• Save
Mdcu Step2 Gen Sx Ii
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
No Downloads

Views

Total Views
8,492
On Slideshare
8,492
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
0
Comments
11
Likes
13

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. MD Chula 2010 x y nl O se Thyroid, Esophagus, Vascular & Trauma U เกณฑมาตรฐานผูประกอบวิชาชีพเวชกรรมของแพทยสภา พ.ศ.2545 (only Gen Sx) al ความรูความสามารถแบงได3กลุม rn กลุมที่1 ตองรูกลไกการเกิดโรค สามารถวินิจฉัยเบื้องตน และรักษาไดทันทวงที ตามความเหมาะสม รูขอจํากัดของตัวเอง และปรึกษาผูเชี่ยวชาญไดเหมาะสม te กลุมที่2 ตองรูกลไกการเกิดโรค สามารถวินิจฉัย และรักษาไดดวยตนเอง รวมทั้งฟนฟู In สงเสริมสุขภาพ และปองกันโรค กรณีที่โรครุนแรงหรือซับซอนเกินความ สามารถ ใหแกไขปญหาเฉพาะหนาและสงตอไปยังผูเชี่ยวชาญ กลุมที่3 ตองรูกลไกการเกิดโรค สามารถวินิจฉัยแยกโรค และรูหลักในการรักษา แกไขปญหาเฉพาะหนาและสงตอไปยังผูเชี่ยวชาญ รูหลักในการฟนฟู สงเสริมสุขภาพ และปองกันโรค
  • 2. MD Chula 2010 เกณฑมาตรฐานผูประกอบวิชาชีพเวชกรรมของแพทยสภา พ.ศ.2545 (only Gen Sx) หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.3.2 Neoplasm กลุมที่3 (2) benign and malignant neoplasm of thyroid gland หมวดที่3 – ทักษะการตรวจโดยใชเครื่องมือพื้นฐาน การตรวจทางหองปฏิบัติการ และการ ทําหัตถการ y 3.5.5 หัตถการเฉพาะทาง nl สามารถบอกขอบงชี้ หลักการ ภาวะแทรกซอนที่อาจจะเกิด สามารถใหคําแนะนํา เพื่อเปนแนวทางในการสงตอผูปวยตอไปไดอยางเหมาะสม และสําหรับใหคําแนะนํา ปรึกษา O แกผูปวย (5) thyroidectomy se Thyroid U Solitary Thyroid Nodule al แยก thyroid function rn 1. Euthyroid 2. Hyperthyroidism – 1% te •Hx ที่บงชี้ hyperthyroidism – เหนื่อยงาย, ใจสั่น, นาหนักลด, ขี้รอน, ขี้ In โมโห, หงุดหงิด, กินเกง, นอนไมหลับ •PE ที่บงชี้ hyperthyroidism – tachycardia, tremor, lid lag, hyperactivity •LAB – FT3, TSH เฉพาะรายที่มี Hx & PE ที่บงชี้ hyperthyroidism Thyroid
  • 3. MD Chula 2010 Solitary Thyroid Nodule แยก benign & malignant •Hx ที่สงสัย malignant – กอนโตเร็ว, เสียงแหบ, กลืนลําบาก •PE ที่สงสัย malignant – hard, fix, lymphadenopathy •Risk – เพศชาย, Hx ฉายแสงบริเวณคอตอนเด็กหรือวัยรุน, อายุ<20 or >60 (ปจจุบันไมใช risk มาประเมินการวินิจฉัย) y •FNA – ทําทุกรายถาไมมีขอหาม เชน bleeding tendency, nl hyperthyroidism O •ETC เชน Ultrasound, thyroid scan, hormonal suppression ไมทํา se Thyroid U Solitary Thyroid Nodule al Euthyroid Hyperthyroid ปกติ rn FNA FT3, TSH Solid or mixed solid cystic Cystic te reaspirate In recurrent หาย surgery No hormonal suppressive therapy Thyroid
  • 4. MD Chula 2010 Solitary Thyroid Nodule Euthyroid Hyperthyroid FNA ปกติ FT3, TSH Solid or mixed solid cystic Cystic Inadequate positive suspicious negative y surgery surgery hormone suppress nl or F/U O malignant benign (near)total thyroidectomy + I131 se ขึ้นกับชนิด และขนาดของมะเร็ง Thyroid U FNA al •Positive : papillary, medullary & anaplastic rn Surgery + I131(papillary) + MRND(if LN+ve or in medullary) te •Suspicious (30%) : follicular, Hurthle cell Lobectomy + frozen section à if +ve for CA à In Surgery + I131+ MRND(if LN+ve) •Negative : colloid, no tumor cell ......hormonal suppressive Rx à evaluate at 6mo Thyroid
  • 5. MD Chula 2010 Solitary Thyroid Nodule Euthyroid Hyperthyroid FNA ปกติ FT3, TSH FT3 สูง, TSH ตา Thyroid scan y Hot nodule toxic MNG Graves + cold nodule nl I131 or surgery Rx hyperthyroid O FNA cold nodule se Thyroid U al Indications for thyroidectomy rn te 1. Fail medical 2. Can’t R/O cancer In 3. Compressive symptom 4. Cosmetic Thyroid
  • 6. MD Chula 2010 Role of TSH suppression in CA 1. Papillary CA 2. Follicular CA y nl O • Medullary CA – Replacement dose se Thyroid U al F/U plans rn te 1. Clinical 2. Thyroglobulin (pap & foll CA) In 3. Calcitonin (med CA) 4. TSH for dose adjustment Thyroid
  • 7. MD Chula 2010 เกณฑมาตรฐานผูประกอบวิชาชีพเวชกรรมของแพทยสภา พ.ศ.2545 (only Gen Sx) หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.1 อาการ / ปญหาสําคัญ กลุมที่1 (10) สะอึก สําลัก กลืนลําบาก หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.3.2 Neoplasm y กลุมที่3 (2) benign and malignant neoplasm of esophagus nl 2.3.11 Disorder of the digestive system กลุมที่2 (3) Dyspepsia, esophagitis O 2.3.19 Injury, poisoning & consequence of external causes กลุมที่2 (10) Corrosions se Esophagus U Caustic injury of esophagus al Liquefaction necrosis (base) or coagulation necrosis (acid) rn te Hyperemia & edema In Vascular thrombosis à ischemia (possible perforation) Scar & stricture (possible premalignant) Esophagus
  • 8. MD Chula 2010 Caustic injury of esophagus Diagnosis •Early à mouth & oropharynx : burn wound, leukocytic membrane (in 24hr) •Late à stricture à dysphagia (>3wk) à UGI study Initial management •Admit + NPO + fluid resuscitation •Respiratory care (esp. 1st 24hr) •No lavage, no dilute, no emetic y •CXR à R/O pneumomediastinum, pleural effusion •ATB : pen or cep x 7-10d nl •No steroid •Flexible or rigid esophagoscope in 24-48hr : GI, larynx, vocal cord & O proximal trachea •+Bronchoscopy •No contrast study except R/O perforation (water soluble) se Esophagus U Caustic injury of esophagus al EGD pathological grading rn Grade Pathology EGD finding te 1st degree Mucosa Hyperemia & edema In Mucosal shedding Mucosa + muscular 2nd degree Exudate, pseudomembrane NO periesophageal tissue Granulation tissue (late) Deep ulcer Obstruction (edema) 3rd degree Full thickness Eschar Infarction or perforation Esophagus
  • 9. MD Chula 2010 Caustic injury of esophagus Management Grade Management 1st degree Supportive & symptomatic Explore-lap 2nd degree If no ischemia – stent x 3wk If ischemia – Rx as 3rd degree Explore-lap y 1. Esophagogastrectomy nl 3rd degree 2. Cervical esophagostomy 3. Jejunostomy O Reconstruction in 6-8wk se Esophagus U Caustic injury of esophagus al rn Management of stricture •Dilate à Savary-Gillard dilator 6-12mo te •Surgery à Bypass surgery In Esophagus
  • 10. MD Chula 2010 Esophageal cancer •Progressive dysphagia, odynophagia à suspect CA esophagus Ba swallowing EGD + biopsy (gold standard) Negative Positive y Staging (No T4, M1, Fistula) nl Vital staining Biopsy or brush cytology functional evaluation O operable inoperable Negative Positive Observe or repeat cytology Improve nutrition (keep alb > 3.4) se Esophagus U Esophageal cancer al • Staging evaluation rn T & N – EUS + FNA M & N – CT scan te Locoregional disease (T1-T3 and/or N0-N1) / advance (T 4 or M1 or fistula) • Functional evaluation In Pulmonary function test & echocardiogram 1. Age > 75yr 2. FEV1 < 1.25L 3. EF < 40% 4. Cirrhosis 5. Other incurable disease 6. Other disease that contraindicated for surgery Esophagus
  • 11. MD Chula 2010 female 25 yr, ingested Vixol , BP 100/60, BT 38 C , RR 24, PR 110, Stridor + sign of peritonitis, X-Ray : Lt pleural effusion and free air below Rt dome of diaphragm. Initial management ? a. Balium swallow b. Explore Lap y c. Large central vein establishment nl d. Rt chest drainage O e. Tracheostomy se Esophagus U al 42 yr, History of intermittent dysphagia , Ba Swallow : esophageal dilatation with smooth tapering , Scope : no rn abnormality. Diagnosis ? te a. Achalasia In b. Benign stricture c. Gastroesophageal reflux d. Globus hystericus e. CA esophagus Esophagus
  • 12. MD Chula 2010 เกณฑมาตรฐานผูประกอบวิชาชีพเวชกรรมของแพทยสภา พ.ศ.2545 (only Gen Sx) หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.2 โรค/ภาวะ/กลุมอาการฉุกเฉิน(รวมทุกระบบ) กลุมที่1 (12) Superior vena cava obstruction หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.3.9 Disorder of the circulatory system y กลุมที่3 (12) Varicose vein of lower extremity nl O se Vascular U Acute arterial occlusion al • Etiology : acute thrombosis & embolism rn • Locations • Thrombosis : distal SFA, popliteal bifurcation, distal aorta, iliac te artery • Embolism : lower limbs (60-70%), cerebral (15-20%), upper limbs (15%) & visceral (7-10%) In • Signs & symptoms : 6P • Pain : progressive à peak à deteriorate • Pallor : waxy à mottling à gangrene • Paresthesia : light touch à deep pain • Paralysis : weakness à paralysis (rigor) • Comorbidity eg. DM. HT, heart & lungs, AF…etc Vascular
  • 13. MD Chula 2010 Acute arterial occlusion Embolism thrombosis Onset Sudden (minutes à hours) Slow (days) History Previous embolism 1/3 No Limb affected Leg:arm = 3:1 Leg:arm = 10:1 Multiple lesions 15% Rare Demarcation Sharp Vague Age Any Older > 40 Arrhythmia Frequent (AF 74%) Possible (AF 4%) y Source of embolus Usual (AF,MI) Less common History of claudication Rare Common nl Sign of chronic arterial occlusion Few Contralateral limb: pulse diminish or absent O Angiogragraphy Sharp cut off, meniscus sign, Diffuse atherosclerosis, few atherosclerosis, tapered, irregular cut off, few collaterals well collaterals DDx between acute embolism & thrombosis se Vascular U Acute arterial occlusion al Finding Doppler signal Description Category Sensory Muscle rn /prognosis Artery Vein loss weakness I. Viable Not immediately None None Audible Audible te threatened II. Threaten a. Marginal Salvageable if Minimal or None (often) Audible In promptly treated none inaudible b. Immediate Salvageable with More than Mile to (usually) Audible immediate toes, asso moderate inaudible revascularization rest pain III. Irreversible Major tissue loss Anesthetic Paralysis Inaudible Inaudible or permanent (rigor) nerve damage Categories according to physical findings Vascular
  • 14. MD Chula 2010 Acute arterial occlusion • Investigations • Doppler u/s : ABI, sequential pressure different >30mmHg • Duplex scan : site of obstruction esp. graft thrombosis • Angiography : “Gold standard” – preop or intraop • Embolism : smooth, no collateral, meniscus sign • Thrombosis : rough, well collaterals • Invasive, contrast need & delay y • CTA or MRA : nl • Noninvasive, no contrast, cross sectional image • Expense, time consume O se Vascular U Acute arterial occlusion al • Management rn 1. Heparinization : load 5,000-10,000u IV à drip 800- 1,000u/hr (keep PTT & INR x2) te 2. Patient evaluation : physical status & comorbidity 3. Nonoperative treatment (endovascular procedure) In • Catheter-directed thrombolytic therapy (CDT) : Category I,IIa • Absolute contraindication • CVA • Active bleeding diathesis • Recent GI bleeding (in 10d) • Neurosurgery (in 3mo) • Intracranial trauma (in 3mo) Vascular
  • 15. MD Chula 2010 Acute arterial occlusion • Management 3. Nonoperative treatment (endovascular procedure) • Percutaneous aspiration thrombectomy (PAT) & percutaneopus mechanical thrombectomy (PMT) 4. Operative treatment • Embolectomy : acute embolism • Bypass surgery : acute thrombosis y • Amputation : category III 5. Repurfusion injury nl • Management plans • Category I : Investigation à Rx (operative or non) O • Category II : a à rapid investigation à Rx b à immediate revascularization • Category III : amputation se Vascular U Chronic arterial occlusion al • Atherosclerosis rn • Claudication à gangrene • Disabling claudication : walk < 1block (50-100m) te • Critical limb ischemia : rest pain, toes ulcer or gangrene, toe & ankle systolic pressure < 30 & 50mmHg (limb loss in 2yr In 30%) Vascular
  • 16. MD Chula 2010 Chronic arterial occlusion Grade Category Clinical description 0 0 Asymptomatic I 1 Mild claudication 2 Moderate claudication 3 Severe claudication II 4 Ischemic rest pain y 5 Minor tissue loss-nonhealing ulcer, focal gangrene with diffuse pedal ischemia nl III 6 Major tissue loss-extending above tarsometatarsal level, functional foot no longer O Clinical categories of chronic limb ischemia se Vascular U Chronic arterial occlusion al • Management plans rn • Category 1-2 : nonoperative management • Category 3-6 : invasive management te • Goal : save limb for normal life & pain control Noninvasive management In • Risk reduction : smoking cessation • Exercise : less claudicaion • Medical treatment • Antiplatelet : less thrombosis eg. Aspirin, cilostazol(pletal), clopidogrel(plavix) • ACE inhibitors • Prostacyclin analogue Vascular
  • 17. MD Chula 2010 Chronic arterial occlusion • Management plans • Category 1-2 : nonoperative management • Category 3-6 : invasive management • Goal : save limb for normal life & pain control Invasive management • Percutaneous transluminal angioplasty (PTA) eg. balloon, laser y • Aortoiliac surgical reconstruction • Extra-anatomic surgical procedure eg. Axillofemoral, nl femorofemoral crossover • Femoropopliteal & femorodistal bypass O • Below knee à autogenous vein graft > PTFE se Vascular U Peripheral vascular injury al • Blunt (50%), penetrating (45%), iatrogenic (5%) • Mechanism rn 1. Transection : arterial occlusion 2. Laceration : massive hemorrhage or false aneurysm/expanding te hematoma 3. Contusion : adventitial hematoma à subintimal hematoma (intimal tear) – occlusion, true aneurysm In 4. Arteriovenous fistula : penetrating injury – miss Dx, late presentation eg. False aneurysm 5. Spasm : reflex smooth muscle contraction (rare) Resuscitation - ABCDE • Stop bleeding : direct pressure compression, no tourniquet, no blind clamping • IV fluid : no affected vein Vascular
  • 18. MD Chula 2010 Peripheral vascular injury • Diagnosis 1. Hard signs à intraop angiogram + vascular repair • Absent distal pulse • Active hemorrhage • Large, expanding, or pulsatile hematoma • Bruit or thrill • Distal ischemia (6P) y 2. Soft signs à investigation + observe nl • Diminished distal pulse • Small, nonpulsatile hematoma • Proximity of injury to major vessel O • Injury to anatomically related nerve • Unexplained hypotension • History of arterial bleeding at scene of accident se Vascular U Peripheral vascular injury al • Investigation rn 1. Arterial pressure index (API) = doppler pressure (injured limb) doppler pressure (uninvolved contralateral limb) < 0.9 à occlusion (accuracy 95%) te 2. Ultrasound : skill dependent, not clear in blunt injury In 3. Contrast angiography : exclusion angiography (no hard sign), site of injury • Only in hemodynamic stable patients Vascular
  • 19. MD Chula 2010 Peripheral vascular injury • Fasciotomy • Any evidence of compartment syndrome – 4 compartments fasciotomy (2 incisions) • Compartment pressure measurement : not routinely use • Endovascular precedure • AVF, false aneurysm – stent, coil or beads y nl O se Vascular U Peripheral vascular injury al Hard signs rn Yes No Intraoperative angiography Risk classification te Vascular repair High Low API<0.9 API>0.9 In Pulse deficit No Pulse deficit Angiography Observation Normal Minimal injury Major injury Observation Observation Operation + serial or angiography endovascular Vascular
  • 20. MD Chula 2010 Buerger’s disease (thromboangitis obliterans) •Progressive nonatheroslerosis segmental inflammation affects small & medium-sized arteries, veins & nerves of extremities (usually infrapopliteal & distal to brachial artery) •Etiology : unknown •Asian, young male smoker < 40yr •Foot, leg, arm or hand claudication à ischemia •Dx : exclude other vasculogenic caused + 4 limbs y angiography à segmental occlusion + skip lesion + extensive nl collateralization •Rx : smoking cessation (often no role of surgery) O se Vascular U Superior vena cava obstruction al •= superior vena cava syndrome rn •Etiology : benign or malignant process à compression, invasion or thrombosis •Increase venous pressure in SVC te •Edema – head, neck & upper extremities •Distended neck vein & dilated collateral vein In •Cyanosis, confusion & headache •Malignant esp. bronchogenic à LN •Dx : CT or MRI (obstruction), FNA or open biopsy (tissue) •Rx : stent, steroid, radiation, chemotherapy, fibrinolytic or anticoagulant, etc. (depend on cause) •Benign process : fluid restriction, upright position & medical (diuretic) à wait until collateral channels open Vascular
  • 21. MD Chula 2010 Varicose vein • 3-15mm • Telangiectasias or thread veins (0.5mm) – intradermal (red or violet) • Reticular varices (1-3mm) – subdermal (green) • Primary or secondary (Brodie-Trendelenberg test) • Perthes’ test – confirm deep venous pathology (No venous stripping) y • Complication – trauma, thrombophlebitis à thrombosis nl • Vascular lab (doppler u/s, duplex scan,…) – for deep venous pathology O • Venogram (invasive) – replaced by duplex se Vascular U Varicose vein al Management – depend on size, extent & symptom rn • Compressive stocking te • Relief symptom • Type - below knee support stocking 20-30mmHg • Poor compliance In • Contraindicate in arterial insuff. • Sclerotherapy • Branch of saphenous <3mm & normal saphenous valve or recurrent varicosities • Sclerosant : detergent (polidocanol), hypertonic solution (saline or dextrose) or chemical irritant (aethoxysclerol) • Complication : anaphylaxis, pigmentation, thrombophlebitis & ulceration or necrosis Vascular
  • 22. MD Chula 2010 Varicose vein Management – depend on size, extent & symptom • Surgery • Indication 1. Pain & valvular incompetence of saphenous vein 2. Complications of varicose vein y • Type – High ligation + venous stripping + multiple stab avulsions • Lesser saphenous varicose vein – preop duplex scan for locate nl saphenopopliteal junction • Complication : bruising & discomfort, skin numbness, saphenous & O sural n. injury, DVT(0.1%) se Vascular U emboli ที่ popliteal artery ทํา embolectomy พบวามี al collateral cir. มาเลี้ยง หลังทําอาการไมดีขึ้น organ แรก rn ที่จะมี irreversible damage คือ a.bone te b.muscle In c.peritoneum d.skin Vascular
  • 23. MD Chula 2010 A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling of his right arm for 3 days. The symptoms are moderately exacerbated by exertion. Examination of the right upper extremity shows erythema and moderate edema. Capillary refill time is less than 3 seconds. Which of the following is the most likely diagnosis? (A) Axillary-subclavian venous thrombosis y (B) Deep venous valvular insufficiency nl (C) Superficial thrombophlebitis of the basilic vein (D) Superior vena cava syndrome O (E) Thoracic outlet syndrome se Vascular U เกณฑมาตรฐานผูประกอบวิชาชีพเวชกรรมของแพทยสภา พ.ศ.2545 (only Gen Sx) al หมวดที่2 – ภาวะผิดปกติจําแนกตามระบบอวัยวะ 2.3.19 Injury rn กลุมที่2 (1) Wound (3) Animal bites te กลุมที่3 (14) Chest injury (15) Abdominal injury In หมวดที่3 – ทักษะการตรวจโดยใชเครื่องมือพื้นฐาน การตรวจทางหองปฏิบัติการ และการ ทําหัตถการ 3.5.5 หัตถการที่มีความซับซอน และ/หรือ อาจเกิดอันตรายที่รายแรงไดถา ปฏิบัติไมเหมาะสม และ/หรือตองอาศัยการฝกฝนเพิ่มเติม สามารถบอกขอบงชี้ หลักการ ภาวะแทรกซอนที่อาจจะเกิด สามารถใหคําแนะนํา ผูปวยไดถูกตอง เมื่อจบแพทยศาสตรบันฑิตและผานการเพิ่มพูนทักษะตองเคยเห็นหรือเคย ชวย (4) peritoneal lavage Trauma
  • 24. MD Chula 2010 Initial Management of Trauma Advance traumatic life support (ATLS by American College of Surgeons) 1)Preparation 2)Triage 3)Primary survey 4)Resuscitation 5)Secondary survey y nl 6)Monitoring & evaluation 7)Definitive care O se Trauma U Initial Management of Trauma al Primary survey & resuscitation – A, B, C, D, E Airway & C-spine control rn - Remove foreign bodies - Head tilt & chin lift or jaw thrust (cervical collar) - Promote oxygenation – nasal or oral airway, ambu, tube, te cricothyroidotomy Breathing & ventilation In - ประเมินการหายใจ :high flow delivery oxygen + normal intrathoracic pressure = optimum hemoglobin oxygen saturation à ABG or pulse oximeter (>95) - Life threatening condition of breathing • Tension pneumothorax : needle thoracentesis (2 -3rd ICS, MCL) à nd +CXR à ICD • Flail chest & lung contusion à pain control + correct hypoxia • Open pneumothorax – 3 sides occlusive dressing à ICD à complete seal occlusive dressing • Massive hemothorax – ICD for evacuation + volume resuscitation Trauma
  • 25. MD Chula 2010 Initial Management of Trauma Primary survey & resuscitation – A, B, C, D, E Circulation & bleeding control - Shock assessment : restless, chill, thirst, pulse เบาเร็ว, capillary refill > 2sec - Bleeding control : direct pressure compression - 14-16F needle x2, cutdown (basilic or great saphenous), cavafix (jugular or subclavian) - Warm crystalloid (RLS or NSS) 1-2L bolus or 20cc/kg bolus (child) - >2,000cc à blood (O,Rh-) or colloid - Cardiogenic shock – cardiac tamponade à needle pericardiocentesis - Neurogenic shock – spinal cord injury (loss sympathetic tone) à fluid resus y nl Disability & Neurologic assessment - GSC, pupil size & light reaction à emergency CT-brain? O Exposure & Environmental control - All parts exam (esp perineum) - Prevent hypothermia se Trauma U Initial Management of Trauma al Secondary survey - After stable à Hx (AMPLE), PE rn Allergies, Medication, Past illness & operation, Last meal, Events & environment te - Film – C-spine, CXR, pelvis - NG tube – prevent aspiration, observe bleeding In (rhinorrhea or raccoon eyes à OG tube) - Foley’s catheter – prevent overdistension, observe hematuria & urine output (contraindication – bloody per urethral meatus, large scrotal hematoma) - Rectal examination – GI bleeding, high riding of prostate gland - FAST or DPL Trauma
  • 26. MD Chula 2010 Initial Management of Trauma FAST The Focused Assessment for the Sonographic Examination of the Trauma patient - 250cc 1. Pericardial sac 2. (Rutherford-)Morrison’s (hepatorenal) pouch - RUQ 3. Splenorenal pouch (recess) – LUQ 3 dependent regions 4. Pelvis 4P = Pericardium, Perihepatic, Perisplenic & Pelvis DPL (Diagnostic Peritoneal Lavage) - Indications - closed head injury, spinal cord injury, equivocal abdominal finding - Contraindications – absolute indication for surgery, previous laparotomy, pregnancy y - Opened & closed technique - Infraumbilicus (asso pelvic fracture à supraumbilicus) nl - Blunt injury Gross unclotted blood >10cc or O RBC>100,000 /mm3, WBC>500 /mm3, amylase>200U/L or present of bile, bacteria, GI contents DPL fluid in Foley or chest tube - Penetrating injury ??? se Trauma U Initial Management of Trauma Shock al Class I Class II Class III Class IV rn Blood loss (ml) 750 750-1500 1,500-2,000 >2,000 Blood loss (%) 15 15-30 30-40 >40 Pulse <100 >100 >120 >140 te BP normal normal decrease decrease Capillary blanch decrease decrease decrease decrease In RR 14-20 20-30 30-40 >35 Urine output (cc/hr) >30 20-30 5-15 - Mental status slightly anxious confused lethargic anxious Fluid replacement crystalloid crystalloid crystalloid crystalloid (3:1 rule) + blood + blood ATLS Guideline of fluid resuscitation Trauma
  • 27. MD Chula 2010 Blood transfusion in perioperative blood loss 1.Blood loss <10% à no blood transfusion 2.Blood loss 10-20% à crystalloid solution 3.Blood loss >25% à PRC + crystalloid or colloid y nl O se Trauma U Priorities in wound management al 3 phases 1st phase – identify & treat life-threatening injuries rn primary survey & secondary survey Wound à prevent major bleeding by direct pressure 2nd phase – after 1st phase being treat te “How to deal with the wound” 2.1) OR? In 2.2) Associated injuries? (bone, tendon, nerve, vascular, visceral) 2.3) Closed or opened? 2.4) Antibiotic? 2.5) Any vaccines? 3rd phase – continue wound care Trauma
  • 28. MD Chula 2010 2.1) Conditions requiring management in OR Large or complicated soft-tissue injury Extensive amount of necrotic or ischemic tissue Heavy contamination Associated injury Perineal wounds Compartment syndrome High-pressure injuries 2.2) Search for associated injuries à locally explored y Scalp à depressed skull fracture? nl Neck à platysma penetration? Chest à crepitus?, CXR for all chest wound O Abdomen à peritoneal penetration? Extremities à bone, tendon, nerve or vascular? Compartment syndrome?se Trauma U 2.3) Closed or opened? 4 options 1) primary intention (immediate closure) al 2) secondary intention (left open) 3) delayed primary or tertiary intention 4) skin substitute (tissue loss) rn Probability of wound infection •Golden period : 6-8hr after 8hr à secondary intention or delay primary te Except : face & scalp (good blood supply, small amount of flora, + cosmetic) •Mechanism of injury Significant contamination, major soft-tissue injury In •Associate medical condition à high risk of infection 2.4) Antibiotic? CONTROVERSY, UNCLEAR •Not indicated for uncomplicated minor wound •Recommendation for the use of prophylactic antibiotic 1) Open joint or open fracture 2) Heavy contamination or major soft-tissue injury Soil contamination, human and animal bites, and degloving injury 3) Delay in care 4) Special problems : immunosuppression or valvular heart disease Trauma
  • 29. MD Chula 2010 2.5) Any vaccines? TETANUS Wound characteristics relating to likelihood of tetanus Clinical features Non-tetanus prone wound Tetanus-prone wound Age of wound <6hr >6hr Stellate, avulsion, Configuration Linear abrasion Depth <1cm >1cm Mechanism Sharp surface Crush, burn, other y Signs of infection Absent Present nl Devitalized tissue Absent Present O Contaminants (dirt, Absent Present soil, feces, etc) Ischemic or Absent Present denervated tissue se Trauma U 2.5) Any vaccines? TETANUS Tetanus prophylaxis al Hx of Vaccinations Non-tetanus prone rn Tetanus prone wound (doses) wound te TT TAT TT TAT In Unknown or <3doses Yes No Yes Yes >3doses Noa No Nob No aYes, if more than 10 years since last doses bYes, if more than 5 years since last doses Trauma
  • 30. MD Chula 2010 Mammalian bites 1)Irrigation 2)IV antibiotic : Augmentin or unasyn (2nd choice – cefoxitin, erythromycin) 3)Elevate wound (if at extremities) y nl 4)Not be closed (except face) 5)Tetanus & rabies vaccine if indicated O se Trauma U Chest injury à hypoxia, hypercarbia & acidosis R/O 6 conditions al 1) Upper airway obstruction 2) Tension pneumothorax rn 3) Open pneumothorax 4) Severe flail chest 5) Massive hemothorax te 6) Cardiac tamponade In Fracture rib & costal cartilage • Blood loss 50cc/rib • Rib 1-2 : asso great vessel & tracheobronchial injury • Rib 11-12 : asso liver, spleen & kidney injury • CXR : missed fracture site 10%, not seen fracture cartilage : Dx pneumohemothorax, lung contusion • Rx : Analgesia & breathing exercise : Intercostal nerve block : Thoracic epidural block Bone union in 4wk, cartilage union in 6wk Trauma
  • 31. MD Chula 2010 Pulmonary contusion • Blunt chest injury + dyspnea + cough (+ hemoptysis) • CXR : 100% Dx in 6hr Finding : increase parenchymal density à patchy infiltration Resolution in 48-72hr Complete clearing in 2-3wk • Rx 1) Tracheobronchial care – clear airway + breathing exercise 2) Adequate analgesia 3) Maintain pulmonary function – keep PaO2 > 65mmHg y 4) Prevent pulmonary complications – pulmonary edema (IV nl fluid), infection (no role of prophylactic antibiotic) 5) Rx associate injury O 6) Improve general condition + symptomatic/supportive care se Trauma U Abdominal injury al CT scan rn • Better than DPL in stable patient • Can evaluate severity grading & retroperitoneal injury • Nonoperative management (decrease negative laparotomy) te • Can’t identify diaphragmatic injury In Diagnostic laparoscopy • In blunt injury : benefit similar to DPL &CT (better in penetrating injury) • Dx diaphragmatic injury, hollow viscus injury • Definitive minimally invasive treatment • R/O diaphragmatic injury when thoracoabdominal (torso) injured site is inferior to the nipple line Trauma
  • 32. MD Chula 2010 A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake and alert and appears fringhtened but in no distress. The chest radiograph suggests an air- fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. Which of the following is the next best step in his management? a.Placement of a left chest tube y b.Thoracotomy nl c.Laparotomy d.Esophagogastroscopy O e.Diagnostic peritoneal lavage se Trauma U During a bar brawl, a 19-year-old male sustains a 4-inch laceration on al his left arm from glass and presents to the emergency room the following morning, 10 hr later. He is neurovascularly intact and the rn wound appropriate management of the wound? a.Closure of the skin only and administration of oral antibiotics for one te week In b.Closure of the skin and subcutaneous tissue and administration of oral ATB For one week c.A single dose of intravenous ATB and closure of the skin only d.A single dose of intravenous ATB and closure of the skin and subcutaneous tissue e.Local wound care without wound closure or ATB Trauma
  • 33. MD Chula 2010 Male 19 yr, sustained 4 inches laceration wound Lt arm 10 day PTA. Neurovascular intact. What is your management ? a. ATB IV 1 dose + close Skin b. ATB IV 1 dose + close Skin + close subcutaneous y c. ATB oral 1 wk + close skin nl d. ATB oral 1 wk + close Skin + close subcutaneous e. Local dressing, no closure , No ATB O se Trauma U A 27-year-old man sustains a single gunshot wound to the left thigh. In al the emergency room,he is noted to have a large hematoma of his medial thigh.He complains of paresthesias in his foot. On examination, rn there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which to the following is the most appropriate te initial management of this patient? In a.Angiography b.Immediate exploration and repair in the operating room c.Fasciotomy of the anterior compartment of the calf d.Observation for resolution of spasm e.Local wound exploration at the bedside Trauma
  • 34. MD Chula 2010 25-year-old man suffered MCA 30 min PTA. He is drowsy, hypotensive & has Distended abdomen airway management? a.cricothyroidotomy b.nasotracheal intubation y c.oral airway nl d.orotracheal intubation O e.tracheostomy se Trauma U Male patient with stab wound at abdomen with knife al retain in wound , V/S stable, full consciousness. Most rn appropriate management ? a. DPL te b. Emergency explore laparotomy In c. Sonography of trauma d. Pull knife off at ER e. Explore wound at ER Trauma
  • 35. MD Chula 2010 ผูปวยชาย อายุ 30 ป โดนแทงมาบริเวณทอง LLQ และยัง มีดามมีดปกคาอยูที่แผลดวย ผูปวยพูดคุยรูเรื่องดี ไมมี ซึมหรือสับสน ตรวจรางกาย vital sign ปกติดี ถามวาจะ ใหการ management อยางไร a.Emergency laparotomy in Operating room y b.Wound exploration at ER nl c.Remove the knife immediately O d.Wound debridement at ER e.Observe se Trauma U al The patient with the motorcycle accident was confused, BP 85/60 mmHg, PR 130/min, RR rn 30/min. How much blood volume did he lose? te a.Less than 15% In b.15-30 % c.30-40 % d.More than 40 % Trauma
  • 36. MD Chula 2010 Male 62 years old, presented with shortness of breath, no history of smoking.PE : BP 90/60 mmHg, PR 120/min, RR 30/min, decreased breath sound left side, tympany on percussion ขณะตรวจรางกายนั้นมี stop breathing, unconscious and pulseless. What is your immediate management? A.Endotracheal intubation y B.Oxygen mask with ambu bag nl C.ICD O D.Needle aspiration E.Cricothyroidotomy se Trauma U ผูปวยชายอายุ 35 ป ไดรับบาดเจ็บจากอุบัติเหตุ al เครื่องบินตก มีอาการปวดที่กระดูกซี่โครงดานขวาแพทย rn เวรประจําหองฉุกเฉินทําการตรวจรางกายพบวามี trachea shift ไปดานซาย, Right pneumothorax (ใหขอมูล te เปนแบบ tension pneumothorax) การปฏิบัติในขอใด In เหมาะสมที่สุดในผูปวยรายนี้ a.Pleural tapping b.Observe vital sign c.Oxygen mask with bag d.Emergency ORIF Trauma
  • 37. MD Chula 2010 ผูปวยชายอายุ 31 ป ไดรับบาดเจ็บจากการถูกแทงที่ left parasternal border 5 นาทีกอนมาโรงพยาบาล มี Blood pressure drop แพทยเวรประจําหองฉุกเฉินทําการตรวจ รางกายพบวามี distant heart sound การปฏิบัติในขอใด เหมาะสมที่สุดในผูปวยรายนี้ a.Echocardiogram y b.Pericardiocentesis nl c.CT chest O d.MRI chest e.Observe vital sign and clinical sign and symptom se Trauma U ชาย45ปมาหองฉุกเฉินดวยเรื่อง car accident มีอาการsevere al neck pain ตรวจรางกายพบ neck muscle spasm , normal neurological sign , film C-spine normal .What is the most rn proper management? te A. Cold pack + soft collar B. Cold pack + intermittent cervical traction In C. Analgesics + intermittent cervical traction D. Exercise + ultrasonogram therapy at neck muscle E. Intermittent cervical traction + ultrasonogram therapy at neck muscle Trauma
  • 38. MD Chula 2010 ผูปวยชายโดนหินเจียรกระเด็นทิ่มคอขณะกําลังทํางาน ตําแหนง ที่โดนใกลลูกกระเดือก 30 นาทีกอนมาโรงพยาบาล ชวงแรกที่ บาดแผลมีเลือดออกตามจังหวะการเตนของหัวใจ, วัดความดัน โลหิตได 86/70 mmHg ขณะนี้เลือดหยุดไหลแลว มีแผล laceration 3 cm anterior to sternocleidomastoid การปฏิบัติใน ขอใดเหมาะสมที่สุดในผูปวยรายนี้ a.Explore wound at ER y b.Explore wound at OR nl c.CT O d.MRI e.Angiography se Trauma U ชายอายุ 30 ป ประสบอุบัติเหตุรถชน ตองทํา distal al below knee amputation แพทยพัน stump ไว หลังจากนั้น rn แพทยควรจะนัดผูปวยมาเพื่อใสขาเทียมแบบถาวร นาน te เทาไร a.7 วัน In b.10 วัน c.15 วัน d.30 วัน e.45 วัน Trauma
  • 39. MD Chula 2010 ผูปวยชายอายุ 65 ปมีประวัติ Car accident มีอาการ ออนแรงตั้งแตคอลงไป มี Blood pressure drop, Bradycardia การวินิจฉัยในขอใดเปนไปไดมากที่สุด a.Cardiogenic shock b.Cushing response y nl c.Hypovolemic shock d.Neurogenic shock O e.Septic shock se Trauma U ผูปวยชายอายุ 14 ป ไดรับบาดเจ็บจากอุบัติเหตุมอเตอร ไซดลมแพทยเวรประจําหองฉุกเฉินทําการตรวจรางกาย al พบวา Blood pressure drop ประเมิน Glasgow Coma rn Score = 8 การปฏิบัติในขอใดเหมาะสมที่สุดในผูปวยราย te นี้ a.Cervical Collar In b.ET intubations c.CT and MRI d.IV fluid and dopamine if necessary e.Refer to the nearest hospial immediately Trauma
  • 40. MD Chula 2010 An 18-year-old man is brought to the emergency department 45 minutes after his car slid off an icy road into a telephone pole at approximately 35 miles per hour. He was the restrained driver, and the air bag inflated. Examination shows multiple contusions over the chest bilaterally; there is tenderness to palpation over the right lower chest wall. The abdomen is flat, soft, and nontender. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Toxicology screening is negative. His urine is pink; urinalysis shows 80 RBC/hpf but no WBCs. Which y of the following is the most appropriate next step in management? nl (A) CT scan of the abdomen and pelvis with contrast (B) Magnetic resonance arteriography of the renal arteries O (C) Intravenous administration of antibiotics (D) Exploratory laparotomy (E) No further studies are indicated. se Trauma U A patient involved in a high-speed automobile collision arrives al in ER unconscious,with multiple facial fractures; brisk bleeding into his nose ,mouth,and throat; and gurgly,irregular,noisy rn breathing.Which of the following would be the best method to te secure an airway in this patient? a.Nasotracheal intubation with visualization of the cords In b.Orotracheal intubation with rapid anesthetic induction c.Percutaneous transtracheal ventilation d.Cricothyroidotomy done in ER e.Emergency tracheostomy done in ER Trauma
  • 41. MD Chula 2010 ชายอายุ 18 ป ถูกหมากัดหนาโรงภาพยนตรที่นิ้วมือขวา ขนาด 2x1 cm (โจทยไมไดบอกลักษณะบาดแผล) หลังจากนั้นลางแผลและได tetanus toxoid การปฏิบัติใน ขอใดเหมาะสมที่สุดในผูปวยรายนี้ a. Rabies vaccine b.Rabies Ig y c.เฝาดูอาการสุนัข 1 สัปดาห nl d.ตัดหัวสุนัขสงตรวจและรอฟงผล O e.Rabies vaccine และ Rabies Ig se Trauma U What is the treatment for coagulopathy from al massive blood transfusion? rn a.Rewarming and correct acidosis by sodium bicarbonate te b.FFP, Plt transfusion In c.Factor VIIa d.Transexamic acid e.Vit. K
  • 42. MD Chula 2010 A 37 year-old woman is brought to the surgical floor after undergoing an appendectomy that morning.She had been fasting since midnight the night prior to her surgery.She has no past medical history except for taking only oral contraceptive pills regularly.During the procedure, she was reported to lose approximately 300 mL of blood.On the floor, she appears well but complains of some fatigue.Her BP is 110/60 mm Hg and her PR 100/min. She is not taking food or water yet because of nausea and vomiting.Which of the most appropriate management? a.No further intervention y b.IV crystalloid nl c.IV 25% albumin O d.PRC transfusion e.Re-explore the patient for possible bleeding se U 1.เด็กจมนา CPR เด็กหายใจดีขึ้นมาพบ Pink Frosty sputum การปฏิบัติในขอใดเหมาะสมที่สุด al a.Positive Pressure ventilation rn b.Mask with bag te 2.อาเจียนอยางมาก ตอมาเหนื่อยขึ้นทันที: Esophageal rupture40. X-ray พบ mediastinal shift, bowel ขึ้นมาใน In thorax a.diaphragmatic hernia 3.pt 45ป สูบบุหรี่ นิ้วมี gangrene a.TAO