Pericadial tamponade ( distended veins. CVP > 20)
Tension Pneumo ( tracheal deviation, loss of breath sounds)
If they are open, laceration can be cleaned and closed only if there is no depression or comminution.
Clear fluid from nose, ear
Ecchymosis behind the ear.
head elevation, hyperventilatoin, and avoidance of fluid overload.
THEN mannitol and furosemide.
NG tube = 1 ml for 1 ml
next 10, 50
Beyond 20, 20 per kg
Neurologic symptoms are a good clue
Even if they don’t have symptoms, do a AP and lateral cervical view. Do a CT if you have high suspicion
Do this immediately.
Do NOT splint or bind because then they will hypoventilate and get pneumonia
Manage: chest tube to underwater seal and suction. Place it high in the chest.
If mediastinum not wide, then still spiral CT. If ct neg, then you can stop.
Treatment is controversial
Fluid restriction, diuretics, colloid fluids
IMPORTANT! If she is going to be put on any kind of positive pressure, she needs bilateral chest tubes because she could get a tension pneumothorax
Don’t forget spiral ct looking for an aortic rupture.
Always on the left.
NG tubecurling up into the left chest might be an added sign
Surgical Repair, generally emergency repair
tension pneumo (often more major things to worry about)
rupture of trachea or major bronchus
Injured bronchus connecting with nearby injured pulmonary vein
Person pulling out central line. Supraclavicular node biopsy mishap
long bone fracture
petechial rashes in axillae and neck, fever and tachycardia.
Bilateral patchy infiltrates and platelet count in low.
USED TO BE always do a colostomy
IE, short blade + fat woman = digital exploration of wound in the ER
Tender abdomen with guarding and rebound in all quadrants
With bleeding, you will have low BP, elevated heart rate and low CVP.
First rule out external hemorrhage by examining the patient
Rule out incranial bleed because that much blood won’t fit in the head
Rule out neck by checking for hematoma
Rule out Chest with chest xray. >150 ml should be easy to spot in decubitus position
Rule out pelvic fracture and femoral fracture with physical exam and xrays
THE BELLY IS SILENT…..and deadly
Do a CT scan if patient is hemodynamically stable.
Otherwise: peritoneal lavage
If stable, observe with serial CT scans
If not, ex-lap
If you definitely need to remove it, then give, pneumovac,Hemophilus B and meningococcus
If hemodynamically unstable, then sucks to be you. Laparotomy is not advised. External fixation may work OR arteriographic embolization
start with a retrograde urethrogram
DO NOT put in a foley
scrotal hematoma, sensation that he wants to urinate but can’t. High riding prostate
And do a retrograde urethrogram
A bladder full of dye may hide a retroperitoneal trigone leak. Rupture at the dome, or extravasation, is pretty obvious.
Surgery only if renal pedicle is evulsed or if the patient is exsanguinating. Ok if it just smashed
Cancer of kidney, bladder or urethra
Check for congenital abnormalities. Sonogram (Better) or intravenous pyelogram
Rupture of the tunica albuginea/ corpus cavernosa
Urologic emergency. Prompt surgical repair needed
Give a tetanus shot and clean the wound. leave the bullet where it is
May need to do a fasciotomy because of the delay in repairing blood vessel
Plenty of fluids, osmotic diuretics and alkalinization of the kidneys.
Fasciotomy of the compartment syndrome.
Need surgical debridement
Possible myoglobinemia leading to renal failure: Fluid, mannitol, alkanization of the urine
Rule out posterior dislocation of the shoulder, compression fractures of vertebral bodies, development of cataracts and demyelination syndromes
Respiratory burns: Bronchoscopy. Degree of damage done by monitoring blood gases.
respiratory support for both
3: in kids: deep bright red. In adults: white leathery analgesic
Silver sulfadiazene cream
9 for head,
9 for each arm
9 for each side of leg ( 2 9s per leg)
Four 9s for torso
Second day: half the calculated amount plus colloids.
Third day: Hold fluids because there should bea brisk diuresis
Electrical Burns: 1-2 ml per hour
Both legs – 3 9s
arms – 9 each
Torso – 4 nines.
Suitable cleaning and topical agents
silver sulfadiazine is essential for reg burns
Mafenide acetate – ONLY for areas of deep burn cause it hurts and can cause acidosis
Eyes – triple antibiotic ointment
IV pain meds. Graft to areas that did not undergo regeneration after 2-3 weeks.
Day or two of ng suction and then nutritional support ( high calorie and high nitrogen)
Tetanus prophylaxis and standard wound care
Immunization plus vaccine
local edema, ecchymotic discoloration, painful and tender to palpation
Blood drawn for type and cross, coag studies and renal and liver function. Antivenin – 5-20 vials. Surcial excision and fasciotomy in severe cases.
Same process and treatment in kids. Same dosage of antivenom regardless of size. Antivenom dosage in based on amount of venom injected.
nausea and vomiting and severe generalized muscle cramps
Dabsone. Local excision and skin grafting after one week when full damage is known
Abduction splinting with Pavlik harness
Decreased hip motion, knee pain on same side. Antalgic gait
Surgery to pin the femoral head in place
Aspirated under general anesthesia to confirm diagnosis
Then open arthrotomy
Bone scan and then antibiotics
Series of plaster casts
appropriate casting and traction
2. Open reduction and internal fixation
Second most common? Describe on xray. What is the age range affected? What do you do?
Ewing sarcoma: Persistant pain deep in the diaphysis. Large fusiform bone tumor pushing the cortex out and producing periosteal onion skinning.
REFER. DO NOT BIOPSY
bence jones proteins on serum electrophoresis
Treat with chemo
AP and lateral xrays
close reduction and lang arm cast
Close reduction of radial head and open reduction and internal fixation of the ulnar fracture.
Open reduction and fixation of the radius and casting of the forearm in supination.
open reduction and internal fixation on xrays shwos dispaced and angulated fracture
Kirchner wire or plate fixation for the bad ones
Open reduction and pinning. worry about DVT and anticoagulate
Hinge cast if isolated tear
Surgery if multiple tears
Athletes need arthroscopic reconstruction
won’t initially show up on xray
cast and repeat xray in two weeks: will show up then
Can be too tight, or rubbed off skin, etc
integrity of pulses, arteriogram and prompt reduction
steroids first then surgery if needed
Splints and antiinflammatories
Lightinigng through big toe: L4-L5 or L5-S1 if through little toe
bed rest. Surgery only if worsens OR sphincteric defecits
anti- inflammatories to treat
Unna bot, support stockings. Varicose vein surgery
Marjolin ulcer: Wide local therapy needed
wearing pointy shoes
excision if conservative treatment fails
Cessation of smoking for 8 weeks and respiratory therapy. Physical therapy, expectorants, incentive spirometry and humidified air.
albumin below 3
prothrombin above 16
3 things: 85%
4 thing: 100%
Albumin under 2
Ammonia above 150
Low serum albumin
Anergy to antigens injected
transferrin level of 200mg/dl
correction of acidosis
3x cultures and IV antibiotics
Water – UTI – Day 3
Walking – Thrombophebitis – Day 5
Wound – infections – Day 7
Wonder Drugs –
Don’t think PE if venous pressure is low. Pulm angioography, VQ scan, or spiral CT
Therapy with heparin. Put in IVC Filter if he has PEs on heprain.
Place chest tube later.
uremia, hyponatremia, hypernatremia, ammonium, hyperglycia, DT, or meds
confused, lethargic, severe headache, grand mal seizure, and coma
Very careful use of hypertonic saline
Overt liver failure suspected if there is hypokalemia alkalosis and high cardiac output-low peripheral resistance
Look at urine sodium to tell
Insulin with glucose
Fluid resuscitation may be a better idea.
rehydration with normal saline and a lot of KCL (10meq/h)
fundoplicaiton in symtpoms worsen
Dysplastic changes require resection
confirm that motility is okay: manometry
Confirm severity of the esophagitis: endoscopy and biopsies
Confirm that gastric emptying is not a problem: isotope gastric empyting study
Barium swallow for anatomy
Emergency surgical repair
probably a strangulated obstruction
Give blood transfusions if they are anemia and eventually surgical resection
DO NOT give anti diarrheals
Metronidazole or Oral Vanc
Don’t scope if you suspect inflammation or friability. you can perf.
Diagnose with technitium
child with nephrosis and ascites
Management: NPO, NG suction, IV fluids
NPO and antibiotics for the acute attack. Resection for recurrent disease
Treat with metronidazole
Can’t grow amoeba from pus
Total bili will be high. Alk phos will be slightly high and transaminases will be very high
Alkphos will be 6 times the upper limit of normal
Also may want to get brushings for cytology
White blood cell count > 16000 cells/mm3
Blood glucose > 10 mmol/L (> 200 mg/dL)
Serum AST > 250 IU/L
Serum LDH > 350 IU/L
After 48 hours:
Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L
CT scan probably the best choice. Watch for 6 weeks and then drain if not gone.
Stop alcohol intake. replace panc enzymes, ERCP for further testing of anatomy
All other hernias, elective surgery if stable. Immediate surgery if strangulated.
Sonogram or FNA. Mammogram is no good cause breast tissue is too dense. excision in optional after diagnosis is confirmed. Reassurance is not the answer
at 14 cancer is very unlikely, don’t need to FNA or sonogram. Excise to prevent cosmetic deformity
Can turn into malignant sarcoma
needs a margin free resection
Start with mammogram to look for other non-palpable lesions. Aspirate the fluid. If bloody, send to cytology. If mass does not go away or recurs, needs biopsy.
Mammogram is best if you suspect cancer that is not palpable. Even if mammo is negative, may want to resect the pappiloma. for symptoms releif
Incision and drainage.
Do not need to terminate the pregnancy
Other presentations: Retracted nipple, Red swollen breast, not tender, not hot, no fever or leukocytosis
Eczemoid lesion in the areola. Won’t go away with lotion.
but do an axillary biopsy. With sentinal lymph node. radiation therapy afterwards
Otherwise Modified radical mastectomy with sentinal lymph node biopsy. No radiation needed when the whole breast is removed
Lobular has a higher incidence bilaterally, but not enough to warrant a mastectomy
Inflammatory has terrible prognosis
all the others have a little better prognosis than infiltrating ductal
Simple total mastectomy if multicentric
This is inoperable and incurable, most likely. Palliation can be offered.
Chemo is first line of treatment. Maybe the tumor will shrink and become operable.
Estrogen and Progesterone receptor positive patients, will be given either tamoxifen or Anastrozole
CT scan of the brain and high dose steroids and radiation
Sestamibi scan and then surgery to follow
Suppress at low dose: normal
If not suppressed at low dose, check 24 cortisol is high and then do high dose.
If suppressed at high dose, MRI of pituitary.
If not suppressed at high dose, CT or MRI of Adrenals
Babies get it. high insulin, low c-peptide
If inoperable, somatostatin for symptomatic relief and streptozocin
Fancy spiral CT or MRi angiogram. and ultimately surgery.
Look for fistulas nearby to determine level of the blind pouch
That will determine if you need to do the surgery right away
in the meantime, endotracheal intubation, low pressure hyperventilation, sedation and NG suction.
put the bowel back in. May need to slowly do it with a silicon silo.
Vascular access for IV nutrition.
Put the bowel back in.
surgery if complete blockage. However, these kids will have other congenital abnormalities, look for them first.
Upper GI study: more reliable
No meconium passed
Abdominal distension, multiple air fluid levels and distended loops of bowel.
Caused by vascular accident in utero
Stop feeding, broad spectrum ABX, IV fluids and nutrition.
Surgical intervention if: abdominal wall erythema, air in the portal vein or pneumopertoneum
Gastrografin enema. Surgery if unsuccesful
HIDA after one week of phenobarbital.
Barium enema to visualize. Full thickness biopsy needed to confirm.
Barium enema or air anema.
Radioisotope scan. gastric muscos in the lower abdomen.