
* 25yo man stabbed in right chest, moderately short of breath, stable vital signs, no sounds at base of right chest, hyperresonant to percussion at apex, air fluid level seen on chest x-ray. We need a chest tube. Either a two tubes (one for base, one for apex) or a tube with a hole at the top and hole at the bottom to drain both the blood and air. * If multiple air-fluid levels seen in chest, usually implies bowel is up in chest.
* 33yo woman involved in high-speed MVC, arrives at ED gasping for breath, cyanotic lips, flaring nostrils, bruising over both sides of chest, tenderness suggestive of multiple rib fractures. BP 60/45, pulse 160, JVD,
diaphoretic, left hemithorax has no breath sounds and dull to percussion. This is tension pneumothorax. Penetrating injury is from broken ribs. Patient needs needle decompression.
* If myocardial contusion is suspected, do blood gases, ECG, and cardiac enzymes.
* Search for traumatic aortic transection, especially if severe deceleration is the mechanism. Look at chest x-ray for wide mediastinum, which gives a high index of suspicion. Next step of management is spiral CT scan of chest. If spiral CT is negative, don’t stop. Do an arteriogram. If there is no widened mediastinum on chest x-ray, do the spiral CT scan but stop there if that is negative.
* Worker injured during explosion at factory, multiple cuts due to flying debris, obviously short of breath, has large flap-like 5cm injury to chest wall, sucks air through it with every inspiratory effort. If left alone, this patient will develop a tension pneumothorax. This is a sucking chest wound. An occlusive dressing is needed, such as a large white petroleum (Vaseline) gauze. One detail is the dressing is taped on three of four sides (semi-occlusive), allowing for some air to leave during expiration.
* 55yo woman crashes car into telephone pole at high speed. She arrives at ED with respiratory distress, multiple chest bruises, and multiple chest fractures. On the left side, part of the chest wall caves in with inspiration and bulges out with expiration. This is paradoxical breathing with flail chest. Even though the chest wall is moving in an abnormal way, it is not affecting breathing in general. So the management is treatment of the underlying contusion. Answer is fluid restriction, possibly diuretics, if fluids needed use colloid (not crystalloid). More important is treatment for ensuing pulmonary failure, which is monitoring blood gases. If PO2 goes down and PCO2 goes up, patient may need intubation and a respiratory ventilator. However, small punctures sites that are not a problem when the patient is breathing on their own may become a problem with positive pressure ventilation. So, they may need a chest tube or tubes on both sides. Also monitor ECG and cardiac enzymes.
* 55yo woman crashes car into telephone pole at high speed. Arrives at ED breathing well, multiple bruises on chest, x-ray shows multiple rib fractures, lung parenchyma is clear, lungs are expanded. Two days later, her lungs white-out on x-ray and is in respiratory distress. These are signs of pulmonary contusion. So we need blood gases, fluid restriction, and diuretics.
* 54yo woman crashes car into telephone pole at high speed. Arrives at ED breathing well, multiple bruises on chest, exquisitely tender of sternum to the point she feels bone grinding on bone. Sternum fracture is likely, so monitor ECG and cardiac enzymes as it may be cardiac contusion. Look for traumatic aortic transection.
* Only survivor of four people in car implies very major crash. Three bones in chest that are very difficult to break are the sternum, first rib, and scapula. Fractures of these means big time trauma.
* 53yo man involved in high-speed MVC. Moderate respiratory distress, no breath sounds on right side, percussion unremarkable. Multiple air-fluid levels seen on x-ray. This is traumatic rupture of the diaphragm, almost always on the left side. Air-fluid levels are bowel. This needs surgical correction, typically done through the abdomen. To make it more obvious, it may say a nasogastric tube is placed and tip curls up into chest.
* Motorcycle daredevil attempts to jump over the 12 fountains in front of Cesar palace in Las Vegas. As he leaves the ramp at high speed, his motorcycle turns sideways and he hits the retaining wall on the other end like a ragdoll. At the ED he is found to be remarkably stable although he has multiple fractures. Left first rib fracture is seen with widened mediastinum. So, we likely have traumatic aortic transection. Begin with a spiral CT, if positive then begin with repair. If negative, go for arteriogram.
* 34yo woman suffers severe blunt trauma in car accident, multiple extremity injuries, head trauma, and left pneumothorax. Shortly after exam she develops progressive subcutaneous emphysema over upper chest and neck. Causes of subcutaneous emphysema are perforation of esophagus (e.g. post-endoscopy), tension pneumothorax, and major tracheal-bronchial injury. So, this patient needs fiber optic bronchoscopy for diagnostic confirmation and to guide the insertion of an airway.
* A patient who received a chest tube for traumatic pneumothorax puts out lots of air through tube (large air leak). The collapsed lung is not expanding. This indicates a major bronchial injury. Indicates fiber optic bronchoscopy. * Patient sustains penetrating chest injury, intubated, placed on respirator, chest tube placed in appropriate pleural cavity. Patient was hemodynamically stable, then suddenly goes into cardiac arrest. This is air embolism. Injury to major bronchus and major vessel next to each other. Patient is fine breathing alone, but once on ventilator the air is forced into lung and leaks out into the major vessel nearby.
* During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is heard and the patient drops dead. This happens during inhalation with negative pressure in chest. 120cc is enough air.
* A patient is receiving total parenteral nutrition (TPN) through a central venous line, becomes frustrated because the nurses are not answering his call button, so he gets up out of bed, disconnects the central line, takes two steps toward the door while the catheter is dangling, and drops dead. The treatment is to put patient into trendelenburg
