Surgery Marrow Pg 407-416 (Trauma)

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Questions and Answers

Which type of lymphoma is associated with increased frequency in immunocompromised patients?

Meningioma

Diffuse large B cell lymphoma (DLBCL) (correct)

Oligodendroglioma

Pilocytic astrocytoma

Chemotherapy is the primary treatment for CNS lymphoma.

True

What histological feature is associated with oligodendroglioma?

Fried egg

The tumor type characterized by perivascular pseudorosettes is known as ________.

Ependymoma Signup and view all the answers

Match the following tumor types with their associated histological features:

Medulloblastoma = Homer Wright rosettes Schwannomma = Verrocay bodies Pilocytic astrocytoma = Rosenthal fibers Meningioma = Psamomma bodies Signup and view all the answers

What is the primary outcome when trauma severity indicates 27 or more?

Amputation is likely Signup and view all the answers

The 'ebb' phase of the metabolic response to trauma is characterized by an increase in physiological changes.

False Signup and view all the answers

What percentage of cases indicate a limb is consistent with being salvageable after trauma?

56% Signup and view all the answers

In trauma, the _____ phase is characterized by physiological stabilizations.

ebb Signup and view all the answers

Match the following phases of the metabolic response with their respective roles:

Ebb = Hormonal response to stress Flow = Enhanced metabolic recovery Signup and view all the answers

What is the correct order of the ATLS process?

Airway, Breathing, Circulation, Disability Signup and view all the answers

In the primary survey, the assessment of life-threatening injuries is categorized under the Red Category.

True Signup and view all the answers

What criteria must be met for cervical spine imaging to be required?

Any signs indicating severe pain or confusion, including neuro deficit, alcohol intoxication, extreme distracting injury, altered consciousness, or spinal tenderness. Signup and view all the answers

The _____ is an instrument used to stabilize the cervical spine in trauma patients.

Philadelphia collar Signup and view all the answers

Match the following instruments with their usage:

Philadelphia collar = Neck stabilization Laryngeal mask airway = Airway management Videolaryngoscope = Visualization of vocal cords CT scan = Detailed internal examination Signup and view all the answers

Which of the following is NOT part of the information that should be collected from the patient using the AMPLE method?

Mechanism of injury Signup and view all the answers

It is acceptable to transport a patient in the lateral position to stabilize the cervical spine.

False Signup and view all the answers

What should be done first when approaching a trauma scene?

Evaluate the scene Signup and view all the answers

The process of removing a helmet from a patient involves _____ to restrict movement of the cervical spine.

Person 1 Signup and view all the answers

Match the following terms with their descriptions:

MIST = Information collected from driver/responder AMPLE = Information collected from patient Supine position = Head and thorax strapped for immobilization Prone position = Position to prevent aspiration Signup and view all the answers

What is the first intervention if endotracheal intubation is not possible?

Needle cricothyroidotomy Signup and view all the answers

What is the recommended fluid bolus amount in the latest ATLS update?

1 litre Signup and view all the answers

Nasotracheal intubation is contraindicated in cases of skull base fractures.

True Signup and view all the answers

A Glasgow Coma Scale score of 11 indicates a mild head injury.

False Signup and view all the answers

What is the maximum duration for high flow oxygen using a Y-connector during a needle cricothyroidotomy?

15-30 minutes Signup and view all the answers

The minimum size of IV lines recommended for circulation is _____ gauge.

18G Signup and view all the answers

What dose of Tranexamic acid is recommended for trauma patients with a systolic blood pressure of 110/min?

1 gm Signup and view all the answers

The pupil reactivity score of ___ indicates that both pupils are reactive to light.

2 Signup and view all the answers

Match the following interventions with their corresponding uses:

Needle cricothyroidotomy = Emergency airway intervention Tracheostomy = Definitive airway management Venous cut-down = Emergency vascular access Intraosseous infusion = Access for fluid resuscitation Signup and view all the answers

Match the Glasgow Coma Scale components with their corresponding scores:

Eye Opening (Spontaneously) = 4 Best verbal response (Oriented) = 5 Best motor response (Obeys commands) = 6 Eye Opening (No response) = 1 Signup and view all the answers

What is the cause of death that occurs immediately after a trauma?

Massive head injury Signup and view all the answers

The 'Golden Hour' refers to the first hour following trauma where care provided decreases mortality.

True Signup and view all the answers

What system is used to prioritize treatment in mass casualty events?

Triage Signup and view all the answers

Within the first hour after injury, patients can be saved from __________ if treated promptly.

massive hemorrhage Signup and view all the answers

Match the priority groups with their corresponding color and description:

P₁ = Red P₂ = Yellow P₃ = Green P₄ = Blue Black = Dead Signup and view all the answers

How many people are required to perform a log roll on a patient without a limb fracture?

4 people Signup and view all the answers

Pelvic binders should be removed once a pelvic fracture is suspected.

False Signup and view all the answers

What does the Injury Severity Score (ISS) measure?

The ISS measures the severity of injuries by squaring and summing the abbreviated injury scores of the top three injuries. Signup and view all the answers

In cases of suspected pelvic fractures, a pelvic binder is used to _____ until the fracture is ruled out.

stabilize the pelvis Signup and view all the answers

Match the trauma severity scores with their descriptions:

ISS = Sum of top 3 injuries' abbreviated scores squared RTS = Measures Glasgow Coma Scale, BP, and respiratory rate TRISS = Information about survival based on multiple parameters MESS = Evaluates type of injury, ischemia, and age group Signup and view all the answers

What is the most common primary malignant tumor in children?

Medulloblastoma Signup and view all the answers

Meningiomas are more common in males than in females.

False Signup and view all the answers

What sign is associated with meningiomas in MRI investigations?

Dural tail sign Signup and view all the answers

Ependymomas can lead to ________ due to blockage of CSF drainage.

hydrocephalus Signup and view all the answers

Match the following tumors with their unique histological features:

Ependymoma = Pseudorosettes Meningioma = Psammoma bodies Medulloblastoma = Homer-Wright rosettes Astrocytoma = Rosettes Signup and view all the answers

What is the most common site for Pilocytic astrocytoma?

Posterior fossa Signup and view all the answers

Glioblastoma multiforme has the best prognosis among astrocytomas.

False Signup and view all the answers

What is the primary management for an oligodendroglioma?

Surgery followed by Radiation Therapy and Oral Temozolomide Signup and view all the answers

The grade of a Pilocytic astrocytoma is _____ grade.

low Signup and view all the answers

Match the type of astrocytoma with their grade:

Pilocytic astrocytoma = I Anaplastic astrocytoma = III Glioblastoma multiforme = IV Low grade (Fibrillary astrocytoma) = II Signup and view all the answers

Study Notes

CNS Lymphoma

Increased frequency in immunocompromised patients (HIV, post-transplant).
Diffuse large B cell lymphoma (DLBCL) is the most common type.
Partial tumor regression with steroids is characteristic, known as "ghost cell" phenomenon.
Diagnosis is made through biopsy.
Treatment involves chemotherapy and sometimes surgery, followed by radiation therapy.

Histopathological Features

Pilocytic astrocytoma:
- Rosenthal fibers and microcysts.
Glioblastoma multiforme (GBM):
- Serpentine necrosis and glomeruloid bodies.
Oligodendroglioma:
- Fried egg appearance, chicken wire blood vessels, and calcification.
Ependymoma:
- Perivascular pseudorosettes and small round blue cells.
Medulloblastoma:
- Homer Wright rosettes.
Meningioma:
- Psammoma bodies, Antoni A, and Antoni B.
Schwannomma:
- Verrocay bodies.

Metabolic Response to Trauma: Ebb and Flow

Post-trauma metabolic response characterized by two phases: Ebb and Flow.

Ebb Phase

Short-term, characterized by decreased metabolic rate and oxygen consumption.
Lasts for 24-48 hours.
Prominent hormonal response with increased release of catecholamines, cortisol, and glucagon.

Flow Phase

Increased metabolic rate, oxygen consumption, and hypercatabolism.
Lasts for several days.
Characterized by increased insulin resistance, hyperglycemia, and protein catabolism.

Advanced Trauma Life Support (ATLS)

A standardized system for the management of trauma patients.
Follows a structured approach: Airway, Breathing, Circulation, Disability.

ATLS Process

Initial assessment focuses on identifying and managing life-threatening injuries.
Primary Survey involves:
- ABCD assessment for immediate, life-threatening injuries, categorized as "Red Category".
Secondary Survey:
- Detailed examination for all injuries.
Tertiary Survey:
- Performed after extubation of intubated patients.
Whole Body CT can be used instead of the Secondary Survey:
- Benefits: quick assessment, reduces radiation exposure.
- Drawbacks: Only appropriate for stable patients.

Airway Assessment

Signs of compromised airway indicative of intubation:
- Unable to speak; GCS ≤ 8; unexplained confusion; coma.
If any sign is positive, a Philadelphia collar and C-spine imaging are required.
Negative signs indicate no need for imaging.

Cervical Spine

C-spine examination must be performed before airway assessment.
NEXUS Criteria used to determine the need for C-spine imaging:
- Neuro deficit; Ethanol intoxication; Extreme distracting injury; Unable to provide history; Spinal tenderness (midline).

Pre-Hospital Care

Initial approach involves evaluating the scene, initial assessment, triage transport, critical investigations, and patient transport.
Information collection from driver/responder (MIST): Mechanism; Injuries; Signs & symptoms; Treatment given.
Information collection from patient (AMPLE): Allergies; Medical conditions; Past history; Last meal; Events leading to trauma.

Transportation

Supine: Head, thorax, and pelvis strapped for immobilization.
Prone: To prevent aspiration.
Lateral position: Not recommended due to instability of C-spine.

Complete Immobilization

Two-person helmet removal:
- Person 1: Restricts cervical spine movement.
- Person 2: Removes helmet and assists with C-spine stabilization.

Secure Definitive Airway

Endotracheal intubation: Preferred method, either orotracheal or nasotracheal (contraindicated in skull base fractures).
Alternative interventions:
- Emergency intervention: Needle cricothyroidotomy.
- Definitive intervention: Tracheostomy.

Breathing

Chest examination with auscultation and pulse oximetry.

Circulation

Minimum: Two 18G IV lines.
Fluid bolus: 1 litre (if not possible).
Alternative interventions:
- Emergency intervention: Venous cut-down (access to great saphenous vein).
- Definitive intervention: Central line (preferred in trauma patients).

Intraosseous Infusion

Implemented below the tibial tuberosity for rapid fluid and medication administration in cases where IV access is difficult.

Timeline Concept: Trimodal Distribution of Mortality

Post-trauma mortality follows a trimodal distribution.
Highest mortality immediately after trauma, followed by a decrease and then a subsequent increase over days/weeks.

Causes of Death

Immediate:
- Head injury: Airway obstruction, tracheobronchial injury, tension pneumothorax, open pneumothorax, acute circulatory arrest, cardiac tamponade, hemothorax.
Within 1 hour of injury: Potential for survival through timely intervention.
Days/weeks: Infections and delayed head injuries.

Golden Hour

The first hour post-trauma during which immediate interventions are critical to reduce mortality.
Serves as a performance metric for trauma centers.

Triage

Involves sorting and prioritizing patients during mass casualty events to direct treatment.

Four Color Coded System

Used for triage prioritization:
- Red: Emergency (immediate treatment required for survival).
- Yellow: Urgent (immediate treatment not essential, can be delayed).
- Green: Delayed (minor injuries, first aid sufficient).
- Blue: Expectant (Moribund patients, pain management provided).
- Black: Dead.

Trauma

Updates in ATLS (10th Edition):
- Smaller fluid bolus (1 litre instead of 2) for more judicious fluid management.
- CRASH-2 Trial (investigational) suggests administering 1g of Tranexamic acid over 10 minutes, followed by 1g over 8 hours for patients with a systolic blood pressure ≥ 110 mmHg.

Disability

Glasgow Coma Scale (GCS): Used to assess level of consciousness (eye opening, best verbal response, best motor response).
Interpretation:
- Mild head injury: GCS 13-15
- Moderate head injury: GCS 9-12
- Severe head injury: GCS ≤ 8.

Pupil Reactivity to Light

Pupil reactivity score (PRS):
- Both pupils reactive: 2
- One pupil reactive: 1
- No pupil reactive: 0

Log Roll

Performed to examine the patient's back, requiring 4-5 people (additional person for limb fracture).
Limited role in pelvic fractures or abdominal trauma (except for penetrating abdominal injuries to check wound path).

Pelvic Binder

Used for suspected pelvic fractures.
Must be kept until fracture is ruled out.
Alternative: Tie a long cloth around the hip if a binder is unavailable.

Severity Scores

Injury Severity Score (ISS):
- Based on the Abbreviated Injury Score (AIS) of the top three injuries.
Revised Trauma Score (RTS):
- Measures Glasgow Coma Scale, systolic blood pressure, and respiratory rate.
Trauma Score and Injury Severity Score (TRISS):
- Predicts survival probability based on RTS, ISS, mechanism of injury, and age.
Mangled Extremity Severity Score (MESS):
- Evaluates the severity of mangled extremity injuries based on injury type, ischemia group, shock group, and age group.

Ependymoma

More common in children than adults.
Spreads through the 4th ventricle, blocking CSF drainage and leading to hydrocephalus.
Investigations:
- MRI for diagnosis.
- Histopathological examination (HPE) reveals pseudorosettes.
Management:
- Surgery followed by craniospinal radiation therapy.

Meningioma

Extra-axial, dural-based tumor.
More common in females.
Clinical presentation:
- Often asymptomatic.
- Motor deficit may occur.
Investigations:
- MRI displays "dural tail sign".
- HPE shows psammoma bodies.
Management:
- Surgery.

Medulloblastoma

The most common primary malignant tumor in children.
Peak incidence between 3-4 years.
Association:
- Turcot syndrome (a variant of FAP with APC gene mutation on chromosome 5).
Metastasis:
- Drop metastasis through cerebrospinal fluid (CSF).
Investigations:
- MRI for diagnosis.
- HPE reveals small round blue cells and Homer-Wright rosettes.
Management:
- Surgery followed by craniospinal radiation therapy.

Astrocytomas

Classified into four grades based on aggressiveness.

Grading

Grade	Astrocytoma Type
1	Pilocytic astrocytoma
II	Low grade (Fibrillary astrocytoma)
III	Anaplastic astrocytoma
IV	Glioblastoma multiforme (GBM)

Pilocytic Astrocytoma

More common in children.
Presentation:
- Mural nodule (non-infiltrative).
Grade: Low grade.
Most common site: Posterior fossa.
Investigations: MRI.
Management: Excision of the lesion.

Glioblastoma Multiforme (GBM)

Rapid progression and the worst prognosis among astrocytomas.
Management:
- Surgery followed by radiation therapy and oral temozolomide.

Oligodendroglioma

Most common age: 40-60 years.
Investigations:
- MRI reveals calcifications.
- HPE is essential for diagnosis.
Management:
- Surgery followed by radiation therapy and oral temozolomide.

Calcifications in CNS Tumors

Calcifications are a hallmark of several tumors, including:
- Medulloblastoma
- Oligodendroglioma
- Meningioma

Surgery v1.0 Marrow 8.0 2024

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Description

Explore the critical aspects of CNS lymphoma, including its frequency in immunocompromised patients and the types of histopathological features associated with different brain tumors. Understand the diagnostic and treatment approaches and the metabolic responses to trauma.