medical school, medical students, Medical Students, student, medicine, physicians, Search, medical education, residency, medical student, the American, Residents, doctor, patients, med student, resident, doctors, residency programs, Medical Education, School of Medicine
Pharmacology
DOC for malignant hyperthermia --> Dantrolene
Drug causing dry cough --> ACE inhibitors
Drug causing Pulmonary fibrosis --> Bleomycin
Neoplasic Diseases
Osteosarcoma
"Sunburst" appearance on XR
"Sunburst" appearance on XR
Toxicology
CO poisoning > treat. > 100% O2 or hyperbaric O2 (but always go for 10% O2 when it's more readily available)
Methanol > blindness, visual disturbances
Cyanide poisoning > bitter almonds breath odor
Methanol > blindness, visual disturbances
Cyanide poisoning > bitter almonds breath odor
Trauma
■ First thing to do is maintain Airway, Breathing & Circulation.
Airway : must be secured first if there is expanding hematoma (or) emphysema
in the neck
Cricothyroidotomy (field) / Orotracheal intubation (ER, most preferred route)
Cervical spine injury ® orotracheal (if head is secured) / nasotracheal
Maxillofacial injury (in adult) ® Cricothyroidotomy / percutaneous
transtracheal ventilation
Maxillofacial injury (in child) ® Percutaneous needle Cricothyroidotomy (not the
classic with tube which causes subglottic stenosis in child) followed by
tracheostomy
Cricothyroidotomy tube can be kept only for 48-hrs in adult. If ventilatory support
required beyond 48-hrs, Tracheostomy should be done.
Breathing : Breath sound on both sides of chest / pulse oxymatory
Circulation : SBP should be > 90 mmHg, Palpable pulse
Shock in Trauma
¯ ¯ ¯
Bleeding Cardiac Temponade Tension Pneumothorax
¯ ¯ ¯
Low CVP High CVP High CVP
¯ ¯ ¯
Treatment - No respiratory distress - Respiratory distress
- Tx: Pericardiocentesis - No breath sound &
OR Hyperresonant to percussion
Pericardial window - Tracheal deviation
- Tx: big needle inserted in
upper pleural space
followed by chest tube
connected to underwater
seal
Trauma center Trauma center
Near by far away
Transportation IV fluids (Ringer lactate/Normal Saline)
Any penetrating injury require surgical intervention and repair of the damage
Unconscious patient with Head trauma ® CT scan ( 1 s t step in management )
Linear skull fracture(closed) ® left alone / observe
Linear skull fracture (open) ® wound closure only (ER)
S.S.Patel. All rights reserved. Registered with US copy right office 130
Comminuted/ depressed skull fracture ® repair in OR (Operating Room)
■ Acute Epidural Hematoma ® Middle meningeal artery ® hit on side of the
head® unconsciousness ® lucid interval ® unconsciousness ; CT scan ®
biconvex, Lens-shaped Hematoma Tx: Craniotomy
■ Acute Subdural Hematoma ® Tear of bridging veins ® bigger trauma and
much sicker & severe neurological damage ® CT scan ® semilunar, crescentshaped
hematoma Tx: craniotomy
Chronic Subdural Hematoma : elderly / severe alcoholics ® Tearing bridging
vein ® mental function deteriorates over several days to Weeks ® Tx ®
Surgical evacuation.
Diffuse Axonal Injury ® CT scan shows diffuse blurring of the gray–white
matter interface and multiple small punctate hemorrhages ® Tx : Prevent rise in
ICP
Gunshots in Neck
¯
Middle Zone Upper / lower Zone
¯ ¯
Surgical Exploration Diagnostic procedures
( even though patient is asymptomatic ) then Surgery
¯
¯ ¯
Upper Zone Lower Zone
¯ ¯
Arteriography for Arteriography
Diagnosis & embolization . Esophagogram
Bronchoscopy
¯
Surgery
Stab wound to Neck ® Observe (if asymptomatic)
Stab wound to Neck, Crepitation at the base of neck ® Bronchoscopy (1st step)
followed by bronchoscopy guided intubation (best choice) / orotracheal intubation
Blunt Trauma to the Neck ® X-ray / CT scan (tenderness over cervical spine,
neurological deficits) ® Intervention
Signs & Symptoms of Spinal cord injuries ® High-dose prednisone ® MRI
S.S.Patel. All rights reserved. Registered with US copy right office 131
Rib fractures ® pain relief by nerve block (no strapping / binding)
Plain Pneumothorax (not tension) ® CXR ® Tx
Sucking Chest wound ( flap ) ® occlusive dressing (taped on 3 sides)
Hemothorax ® CXR ® Chest tube / Thoracotomy (> 1500 ml blood / > 600 ml
in 6 hrs)
Flail chest ® segment of the chest wall cave inside during inspiration and bulge
out during expiration in multiple ribs fractures – Tx: fluid restriction, Diuretics,
use of colloids, Respirators with bilateral chest tubes. (to prevent tension
pneumothorax)
Pulmonary contusion ® “white out” of the lungs on CXR ® Tx: same as
above
Traumatic rupture of Diaphragm ® bowel in the left chest on X-ray ® Tx :
Surgical repair from the abdomen
■ Subcutaneous Emphysema ® CXR ® Bronchoscopy ® Surgical repair
■ Traumatic rupture of Aorta ® deceleration injury / 1st rib /sternum fracture
CXR (wide mediastinum) ® transesophageal echo / spiral CT ® Aortogram
(if 2nd fail) ® surgical repair
■ Air embolism : subclavian vein is opened to the air which sucks air during
inspiration (hissing sound) ® sudden death (Supraclavicular node biopsy , CV
line placement , CV line disconnected and leave it open to the air) ® Tx:
Immediate head down and raised right shoulder
■ Fat embolism ® long bones fracture (femur) ® CXR : Bilateral patchy
infiltrates ® fever , tachycardia ® Tx : Respiratory Support
■ Gunshot wound to the Abdomen (any entrance / exit wound below the level of the
nipple) ® exploratory laparotomy
■ Stab wound to the Abdomen (Stable patient with no protruding viscera) ®
observe & Standard wound care
■ Stab wound to the Abdomen (unstable patient / protruding viscera) ® exploratory
laparotomy
S.S.Patel. All rights reserved. Registered with US copy right office 132
■ Blunt abdominal Trauma ® Signs & Symptoms of peritoneal irritation ®
Exploratory laparotomy
■ Blunt Abdominal Trauma ® Signs & Symptoms of internal bleeding (shock) ®
Stable patient ® CT scan ® Intervention
■ Above scenario ® unstable patient ® Diagnostic peritoneal lavage /
sonogram ® intervention
■ Fractures of lower ribs on Left side ® rupture spleen
■ Coagulopathy during operation ® FFP + platelate transfusion
■ Prolonged laparotomy ® more IV fluids given ® Abdominal compartment
Syndrome ( Abdomen can’t close without tension ) ® Tx : temporary cover
with absorbable mesh / non – absorbable plastic
■ Pelvic Fracture ® External fixation / arteriographic embolization.
■ Hemodynamically unstable with pelvic fracture due to blunt trauma – first step?
USG abd or Diagnostic peritoneal lavage to rule out intraperitoneal hemorrhage
(h’ge) – If negative, next step? Pelvic angiogram to rule out retroperitoneal h’ge –
if h’ge present, prepare for appropriate embolization
■ H/O Trauma ® Blood in the Urine (urological injuries)
Gross Hematuria Microscopic Hematuria
¯ ¯
sonogram ( Best ) / IVP ¯ ¯
Children Men ( Adults )
¯ ¯
Asymptomatic / Symptomatic Asymptomatic
¯ (do nothing)
Sonogram / IVP ¯
(When ask best diagnostic test for suspecting renal damage, Symptomatic
Answer CT scans of abdomen) ¯
Sonogram / IVP
- Penetrating urologic injuries (gunshot in lower abdomen) – surgical exploration &
repair
- Pelvic Fracture + Hematuria (Blood at urethral meatus) ® retrograde
urethrogram ® surgical repair
S.S.Patel. All rights reserved. Registered with US copy right office 133
- Pelvic fracture + gross blood on catheterization ® retrograde cystogram then
surgical repair
- Rib fractures, Abdominal contusion + Gross hematuria and normal retrograde
cystogram ® CT scan Abdomen (Renal damage)
- H/O Renal damage + few weeks after develop CHF & Flank bruit ® Traumatic
arteriovenous Fistula & subsequent CHF
- Blunt Renal trauma doesn’t require operation unless avulsion of renal pedicles
which can be complicated by arteriovenous fistula later
.
■ Sensation that patient wants to urinate but he can’t ® Posterior urethral injury
■ Hematoma of penile shaft (corpora cavernosa fracture) ® urological emergency
® immediate surgical repair
Gunshot wound to Extremities
¯ ¯ ¯
No or vascular injury possibility of vascular definite vascular
Unlikely injury injury
¯ ¯ ¯
Standard wound care Arteriogram / Doppler surgical exploration
And repair
¯
Surgical repair if
Injury present
Complex extremity Injury ® 1st fracture stabilization ® 2nd vascular repair ®
lastly nerve repair
Crushing Injury ® Tx: plenty of fluids, diuretic, Alkalization of urine
Compartment Syndrome ® Fasciotomy
