Surgery 2
Terms
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Case #1:
A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20 minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks for a blanket and water. Initial survey confirms the p -
Diagnosis: Hemorrhagic shock
• Most common shock post trauma: hypovolemic (hemorrhagic)
• If trauma to the chest occurs: must also consider pericardial tamponade and tension pneumothorax. Look for elevated CVP and distended neck veins. -
Case #2:
A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is breathing well and his head and neck veins are not dist -
Diagnosis: Hemorrhagic shock
• Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to the chest. Must r/o pericardial tamponade and tension pneumothorax.
• Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely diagnosis. -
Case #3:
An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his pulse rate is 120, and he has no visible disten - Diagnosis: Hemorrhagic shock
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Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has lar -
Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.
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Diagnosis: Cardiogenic shock due to pericardial tamponade
• Can r/o tension pneumothorax because he has normal breath sounds and is breathing well
• By exclusion, correct diagnosis is pericardial tamponade -
Case #5:
A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest. Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead. He is pale, cold, sweating, shivering, and mumbles that -
Diagnosis:
Tension pneumothorax -
Case #6:
During a round of golf, a business executive is hit on the right side of his head with a golf ball. He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1 hour later he is found unconscious in the locker r -
Diagnosis: Epidural hematoma
• Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil and contralateral hemiparesis suggests acute intracranial hematoma with displacement of the midline structures.
Diagnosis: Epidural hematoma
• Epidural vs. subdural: subdural requires a much bigger trauma and presents with a sicker patient.
• Blow to side of head where middle meningeal artery lies, as well as the very lucid “lucid interval” suggests acute epidural bleed.
• In 90% of cases dilated pupil on same side as hematoma. -
Case #7:
The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in the ambulance, and then lapsed into a coma again. His -
Diagnosis: Acute subdural hematoma
• Severity of trauma and profound neurological deficits suggest acute subdural hematoma, probably on the right side. -
Case #8:
An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap wine. While doing so, he bumps his head against the counter, but suffers no apparent injury. Over the next week, however, he gradually loses his -
Diagnosis: Chronic subdural hematoma
• Shrinkage of brain (but not skull) in old people and alcoholics
• Torn venous sinuses with slow venous bleeding -
Case #9:
A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but his other vital signs are stable. Physical examination reveals an absence of breath sounds in the right hemithorax, which sounds hyperresonant to - Diagnosis: Pneumothorax
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Case #10:
A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his other vital signs are stable. Physical exam reveals no breath sounds at the right base, and faint, distant breath sounds at the right apex. Right -
Diagnosis: Hemothorax
• Bleeding from penetrating chest injuries most often from lung -
Case #11:
A 19-year-old male is stabbed in the right chest. On arrival at the ER he is short of breath, pale, with a pulse rate of 95 and a blood pressure of 90/70. His right hemithorax has no breath sounds and is dull to percussion. CXR shows the -
Diagnosis and Management:
• Hemothorax with systemic vessel bleeding (usually intercostals)
• Emergency thoracotomy to control bleeding
• Vigorous fluid and blood replacement -
Case #12:
A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey shows multiple bruises and minor lacerations, but t -
Diagnosis:
• Consider: severe trauma to the chest, deceleration injury
• Think of obvious injuries as well as hidden ones
• Broken ribs and flail chest are obvious
• Consider possibility of traumatic rupture of aorta
• Manage the obvious, uncover the hidden -
Case #13:
A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely tender at a point in the sternum, where palpatio -
Diagnosis: Sternal fracture
• Probable myocardial contusion
• Fracture of hard-to-break bones (sternum, scapula, first rib) suggest major trauma
• Sudden deceleration chest trauma- possibility of aortic rupture -
Case #14:
Two airplanes collide on runway and there are multiple casualties. One of the survivors is found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he is taken to the hospital, where a CXR shows a wide medias -
Diagnosis: Traumatic rupture of aorta
• Intima and media may have cracked and be asymptomatic until adventitia gives way