Kaplan USMLE - Step 2 CK Lecture Notes 2017- Surgery

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Editors

Carlos Pestana, M.D., Ph.D.

Emeritus Professor of Surgery

University of Texas Medical School at San Antonio

San Antonio, TX

Adil Farooqui, M.D., F.R.C.S.

Clinical Assistant Professor of Surgery

Keck School of Medicine, University of Southern California

Kaiser Permanente, West Los Angeles Medical Center

Los Angeles, CA

Mark Nolan Hill, M.D., F.A.C.S.

Professor of Surgery

Chicago Medical School

Chicago, IL

Contributor

Ted A. James, M.D., F.A.C.S.

Associate Professor of Surgery

Director, Skin and Soft Tissue Oncology

Director, Surgery Senior Student Program

University of Vermont College of Medicine

Burlington, VT

The editors wish to also acknowledge Gary Schwartz, M.D., Baylor University Medical Center.

We want to hear what you think. What do you like or not like about the Notes? Please email us at medfeedback@kaplan.com.

Contents

Section I. Surgery

v

USMLE Step 2 CK λ Surgery

Section II. Surgical Vignettes

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SECTION I

Surgery

Trauma 001

Chapter Title

Learning Objectives

List the ABCs of evaluating a trauma patient

Demonstrate a head-to-toe review of a trauma patient

Provide basic information about treatment of burns, bites, and stings

PRIMARY SURVEY: THE ABCs

Airway

The first step in the evaluation of trauma is airway assessment and protection.

•An airway is considered protected if the patient is conscious and speaking in a normal tone of voice.

•An airway is considered unprotected if there is an expanding hematoma or subcutaneous emphysema in the neck, noisy or “gurgly” breathing, or a Glasgow Coma Scale <8.

An airway should be secured before the situation becomes critical. In the field an airway can be secured by intubation or cricothyroidotomy. This is called a “definitive airway.” In the emergency department, it is best done by rapid sequence induction and orotracheal intubation, with monitoring of pulse oximetry. In the presence of a cervical spine injury, orotracheal intubation can still be done as long as the head is secured and in-line stabilization is maintained during the procedure. Another option in that setting is nasotracheal intubation over

a fiberoptic bronchoscope. If severe maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, cricothyroidotomy may become necessary.

In the pediatric patient population (age <12), tracheostomy is preferred over cricothyroidotomy due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.

Breathing

Breath sounds indicate satisfactory ventilation; absence or decrease of breath sounds may indicate a pneumothorax and/or hemothorax and necessitate chest tube placement. Pulse oximetry indicates satisfactory oxygenation; hypoxia may be secondary to airway compromise, pulmonary contusion, or neurological injury impairing respiratory drive and necessitate intubation. Measurement of CO2 (capnography) is also very useful.

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