Name the 3 types of traction and briefly describe each.
Manual traction- hands
Skin traction- tape/bandage applied to the skin
Skeletal traction- pins w/ the OR fx bed
What are the maximum tourniquet pressures and times?
Upper extremity & lower leg is 205-300 mmHG/hr
Thigh is 300-350mmHG/2 hrs
Explain exsanguination
The removal of blood in an extremity to create a bloodless field for
visual acuity (with the use of Esmarch)
How are fractures classified?
Fractures are classified according to the type of fracture and the
extent of damage
Name the groups of fractures included under each classification.
Whether or not bone pierces the skin- simple(closed), compound (open)
Type of fx line through a bone- complete or incomplete
Direction of the fx line- linear, spiral, transverse, intra articular
Manipulating a bone fx into alignment w/o incising the skin is called?
Closed reduction
Which style cast is applied to the trunk around the affected leg
& around 1/2 of the unaffected leg?
Hip spica
Cortical screw
Threads are closer & narrower & run the entire length of the
screw. It transfixes bone by gaining purchase (grab) of the bone cortex.
Cancellous screw
Threads are broader & further apart; they do not run the entire
length of the screw. Bone accumulates w/i the threads to provide
purchase for fixation.
Explain the correct sequence for the insertion of a bone screw.
Drill, measure, tap, screw
How does a buttress plate function?
It is less rigid & can't produce dynamic compression. It may be
used as a secondary plate in comminuted fractures of long bones or pelvis.
Why are plates/screws NOT commonly used for the repair of femoral
shaft fractures?
Bent/broken plates
Refractures
SSI's
What is the preferred method of tx for femoral shaft fractures?
IM fixation
What anatomical consideration must be given attention during the
repair of a distal femur fx?
Attachment of the cruciate ligament
The use of plate & screw geometry to apply through a fx site
utilizes which type of plate?
Dynamic compression
In which bone are open fractures most common and why?
The tibia because 1/3 of the tibial surface is subcutaneous
List 2 advantages of external fixation
Fx stabilization @ the distance from the injury site
Minimal joint interference
Early mobilization for the pt
Absence of casting material
In the total knee reconstruction, what anatomical structure is
incised to allow complete visualization of the plateau surfaces?
ACL
On which bone is the chamfer cut performed during a TKA?
Femur
How many components are implanted during a TKA?
Four
Self-tapping screw
Sharp threads that cut into bone & drill away material making a
hole for the screw
Non-tapping screw
Needs the hole to be drilled prior to the insertion of the screw
Name 1 advantage of the Herbert bone screw
Fx site compression
Which bones are the Herbert bone screw commonly used for?
Carpal bones
How are hip fractures classified & name the 3 classifications
Anatomical location
Femoral neck, Intertrochanteric, & subtrochanteric
Describe 1 characteristic of a fx of the acetabulum
The fx is from the femoral head force which results from an MVA or
fall (internal fixation will be delayed 3-10 days)
Unipolar femoral head prosthesis
Solid metal ball that fits onto the stem to replace the femoral head
Bipolar femoral head prosthesis
Larger, hollow, metal ball w/ a polyethylene cup that swivels at its
attachment to the stem
To replace a femoral head, name a specific piece of instrumentation
that would be necessary
Oscillating saw
IM reamer
Caliper
Considering the surgical procedure to a THA, what are the femoral
broaches used for?
To remove cancellous bone & expose cortical bone
Hemiarthroplasty
Reconstruction of 1 side of the joint
Total hip replacement
Reconstruction of both sides of the joint
What considerations factor into the decision for or against a total
hip replacement?
Pt medical history
Age
Activity level
Which instrument is used to prepare the acetabulum during a total hip replacement?
Reamer
What is the correct position for a total hip replacement?
Lateral
What are the 2 components for a total hip replacement?
Femoral component
Acetabular component
Discuss the procedural considerations when surgical implants will be placed
Types of implants and their components
Handling of implants w/i the sterile field
Documentation & tracking
Use of similar alloys
Cemented vs. non-cemented
What is the mechanism of PMMA & how does it work?
It fills the cavities & spaces of bone to form a bond between the
prosthesis & bone to hold the prosthesis in place
What is the primary reason for performing a THA?
DJD
(Degenerative Joint Disease)
What is the major disadvantage of ORIF?
Increased incidence of infection
What is a Monteggia fracture?
A proximal ulnar fx w/ dislocation of the radial head
What is the tx of choice for a Monteggia fracture?
Closed reduction is attempted to repair the radial head dislocation
& dynamic compression plating is used to repair the ulnar nerve fx
Describe the boundaries of prep that would be used for a femoral head
prosthetic replacement
From the umbilicus down to & including the foot
Static locking
Locks proximal & distal
Dynamic locking
Locks @ the end closest to the fx
Which cuts complete the femoral resections of a TKA?
Trochlear cuts
What instrument is used to make the femoral head resection?
Oscillating saw
Name 2 specialty equipment/instrumentation items specific to cardiac
surgery which would not be found in another surgical specialty
IMA retractor
Sternal retractor
Rib spreader
Sternal Saw
Knitted grafting material
Does not easily fray
Easier to handle
Straight or bifurcated
Woven grafting material
Tighter
Decreased bleeding
Systemic heparinization
Name the 2 types of valve prosthesis
Mechanical
Biological
Mechanical Valve Prosthesis
Tilting disk
Ball & cage
Biological Valve Prosthesis
Porcine
Bovine
Cadaver
Name 2 benefits of placing the pt in supine position for cardiac surgery
Optimum exposure for CPB instillation
Optimum exposure to the heart & great vessels
Decreased respiratory impairment
Decreased discomfort for pt
Prep for vein harvesting
Jaw to toes including chest, abdomen, groin, legs, & feet
Prep for non-harvesting
Prep extends to the knees
Explain the median sternotomy procedure used to access the heart
& great vessels for open cardiac procedures. Begin @ the incision
site & describe the procedure until the heart is accessed
Incision from the sternal notch to the xiphoid process
Sternum is divided w/ a saw
Sternal retractor is inserted
Pericardium is incised & retracted w/ suture
Considering the CABG operative procedure, why is the Satinsky clamp
placed on the ascending aorta?
The clamp is placed for an aortic punch procedure to be performed
Explain the operative steps that occur after the Satinsky clamp is
placed until it is removed
The proximal harvested vein is anastomosed to the aorta & the
clamp is removed
What is the name of the technique that protects the heart from damage
during CPB?
Hypothermia
Considering a CPB, what are 2 main advantages of diverting blood away
from the heart?
Decrease myocardial oxygen demand
Decompresses the ventricles
Into which portion of the heart is the perfusion cannula placed to
achieve venous cannulation for the traditional CPB?
Right atrium
An alternative to cannulation of the aortic root is the cannulation
of which vessel?
Femoral artery
In which portion of the heart may a venting cannula be placed during
a CPB?
Ascending aorta
Left ventricle
Pulmonary vein
During a CPB, blood is oxygenated, filtered, warmed/cooled, and is
returned back to the circulatory system, in both traditional &
minimally invasive cannulation via which vessel?
Ascending aorta
Antegrade cardioplegia delivery
Delivered via the aortic root, the right & left coronary arteries
& coronary circulation
Retrograde cardioplegia delivery
Delivered via the coronary sinus, coronary venous system &
myocardial circulation
Which 3 vessels may possibly be harvests as the graft for use during
a CABG procedure?
Saphenous vein
Internal mammary artery
Radial artery
Name 2 reasons why heart valve repair is preferred over replacement
Prosthetic complications
Avoidance of anticoagulant therapy
What is the name of the instrument that determines the appropriate
size of the annuloplasty ring/prosthesis in heart valve surgery?
Obturator
Which leaflet is often retained during a mitral valve replacement procedure?
Posterior leaflet
Biological heart valve prosthesis
Lasts 10-15 years
No anticoagulant tx needed
Mechanical heart valve prosthesis
For pt's < 65 yrs of age for longer life span
Anticoagulant tx needed due to formation of blood clots
Why would the pt be places in reverse Trendelenburg after the left
atrium is closed during the mitral valve replacement procedure?
To remove air from the pulmonary veins & atrium
Define regurgitation in relation to heart valves
Blood escaping back into the area it has just been ejected from
during systole (occurs when valve leaflets are perforated or don't
close properly)
List 3 reasons that a cardiac surgical procedure would be considered
minimally invasive
Smaller incisions
Decreased use of CPB
Cosmetically appealing incisions
Why is the midcab procedure considered useful tx for only a single
vessel disease?
This is only used for the LAD when it is anastomosed w/ the left
internal mammary artery
Explain the procedure used w/ PTCA & what does it accomplish
Polyvinyl balloon expands to a pre-determined circumference to
compress the atheroma against the coronary artery wall to make space
Describe the mitral valve annuloplasty. What pathology does it
correct and by what method?
It corrects leaflet edges of the valve that don't come together properly
A prosthetic ring is implanted to put tension on the floppy leaflets
& corrects the regurgitation
A DeVega annuloplasty uses pursestring suture around the
circumference of the annulus to correct regurgitation of which valve?
Tricuspid valve
CMC incision
Incision is made into the left ventricle
OMC incision
Incision is made into the left atrium
How were advancements in trauma care accomplished through experience
w/ the military?
MASH (Korean & Vietnam wars)
Shorter response time
Greater survival rate
What are the 3 phases of traumatic death?
Immediately after injury
First 1-2 hours after injury
Days to weeks after injury
Immediately after injury
50% fatality rate
Lacerations to the heart/aorta or brainstem injury
Pt dies @ the scene
First 1-2 hours after injury
30% fatality rate
Injuries to the spleen, liver, lungs, or significant blood loss
Definitive trauma care may have the most significant effect
Days to weeks after injury
Sometimes during ICU or CCU care
Usually caused by complications or a failure of multiple organ systems
Blunt trauma
Injury resulting from a combination of forces that don't break the
skin such as deceleration, acceleration, compression & shearing.
Examples include MVA, falls, assault, & sports injuries
Penetrating trauma
Injury resulting from passage of foreign objects through tissue.
Examples include gunshot/bullet wounds & stab/knife wounds
Primary blast
Direct pressure wave on the body
Secondary blast
Impact of debris/fragments energized by the primary blast
Tertiary blast
Result of blast wind (air that is accelerated & can cause fx or amputation)
Glasgow coma scale (GCS)
A neurological scale for recording the conscious state of a person.
Evaluates head trauma based on eye movement, verbal acuity, &
motor response
Provides standardized methods for communicating between facilities
Revised trauma scale (RTS)
Assists in the triage process for multiple casualty incidents
Based on the GCS plus BP & respirations
Provides standardized methods for communicating between facilities
Name 2 airway management techniques
Manual (chin lift or jaw thrust)
Insertion or oral or nasopharyngeal airway
Intubation
Tracheotomy
When multiple operative procedures must be performed on a trauma pt,
how is the order of priority determined & what is the order?
Order of procedures is based on life-threatening or permanently
disabling tx before other lesser injuries
Order of priority is head, chest, abdomen, extremities
List 2 reasons trauma patients may be at an increased risk for infection
Contaminated wounds
Compromised sterile technique
Perforation of internal organs causing peritonitis
What is the typical prep for a trauma pt & why is this the method?
Pouring antimicrobial solution across the surgical site from the
suprasternal notch to the top of the mid-thigh
This will create access to the chest for aortic clamping &
expose the femoral arteries for potential cannulation
List 3 techniques that may be used for the preservation of evidence
in the OR
Clothing is cut along seams & around injury hole
Gurney sheet is evidence
Bags should be placed over hands & taped into place
Bullets should not be handled w/ forceps or clamps
Explain why DVT is a possibility in trauma patients & give a
measure taken to try and prevent it
Due to prolonged immobilization
SCD's should be placed
Explain why PE is a possibility in trauma patients & give a
measure taken to try and prevent it
Prolonged immobilization, pelvic fx
IVC filter may be inserted
Why is cricoid pressure applied to all trauma patients?
All trauma patients are assumed to have a full stomach (prevents aspiration)
Explain RSI
100% oxygen, analgesia (Etomidate), neuromuscular blocker
(Succinylcholine), cricoid pressure, ET tube
What approach is typically used when an emergency thoracotomy is performed?
A left sided approach
What type of injury requires an emergency thoracotomy most often?
Penetrating injuries
Define hematoma
A collection of blood w/i the skull resulting in increased cranial
pressure & shifting of the brain w/i the cranium
Epidural hematoma
Results from a blow to the head or skull fx
Results from a tear in the branch of the middle meningeal artery
Subdural hematoma
Results form a tear in vein on the cerebrum
Name the 3 types of subdural hematomas & a symptom for each
Acute: unconscious state
Subacute: progressive symptoms
Chronic: encased in membrane & enlarges
What is the tx of choice for a subdural hematoma?
Craniotomy
At what level is a cervical spine injury considered the most critical
& why?
C3-C5 because it has the greatest risk of respiratory difficulties to
the area of diaphragmic intervention
Name the 3 types of mid-facial fractures
LeForte 1, 2, & 3
What is the tx of choice for mandibular fractures?
Rigid fixations w/ plates & screws
What is the tx of choice for pneumothorax associated w/ a rib fx?
Chest tube w/ chest drainage system
What is the tx of choice for penetrating chest trauma w/ a full
cardiac arrest?
Emergency thoracotomy
Which abdominal organ is most commonly injured in blunt trauma?
Spleen
Name 2 tx options that could be used to repair the spleen
A splenectomy
Splenic salvage
(repair of lacerations or partial splenectomy)
What is the most critical factor when considering a penetrating
trauma to the liver?
To control bleeding
What specific tx option is used to control bleeding for a penetrating
injury to the liver?
Pringle maneuver: clamping of hepatic inflow w/i the hepatoduodenal ligament
Name 3 classifications of hypothermia
Mild
Moderate
Severe
Mild hypothermia
32-36 degrees C
Skin appears grey & cool to touch
Passive re-warming
Moderate hypothermia
30-32 degrees C
Dysrhythmia, shivering maybe
Warm fluids, Hubbard tank
Severe hypothermia
< 30 degrees C
Comatose
CPB, Hubbard tank to 35 degrees C
What is the most important consideration for thermal injury patients?
Fluid management
Which tissue/organ is removed FIRST during a tissue/organ procurement?
Heart is removed first in conjunction w/ the lungs
Define kinematics
Action of force on the human body & their effects
What 3 factors are considered for the resulting injury?
Velocity of force
Flexibility of tissue
Shape of injuring force
Name 1 method of accessing the neurovascular status of a trauma pt
Skin color
Skin temp
Pulse
(all distal to injury)
Reaching and providing tx w/i the 1st hour following an injury is
critical in determining the pt outcome
Golden hour