The document discusses standards for medical professionals in Thailand and focuses on conditions related to the thyroid, esophagus, vascular system, and trauma. It covers topics such as solitary thyroid nodules, hyperthyroidism, caustic esophageal injuries, esophageal cancer, and achalasia. Diagnostic criteria, management guidelines, and follow-up plans are provided for various conditions.

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