Еще одна пилюлька Hескучина

[yananshs]

The correct answer is C. This patient is suffering from a significant diverticular bleed. His initial bleed was self-limited and his vital signs were stable. An abdominal CT scan confirmed the presence of diverticular disease. At that time, supportive therapy with blood transfusions was initiated. During his second bleeding episode, the patient had become tachycardic with a lower blood pressure suggesting worsening hemodynamics and significant blood loss. Imaging with a tagged red blood cell scan confirmed active bleeding and the general site. Angiography of the mesenteric blood supply located the site of bleeding. The appropriate intervention at this time would be a directed vasopressin infusion into the arterial mesenteric circulation to constrict the bleeding vessel. Because the patient has significant pulmonary disease and multiple lung resections, he is not a good candidate for surgical intervention. Vasopressin infusion is less invasive, and if it is administered at the time of angiography, systemic side effects can be limited. This intervention is relatively contraindicated in patients with significant coronary artery disease due to risk of ischemia or infarction.

Colonoscopy and sclerotherapy (choice A) of a diverticular bleed are difficult due to typically poor visualization of the bleeding source from an incomplete bowel prep. In addition, the patient must generally be hemodynamically stable.

Like vasopressin therapy, arterial embolization (choice B) of the bleeding source can be done at the time of angiography. However, embolization carries a higher risk of bowel infarction or perforation than vasopressin infusion in colonic bleeds, so it is mostly used in upper gastrointestinal bleeds. Embolization can be considered an alternative intervention if a vasopressin infusion fails.

Supportive care and observation (choice D) is typical management for a patient with a first-time lower gastrointestinal bleed, since these bleeds are usually self-limited. However, this patient continued to experience bleeding episodes and became hemodynamically unstable. Therefore he required further measures to prevent continued bleeding and volume loss.

This patient suffers from severe respiratory disease and would not be a good surgical candidate. Unless other interventions have failed, a partial colectomy and temporary colostomy(choice E) should not be done in this patient.

[yananshs]

A 42-year-old man is brought to the emergency department after being stabbed in the chest with a knife at a local bar. A witness says that the patient was attacked with the knife from behind and suffered multiple kicks to the abdomen. The stab wound was with an unknown type of blade to the right chest. The patient's past medical history is unknown and the patient's allergies are unknown. The patient last ate three hours ago. On initial presentation, there are large patches of dried blood on his shirt and face and his lips are covered with dried blood. He is diaphoretic but speaking in full sentences. He has multiple stab wounds on his right chest, both inferior and superior to the right nipple. A chest tube is inserted on the right with drainage of 1200cc of blood. A diagnostic peritoneal lavage is negative for any blood. His blood pressure is 90/50mm Hg. Physical examination shows jugular venous pulsations visible at 14cm. The heart sounds are distant and barely audible. The lungs are clear bilaterally and the patient has a tender left upper quadrant. The most likely cause for this patient's hypotension is
A. myocardial contusion
B. pericardial tamponade
C. pericarditis
D. pulmonary contusion
E. splenic contusion

[riltsov]

Давление 90/50, тоны сердца едва слышны, повышено давление в яремных венах. Ответ - B. pericardial tamponade

[Delsol]

A 26 y/o man is brought into the ER after a MVA in which he was not wearing a helmet. CT scan shows bifrontal hemorrhagic contusions. GCS=6. He has no verbal response, opens his eyes to painful stimulation only, and shows a flexion response to pinch of the
extremities.
1- This patient's head injury may be classified as
a. Minimal
b. Mild
c. Moderate
d. Severe
e. Vegetative

[riltsov]

Тут вариантов два. Или d. Severe или e. Vegetative. Коль скоро на боль реагирует, глаза открывает, рискну d. Severe.

[Delsol]

1- The answer is d.
Head injuries may be defined on the basis of the GCS: mild injury (GCS 14-15), moderate injury (GCS 9ЁC13), and severe injury (GCS 8). Of note, although patients with mild head injuries may receive a score of 15, the maximum on the GCS, they may still have more subtle cognitive difficulties that are not reflected by this easy-to-use and simple scale.

[Delsol]

2- The presence of periorbital ecchymosis in this patient should be considered a sign of
a. Subdural hemorrhage
b. Parenchymal hematoma
c. Ocular injury
d. Retinal detachment
e. Basilar skull fracture

[riltsov]

e. Basilar skull fracture. Именно этот перелом в данном случае, скорее всего, обусловливает явление называемое в англоязычной литературе raccoon eyes.

[Delsol]

2- The answer is e.
The presence of periorbital ecchymosis (raccoon eyes), ecchymosis over the mastoid region (Battle's sign), hemotympanum (blood behind the eardrum), or CSF rhinorrhea or otorrhea should be considered evidence of a basilar skull fracture.

[Delsol]

3- MRI shows multiple foci of punctate hemorrhage in addition to the contusions indicated above. These are most likely indicative of
a. Diffuse axonal injury (DAI)
b. Uncontrolled hypertension
c. Amyloid angiopathy
d. Ischemic infarction
e. Coagulopathy

[riltsov]

a. и только а. Все остальное не может рассматриваться, как причина этих multiple foci of punctate hemorrhage, исходя из контекста задачки. В задачке речь о травматическом повреждении(injury), выбираю ответ - Diffuse axonal injury (DAI)

P.S. Кстати, очень меткое образное это название Racoon eyes, оно мне гораздо больше импонирует, чем отечественный термин «симптом очков».

[Delsol]

3- The answer is a.
Diffuse axonal injury is the most common cause of coma in the head-injured patient without an intracranial mass lesion. It is characterized pathologically by diffusely spread axonal swellings affecting white matter, corpus callosum, and upper brainstem. These foci are usually hemorrhagic. The etiology is thought to be due to shearing forces on axons in certain susceptible regions of the brain, notably those that are particularly vulnerable to rotational forces, such as the subcortical white matter, corpus callosum, and upper brainstem. Uncontrolled hypertension may occur in patients with hypertension, but would be unlikely to produce this pattern of injury. Amyloid angiopathy causes multiple hemorrhages, but affects elderly patients. The decreased cerebral perfusion pressure
associated with brain swelling and increased intracranial pressure could cause ischemic infarction, but this would not be expected to give this appearance on MRI. Coagulopathies also occur in up to 20% of patients

[Delsol]

4- Which of the following Tx could be recommended to improve this patientЎЇs long-term outcome?
a. Corticosteroids
b. Prophylactic hyperventilation
c. Hyperthermia
d. Hypothermia
e. Prophylactic anticonvulsants

[riltsov]

Может гипотермия поможет.
d. Hypothermia

[Delsol]

4- The answer is d.
Hypothermia has been shown to reduce cerebral injury from ischemia both in experimental models and in clinical studies in patients with traumatic brain injury. Hypothermia decreases cerebral metabolism, reduces acidosis, attenuates changes in the
blood-brain barrier, and inhibits the release of excitatory neurotransmitters that can be harmful. Corticosteroids, prophylactic hyperventilation, and prophylactic anticonvulsants have not been shown to be of benefit in the long-term prognosis of severely head-injured patients. Hyperthermia is detrimental to such patients.