Surgery Marrow Pg 447-456 (Trauma&Hernia)
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Questions and Answers

What is a characteristic feature of 3rd degree burns?

  • Red and swollen
  • Blanching present
  • Blistering
  • Painless (correct)

    • Fluid resuscitation is a general measure in the management of burns.

    True

    What is the pressure threshold in compartments that indicates compartment syndrome?

    30 mm Hg

    In severe burns, the caloric requirement is estimated at _______ kcal/kg/day.

    <p>40</p> Signup and view all the answers

    Match the following types of burns with their recommended dressing:

    <p>1st degree = Hydrocolloid dressing (e.g. Duoderm) 2nd degree: a. Superficial = Collagen dressing (if not infected) 2nd degree: b. Deep = Vaseline/paraffin gauze 3rd degree = Split thickness skin grafting</p> Signup and view all the answers

    What is the main advantage of hernioplasty compared to herniopathy?

    <p>It has the least recurrence rate</p> Signup and view all the answers

    Biological mesh can be used for infected hernias.

    <p>True</p> Signup and view all the answers

    Name one type of synthetic mesh used in hernioplasty.

    <p>Prolene</p> Signup and view all the answers

    The surgical procedure for congenital inguinal hernia is considered ______.

    <p>herniopathy</p> Signup and view all the answers

    Match the type of mesh with its characteristics:

    <p>Synthetic Mesh = Can be used for non-infected hernias Biological Mesh = Can be used when infection is present Fenestrated Mesh = Allows fibrous ingrowth with large pores Solid Biological Mesh = Shows solid mesh material</p> Signup and view all the answers

    Which type of hernia contains the bowel as its content?

    <p>Enterocele</p> Signup and view all the answers

    Herniorrhaphy is one of the types of hernia surgeries.

    <p>True</p> Signup and view all the answers

    What is the initial step in hernia surgery?

    <p>Identify the sac</p> Signup and view all the answers

    In an omentocele, the content is the ______.

    <p>omentum</p> Signup and view all the answers

    Match the type of hernia with its description:

    <p>Enterocele = Contains bowel contents Amyand's Hernia = Appendix within a hernia sac Littre's Hernia = Contains Meckel's diverticulum Omentocele = Contains omentum</p> Signup and view all the answers

    Which type of inguinal hernia is the most common overall?

    <p>Indirect inguinal hernia</p> Signup and view all the answers

    Prolene mesh is hydrophilic, encouraging faster cellular ingrowth.

    <p>False</p> Signup and view all the answers

    What is the purpose of covering 5 cm beyond the defect with hernia mesh?

    <p>To prevent recurrence when the mesh shrinks.</p> Signup and view all the answers

    A direct hernia occurs through the _______ triangle.

    <p>Hesselbach's</p> Signup and view all the answers

    Match the mesh materials with their characteristics:

    <p>Prolene = Hydrophobic - Reduces bacterial contamination Polyester = Hydrophilic - Encourages faster cellular ingrowth PTFE = Does not adhere to the bowel inside the peritoneal cavity Plug Mesh = Low weight, thin fibers, large pores</p> Signup and view all the answers

    What are common causes of death associated with 3°/4° burns?

    <p>Arrhythmia</p> Signup and view all the answers

    Indirect lightning injuries can cause filigree burn patterns.

    <p>True</p> Signup and view all the answers

    What is the typical core temperature range for Stage I hypothermia?

    <p>35°C to 32°C (95 to 89°F)</p> Signup and view all the answers

    The initial management for 3°/4° burns includes examining both entry and exit ______.

    <p>wounds</p> Signup and view all the answers

    Match the stages of hypothermia with their characteristics:

    <p>Stage I = Conscious, shivering Stage II = Impaired consciousness, not shivering Stage III = Severe hypothermia with potential cardiac issues Stage IV = Coma or death due to prolonged exposure</p> Signup and view all the answers

    Which of the following is NOT a boundary of the myopectineal orifice of Fruchaud?

    <p>Transverse abdominis muscle</p> Signup and view all the answers

    A femoral hernia is located above and medial to the pubic tubercle.

    <p>False</p> Signup and view all the answers

    What is the significance of the myopectineal orifice of Fruchaud?

    <p>It covers the defects of inguinal, femoral, and obturator hernias.</p> Signup and view all the answers

    The __________ test is considered the single best test for diagnosing hernias.

    <p>deep ring occlusion</p> Signup and view all the answers

    Match the type of hernia with its description:

    <p>Inguinal hernia = Above &amp; medial to the pubic tubercle Femoral hernia = Below &amp; lateral to the pubic tubercle Direct hernia = Pulp of finger within the scrotum Indirect hernia = Tip of finger within the scrotum</p> Signup and view all the answers

    What is the best method for active rewarming in a trauma situation?

    <p>Cardiopulmonary bypass</p> Signup and view all the answers

    Passive rewarming involves providing heat directly to the patient.

    <p>False</p> Signup and view all the answers

    What temperature range defines mild hypothermia?

    <p>35°C to 32°C</p> Signup and view all the answers

    For effective active rewarming, one recommended method is __________ immersion.

    <p>warm water</p> Signup and view all the answers

    Match the following warming techniques to their categories:

    <p>Heating pad = External Gastric lavage = Internal Warm water bottles = External Cardiopulmonary bypass = Internal</p> Signup and view all the answers

    Which type of electrical burn is associated with high-grade electrical injury?

    <p>Direct lightning injury</p> Signup and view all the answers

    Hypothermia can be caused by as little as 10 minutes of cold exposure.

    <p>False</p> Signup and view all the answers

    What is the typical core temperature for Stage I hypothermia?

    <p>35°C to 32°C (95°F to 89°F)</p> Signup and view all the answers

    Patients with Stage II hypothermia exhibit __________ consciousness and are not shivering.

    <p>impaired</p> Signup and view all the answers

    Match the types of burns with their characteristics:

    <p>DC current = Entry and exit wounds management AC current = Potential arrhythmias Direct lightning injury = High-grade electrical injury Indirect lightning injury = Filigree burns pattern</p> Signup and view all the answers

    Which type of hernia is characterized by being irreducible and having a negative cough impulse?

    <p>Obstructed hernia</p> Signup and view all the answers

    All obstructed hernias should be treated as strangulated unless proven otherwise.

    <p>True</p> Signup and view all the answers

    What is the definition of a hernia?

    <p>Protrusion of viscus or part of viscus through the wall containing it.</p> Signup and view all the answers

    A hernia that has intact blood supply but is irreducible is known as an ______ hernia.

    <p>obstructed</p> Signup and view all the answers

    Match the following types of hernia with their characteristics:

    <p>Uncomplicated hernia = Reducible with cough impulse (+) Obstructed hernia = Irreducible with intact blood supply Strangulated hernia = Irreducible with compromised blood supply Complicated hernia = Includes both obstructed and strangulated hernias</p> Signup and view all the answers

    What is the most common causative organism for septic shock in burn patients after three days?

    <p>Pseudomonas</p> Signup and view all the answers

    Silver nitrate is a cost-effective treatment option for burns.

    <p>False</p> Signup and view all the answers

    What is the primary management for Marjolin's ulcer?

    <p>Wide local excision</p> Signup and view all the answers

    In the case of hydrofluoric acid burns, calcium gluconate is used for ________.

    <p>management</p> Signup and view all the answers

    Match the following chemicals with their characteristics in burn treatment:

    <p>1% Silver sulphadiazine = Effective against Pseudomonas 5% Mafenide acetate = Penetrates eschar Cesium nitrate = Immunomodulator Silver nitrate = Painful application</p> Signup and view all the answers

    Study Notes

    Thermal Injuries

    • 3rd and 4th degree burns:
      • Black, charred appearance.
      • No blanching.
      • Painless due to nerve damage.
      • Require early excision and skin grafting.

    Overall Burns Management

    • General measures:
      • Wash burns with room temperature water.
      • Insert a Ryle's tube for patients with >15-20% burns to prevent vomiting associated with ileus.
      • Avoid bursting blisters as they protect the burn.
      • Perform fluid resuscitation.
      • Administer intramuscular and subcutaneous injections.

    Compartment Syndrome

    • Features of compartment syndrome

      • Pressure within the compartment exceeds 30 mm Hg.
      • Often caused by circumferential eschar.

    • Treatment:

      • Escharotomy, a type of fasciotomy.

    • Clinical features of compartment syndrome:

      • Severe pain not relieved by medication.
      • Pain on passive flexion.

    • Layers cut during escharotomy:

      • Skin
      • Subcutaneous tissue
      • Superficial fascia
      • Deep fascia until muscle is exposed.

    Nutrition

    • Basal/resting energy expenditure (BEE/REE):

      • Normal BEE/REE is 1.
      • Increased in sepsis and severe burns.
        • Mild/moderate sepsis: 1.4
        • Severe sepsis: 1.8
        • Severe burns: 2 (40 kcal/kg/day)

    • Calorie requirement:

      • Curreri/Sutherland formula is used to calculate calorie requirements.

    • Protein requirement:

      • Day 5 to Day 10: Negative nitrogen balance due to increased protein breakdown.
      • Davies formula is used to calculate protein requirements.
      • Protein should constitute 20% of total nutritional intake.

    Dressing materials

    • Aims of dressing materials:

      • Protect damaged epithelium.
      • Minimize infection.
      • Promote healing.

    • Types of dressings:

      • 1st degree burns:
        • Expose the wound.
        • Use Vaseline/paraffin gauze, collagen dressing (if not infected) or hydrocolloid dressing.

    Herniopathy

    • Indications for herniopathy:

      • Surgery of choice for congenital inguinal hernia, congenital hydrocele, and inguinal hernia in children.

    • Disadvantages:

      • Highest recurrence rate.

    • Anatomy:

      • High muscle tone spontaneously blocks the defect, reducing the risk of recurrence.

    Hernioplasty

    • Indications for hernioplasty:

      • Surgery of choice.
      • Least recurrence rate.
      • Used for infected hernias.

    • Types of mesh:

      • Synthetic:
        • Examples: Prolene, Vipro (Vicryl + Prolene), PTFE (Polytetrafluoroethylene - can be placed intraperitoneally).
        • Cannot be used for infected hernias.
      • Biological:
        • Examples: Acellular human dermis (AlloDerm), Acellular porcine dermis.
        • Can be used when infection is present.

    Hernia: Part 1

    • Taxis:

      • Process of hernia reduction.
      • Contraindicated in obstructed or strangulated hernias.
      • Can lead to reduction en masse, which can cause obstruction.

    • Types of hernias based on content:

      • Omentocele:

        • Content: Omentum.
        • Peristalsis: Absent.
        • Consistency: Doughy.
        • Reducibility: Easy to reduce initially.
        • Percussion: Dull note.
        • Bowel sounds: Absent.

      • Enterocele:

        • Content: Bowel.
        • Peristalsis: Present.
        • Consistency: Variable.
        • Reducibility: Difficult to reduce initially but easy to reduce later.
        • Percussion: Tympanic note.
        • Bowel sounds: Present.

    • Named hernias:

      • Enterocele.
      • Amyand's Hernia.
      • Littre's Hernia.

    Basics of Hernia Surgery

    • Types:

      • Herniorrhaphy.
      • Hernioplasty.
      • Herniotomy.

    • Steps:

      1. Identify the sac (glistening white).
      2. Open the sac.
      3. Push contents down.
      4. Cut the excess sac and close the sac.
      5. Defect is left intact.

    Inguinal Hernias

    • Mesh materials:

      • Prolene: Hydrophobic, reducing bacterial contamination.
      • Polyester: Hydrophilic, encouraging faster cellular ingrowth.
      • PTFE: Does not adhere to the bowel inside the peritoneal cavity.

    • Mesh overlap:

      • Weight of mesh: Low weight (80 g/m²) leads to more shrinkage.
      • Ideal hernia mesh: Covers 5 cm beyond the defect in all directions to prevent recurrence after shrinkage.
      • Plug mesh:
        • Low weight.
        • Thin fibers.
        • Large pores.

    • Complication: Meshoma due to excessive collagen deposition can lead to pain due to nerve entrapment.

    • Types of inguinal hernias:

      • Most common overall: Indirect inguinal hernia.
      • Most common in men and women: Indirect inguinal hernia.

    • Anatomy:

      • Internal inguinal ring: Modification of the transversalis fascia.
      • External inguinal ring: Modification of the external oblique aponeurosis.

    • Other Structures:

      • Interior epigastric artery and vein.
      • Internal/deep inguinal ring.
      • Inferior epigastric vessels.

    • Hesselbach Triangle:

      • Direct hernia: Through Hesselbach's triangle.
      • Indirect hernia: Lateral to Hesselbach's triangle, through the deep inguinal ring.

    Myopectineal Orifice of Fruchaud

    • Boundaries:

      • Superior: Arching fibers of internal oblique.
      • Medial: Outer border of rectus.
      • Lateral: Tendon of iliopsoas.
      • Inferior: Pectineal/Cooper's ligament.

    • Significance: Covers the defects of:

      1. Inguinal hernia.
      2. Femoral hernia.
      3. Obturator hernia.

    Clinical Examination

    • Position for examination: Standing and lying down.

    • Tests:

      • Helps differentiate between inguinal and femoral hernia.
      • Inguinal hernia: Above and medial to the pubic tubercle.
      • Femoral hernia: Below and lateral to the pubic tubercle.
      • Appreciate cough impulse.
      • Assess abdominal muscle tone.
      • Complete vs. incomplete hernia.

    • Clinical tests:

      • Deep ring occlusion test: Single best test for hernia.
      • Ring invagination test:
        • Little finger placed in the superficial ring through the scrotum.
        • Low sensitivity.

    Electrical Burns

    • 3rd/4th degree burns

      • Types:

        • DC current.
        • AC current.

      • Management:

        • Examine both entry and exit wounds.
        • Administer IV fluids due to potential heart blocks, tetanus, muscle damage, and myoglobinuria.
        • Increased IV fluids are required to prevent acute tubular necrosis (ATN).
        • Arrhythmia is a common cause of death.

    Lightning Injury

    • Types:

      • Direct lightning strike:

        • High-grade electrical injury.
        • Arrhythmias.

      • Indirect lightning strike:

        • Filigree burns pattern.
        • Superficial burns due to sparks from an adjacent object.

    Hypothermia

    • Usually caused by: 30 minutes of cold exposure.

    • Stages of hypothermia:

      • Stage I:

        • Conscious, shivering.
        • Core temperature 35°C to 32°C (95 to 89°F).
        • Treatment: Warm environment and clothing, warm sweet drinks, and active movement.

      • Stage II:

        • Impaired consciousness, not shivering.
        • ECG: J/Osborne waves.
        • Treatment: Passive rewarming (prevent heat loss) and active rewarming (provide heat).

    Rewarming Techniques

    • Active space: Likely refers to the area surrounding a patient in a trauma situation.

    • Rewarming Techniques:

      • Passive rewarming (prevent heat loss):

        • Mild hypothermia (35°C to 32°C).

      • Active rewarming (provide heat):

        • External:

          • Heating pad.
          • Warm water, blankets.
          • Warm water bottles.
          • Warm water immersion.
          • External convection heaters (lamps and radiant warmers).
          • Cover the head.

        • Internal:

          • Heated intravenous fluids.
          • Gastric or colonic lavage.
          • Cardiopulmonary bypass (most effective).

    Special Agents in 2º Burns

    • Agent | Advantages | Disadvantages
    • ------ | -------- | -------- 1% Silver sulphadiazine (m/c) | Effective against Pseudomonas, Gram negative bacteria | Requires frequent dressing changes.Doesn't penetrate eschar (useful only in superficial wounds).Silver nitrate | Effective against Pseudomonas, Gram negative bacteria | Black stain.Painful application.Metabolic acidosis.Expensive. 5% Mafenide acetate | Penetrates eschar |
      Cesium nitrate (best agent) | Immunomodulator |

    Management of Complications

    • Hypertrophic scar:

      • Spontaneous resolution with time.

    • Keloids:

      • Intralesional triamcinolone injection.

    • Contracture:

      • V-Y plasty or Z plasty.

    • Marjolin's ulcer:

      • Wide local excision.

    Causes of Death in Burns

    • Time Period | Cause of Death
    • ------ | -------- Immediate | Asphyxia, followed by neurogenic shock Early (1-3 days) | Hypovolemic shock Late (>3 days) | Septic shock (most common) - most common causative organism: Pseudomonas

    Special Situations: Chemical Burns

    • Alkali burns are deeper penetrating than acid burns.
    • Management:
      • Wash with water (do not attempt neutralization).
      • Chemical powder: Brush off.
      • Hydrofluoric acid burns:
        • Features: ↓ Ca2+, ↑ K+, acidosis, tissue damage.
        • Management: Calcium gluconate (topical gel, oral, IV, IA).

    m/c - most common

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    Description

    This quiz covers critical aspects of managing severe burns, especially 3rd and 4th-degree burns, and addresses the features and treatment of compartment syndrome. Understand essential protocols, including general measures for burn care and the surgical interventions required for complications. Test your knowledge and readiness for handling such medical emergencies.

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