Soft Tissue

Question 1

What are 5 indications for hospital admission for human bites of the hand?

Answer 1

1. Infection at time of presentation
2. Tendon/Joint/Bone violated
3. Crush/Avulsion/Contaminated/FB
4. High-risk patient (immunocompromised)
5. Wound >24h old
6. Social issues

Question 2

List 5 features that indicate a snake is more likely to be venomous.

Answer 2

1. Triangular head
2. Elliptical eyes
3. Pits
4. Fangs
5. Single row anal plate

Question 3

For the following bites, give “Yes/No” for suturing and prophylactic antibiotics:

• Dog
• Cat
• Human
• Hand
• Oral Mucosa
• Oral Mucosa through and through

Answer 3

Dog

• ABx: No except hand
• Sutures: Yes except hand

Cat

• ABx: Yes
• Sutures: No except face

Human

• ABx: Yes
• Sutures: No except face

Hand

• ABx: Yes
• Sutures: No

Oral Mucosa

• ABx: No
• Sutures: Yes

Oral Mucosa through and through

• ABx: Yes
• Sutures: Yes

Question 4

What are the zones created in the pathophysiology of burns?

Answer 4

1. Zone of Coagulation
   * Irreversible necrosis
2. Zone of Stasis
   * Fixable
3. Zone of Hyperemia
   * Recovery likely

Question 5

Outline the mechanism of injury and management of a HF acid burn.

Answer 5

Hydrofluoric Acid

• Causes coagulative and liquefactive necrosis
• Necrosis can lead to hyperkalemia
• F^- binds Ca²⁺ and Mg²⁺
• Hypotension
• Long QTc
• Ventricular arrhythmia

Treatment

• Poison control
• Water/Saline irrigation
• Titrate treatment to pain-free status
• Calcium gluconate paste
• 3.5g in 150 mL lubricant, put in glove, wear glove
• Calcium gluconate locally SC or intra-arterially
• To ICU for monitoring

Question 6

What are 6 indications for transfer to a burn unit?

Answer 6

Burn Unit

1. Hands/Feet/Head/Genitalia/Joint
2. Inhalational injury
3. Non-thermal burn
4. >10% TBSA
5. Any 3rd degree burn
6. Trauma + Burn

Question 7

A lab worker presents following a macaque monkey bite. How do you manage this?

Answer 7

• Clean, irrigate wound
• ABx
• No sutures
• Tetanus prophylaxis if needed
• Monkey B virus prophylaxis
• Valacyclovir 1g TID x2 weeks
• Give if:
  * Skin/Mucosal exposure to sick monkey
  * Inadequately cleaned wound on scene
  * Head/Neck/Torso bite
  * Deep wound
  * Needle-stick injury
  * Basically anything….

Question 8

List 5 strategies for managing an esophageal food bolus.

Answer 8

1. Carbonated beverage
2. Glucagon
3. Nitroglycerin
4. Benzos
5. Foley
6. Bougie
7. Endoscopy
8. Wait

No real evidence for anything other than endoscopy

Question 9

What is the mechanism of action of the toxin from a black widow spider? How do you manage this?

Answer 9

Lactrodectus mactans

• Neurotoxin - depletes ACh in presynapse

Symptoms

• Dull crampy pain
• Facial swelling
• HTN, sweating
• Weakness, speech issues

Treatment

• Symptomatic
• Wound care
• Ice pack to bite
• Poison control
• Benzos for cramps
• Antivenin if child, elderly, pregnant, or sick
• 1 vial over 15 min

Question 10

How do you approach a choking infant?

Answer 10

Mild

• Allow them to cough

Severe

• 5 back blows then 5 chest compressions, repeat

Unconscious

• 30 chest compressions, check airway
• 2 breaths and 30 compressions, check airway
• 15:2 if two-person rescue

Question 11

How does a scorpion sting (centruroides) present? Management?

Answer 11

Symptoms

• Immediate, severe pain
• Allodynia
• Systemically sympathomimetic

Treatment

• Symptomatic
• Wound care
• Ice pack to sting
• Poison control
• Benzos for cramps
• Atropine for bradycardia
• Alpha-blockers/NTG for HTN
• Antivenin if severe

Question 12

Differentiate the various degrees of burns.

Answer 12

• 1st Degree
• Pink, no blisters, dry
• Epidermis
• 2nd Degree (superficial)
• Pink, clear blisters, moist
• Superficial (papillary) dermis
• 2nd Degree (deep)
• Pink, hemorrhagic blisters, moist
• Deep (reticular) dermis
• 3rd Degree
• White, insensate, dry
• Subcutaneous fat
• 4th Degree
• Leathery, dry, insensate
• Bone/Tendon

Question 13

Compare and contrast a pit viper and coral snake bite. How do you manage these?

Answer 13

Pit Viper (Viperidae)

• Hematologic toxin (Blocks coagulation)
• Immediate pain
• Swelling, bullae, compartment syndrome
• Die from shock, DIC

Coral Snake (Elapidae)

• Neurotoxin (Blocks AChR)
• Ptosis, Paresthesias, Slurred speech
• Weakness
• Die from respiratory failure

Treatment

• Supportive
• Send DIC b/w and crossmatch blood
• Wound care (clean, irrigate, Td, ABx if necessary)
• Tourniquet only if <30 min ago
• Antivenin for pit viper/coral snake
• Give 4 vials over 1 hr and R/A.
  * If stable stop.
  * If not, give 4 more. Repeat until stable.
• Maintenance = 2 vials q6h x3 once stable

Question 14

How can you tell if a snake is poisonous by its colours?

Answer 14

• Red next to yellow, kill a fellow
• Red next to black, venom lack

But not reliable so don’t mess with snakes.

Question 15

What are the indications for tetanus prophylaxis?

Answer 15

>10 years since vaccine/Unsure

• Td vaccine

5-10 years since vaccine

• None if clean
• Td vaccine if dirty

<5 years since vaccine

• None

Didn’t have primary series

• Td vaccine if clean
• Td + TIg if dirty
• TIg dose = 4 IU/kg (max 250 IU) IM

Question 16

How do you manage a box jellyfish sting?

Answer 16

• Remove from water
• Remove stinger
• Heat/Vinegar to neutralize remaining stingers
• CCBs for tachydysrhythmia
• Antivenin
• Td prophylaxis

Question 17

List 4 methods of heat transfer.

Answer 17

1. Conduction
2. Convection
3. Radiation
4. Evaporation
5. Respiration (listed in some)

Question 18

List 4 risk factors for infection by Capnocytophagia carnimorus.

Answer 18

1. Asplenia
2. Alcoholic liver disease
3. Lung disease
4. Steroids

• Causes gangrene at site and overwhelming sepsis
• Adrenal hemorrhage
• Mortality = 30%

Question 19

List 5 factors that determine the rate of heat transfer.

Answer 19

1. Heat capacity of agent
2. Temperature of agent
3. Duration of contact
4. Conductivity of local tissues
5. Transfer coefficient

Question 20

List 5 discharge instructions relevant to wound care.

Answer 20

1. Elevate
2. Clean/Dry
3. Analgesia
4. Immobilize until sutures out
5. Signs of infection
6. Suture removal time

Question 21

What are the toxic doses of lidocaine/bupivacaine with and without epi?

Answer 21

• Lidocaine w/ = 7 mg/kg
• Lidocaine w/o = 5 mg/kg
• Bupivacaine w/ = 3 mg/kg
• Bupivacaine w/o = 2.5 mg/kg

Question 22

Outline the rule of 9’s in adults. What changes are made for children?

Answer 22

Adults

• 9% head
• 9% each arm
• 18% chest
• 18% back
• 1% genitalia
• 18% each leg

Children

• 18% head
• 9% each arm
• 18% chest
• 18% back
• 14% each leg
• Difference is no % for genitalia and head is bigger

Question 23

List the types of local anesthetics. Give 2 examples of each.

Answer 23

Amide (have two i’s)

• Procainamide
• Lidocaine
• Bupivacaine
• Ropivacaine

Esters (more likely to have allergy)

• Tetracaine
• Cocaine
• Procaine

Question 24

List 10 indications for antibiotic prophylaxis for lacerations.

Answer 24

1. Human
2. Cat
3. Dog (hand)
4. Thru buccal
5. Nose
6. Ear
7. Foot puncture
8. Open fracture
9. Exposed joint/tendon
10. Crush
11. Contaminated
12. Immunocompromised

Question 25

List 5 indications for **intubation** in a burn victim.

Answer 25

1. Hypoxia 2. Hypoventilation 3. Low GCS 4. Stridor 5. Soot around face 6. Can't handle secretions 7. Fatiguing

Question 26

List 8 risk factors for **wound infection**.

Answer 26

1. Location (leg \> arm \> feet \> chest \> back \> face \> scalp) 2. Delay to clean/present \>8h 3. Contaminated 4. Crush 5. Human/Cat Bite 6. GSW 7. Anesthesia with epinephrine 8. Repair type (Suture \> Staples \> Tape) 9. Immunocompromised (DM, Cancer, HIV, Transplant) 10. Elderly 11. Cirrhosis

Question 27

List 3 **venomous families** of snakes.

Answer 27

1. Viperidae (vipers) 2. Elapidae (coral snakes) 3. Crotalidae (rattlesnakes) 4. Hydrophilidae (sea snakes) 5. Colubridae

Question 28

List and describe 2 formulas for **fluid resuscitation** in burns.

Answer 28

**Parklard** 4 cc/kg/TBSA * Ringer's Lactate * ½ over 8h (time from burn) * ½ over 16h **Galveston** 5000 mL/**m²** \* %Burned + 2000 mL/**m²** * RL + Albumin 12.5g/L + D5 PRN * ½ over 8h (time from burn) * ½ over 16h **Target U/O 1-2 cc/kg**

Question 29

List 6 complications of **esophageal foreign body**.

Answer 29

1. Obstruction 2. Airway compromise 3. Erosion 4. Perforation 5. Migration 6. Mediastinitis 7. Stricture 8. Fistula 9. Abscess 10. Spondylodiskitis

Question 30

What is the mechanism of action of the toxin from a **brown recluse spider**? How do you manage this?

Answer 30

**Laxosceles reclusa** * Sphingomyelinase D toxin - local tissue destruction **Symptoms** * Bleb with a red ring at the bite site * Fever, petechiae, N/V * Hemolysis, Thrombocytopenia * Pulmonary edema, Renal failure **Treatment** * Symptomatic * Wound care * Poison control * Dapsone for local wound