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Pharmacology


DOC for malignant hyperthermia --> Dantrolene

Drug causing dry cough --> ACE inhibitors

Drug causing Pulmonary fibrosis --> Bleomycin

Neoplasic Diseases

Osteosarcoma

"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

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

Friday, January 29, 2010

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1 comment:

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