● Emergency

○ Trauma
■ Blunt chest trauma
● Pulmonary contusion
○ Decreased breath sounds over affected area
○ Tachypnea, dyspnea, hypoxemia
○ May be missed initially = several hours to show up on
cxr/clinical signs
○ Rx
■ Supportive
■ Admit to hospital and monitor for 24-48 hours
● Flail chest
○ Presentation
■ Tachypnea
■ Tachycardia
■ Shallow breathing
■ Anterior chest bruises
■ Cyanosis
○ Rx
■ Uncomplicated cases - nonoperatively with
supplemental oxygen, noninvasive
positive-pressure ventilation, and medications for
pain contro
■ mechanical ventilation and surgical stabilization
may be necessary in more severe cases
● Blunt cardiac injury
○ Cardiac contusion = most common
○ Eval with ECG
○ If patient is hypotensive or abnormal cxr = FAST or CT of
chest or TEE
■ Aortic injury = most common cause of sudden death due to steering
wheel injury
■ Abdominal gunshot wounds
● Unstable patients with signs of peritonitis or organ evisceration =
immediate laparotomy
■ Femoral nerve injury
● inability to extend the knee, loss of knee jerk reflex, and sensory
loss over the anterior and medial aspects of the thigh, medial
aspect of shin, and arch of the foot
○ Appendicitis
■ Pregnancy
● second trimester can have premature delivery
● first trimester may experience abortion
 ● Third trimester = appendix perforation with peritonitis and
subsequent pylephlebitis
○ Gallbladder
■ Acute cholecystitis
● Initial test of choice = ultrasound
● Most common complications
○ Gangrene and preforation
○ Cholecystoenteric fistula
○ Emphysematous cholecystitis
● Rx
○ Empiric antibiotic therapy
■ Amp-sulbactam
■ Ceftriaxone + metro
■ Acute cholangitis
● Charcots triad
○ RUQ pain
○ Fever
○ Jaundice
● Elevated direct dili + ALKP without rise aminotrans
● Rx
○ Blood culture + empiric antibiotics
■ Amp + gent
■ Imipenem
■ Leofloxacin
○ Bowel obstruction
■ Rx
● Partial
○ Initially consevative therapy - admit for observation
○ Acute mesenteric ischemia
 ■
○ GU
■ Acute urinary obstruction
● No evidence of trauma or history of strictures = Rx = urethral
catheterization
■ Ureteral stones
● Rx
○ <5 mm
■ Usually pass spontaneously
○ >8-100 mm
■ Unlikely to pass spontaneously
○ Stone removal
■ extracorporeal shockwave lithotripsy (ESWL)
● Rx of choice <100 mm
■ flexible ureteroscopy
● >10 mm
■ percutaneous ureterolithotomy
● Only when above failed
■ Blunt testicular trauma
 ●
○ Hip fracture
■ LMWH = prophylaxis
● Started on admission een if patient scheduled for srugery
○ Stopped 12 hours before surgery
○ Ortho
■ Achilles tendon
● Most accurate test to confirm
○ Thompson test
■ patient lying in the prone position, feet hanging
■ off the table, the clinician should squeeze the
patient's calf muscles and observe for the presence
of plantar flexion of the foot. If plantar flexion is
observed on calf squeeze, the test is negative and
indicates normal function of the Achilles tendon
■ Clavicular fracture
● Rx
○ Open reduction and internal fixation
■ open fractures with neurovascular injury or tenting
of the skin, widely displaced fractures (> bone width
size), significant shortening, and comminution
 ●
■ Scaphoid fracture
● Fall on outstreched hand
● Pain at wrist and radial dorsal aspect - snuff box
● Rx
○ X-ray
■ Initiall may be normal - up to 2 weeks
○ Additional imaging
■ Mri
○ Orthopedic surgeon referall
■ associated tilt of the lunate, a scaphoid fracture
displaced >1 mm, nonunion during follow-up,
osteonecrosis, or scapholunate dissociation
○ Nondisplaced fractures should be treated with a short-arm
thumb spica cast
● Complications
○ Nonunion
○ Avascular necrosis
■ Colle’s fracture
● Fall on outstreched hands
● dorsally angulated or displaced distal radius fracture that is
typically associated with visible angulation proximal to the wrist
joint = dinner fork
■ Patellar tendon tear
● sudden and unusual quadriceps contraction with the foot firmly
planted, and with the knee in partial flexion during the injury
● Swelling and tenderness in anterior part of leg
● Extreme pain and difficulty bearing weight
● Unable to perform active extension of the leg
 ● Unable to maintain the passively extended knee against gravity
● Rx
○ Complete = Early surgical intervention
○ Partial = cast or brace
■ Anterior cruciate ligament tear
● Pain, inability to ambulate
● Popping sensation or sound at time of injury
● Anterior drawer test

○
■ Collateral ligament
● Medial = Valgus stress test
● Lateral = Varus
● Tenderness on joint line
■ Meniscal injury
● Twisting force with foot fixed on ground
● McMurray’s maneuver

○
 ○ Positive if click or popping sensation
○ Bites
■ Cat and dog bites
● Prophlactic amox/clav
● Dog bite injuries of the hand and puncture wounds anywhere on
the body should not be closed primarily due to a high risk of
development of wound infection.
■ Tetanus toxoid
● Dirty wounds received booster >5 years ago
● Clean wounds booster >10 years ago
■ Tetanus immune globulin
● Any individual with dirty wounds and unclear immunization history
○ Lightening injuries
■ Rx
● Chest compressions should be continued while adminstering
vasopressors
● Identifying and treating reversible causes of cardiac arrest
■ Temporary autonomic dysfunction
● Fixed dilated pupils
○ Should not stop CPR
○ Burns
■ Most concern to developing in the next 24 hours after inhalation
● Supraglottic edema
○ Traumatic amputation of a body part
■ requires rapid transport of the appendage, which should be wrapped in a
■ saline-moistened gauze, placed in a plastic bag, and transported in a
container filled with ice mixed with either
■ saline or sterile water to best preserve the body part and attempt
replantation
○ Glasgow coma scale
 ■
■ Intubation </= 8
○ Elevated ICP
■ Signs
● Bradycardia
● Hypertension
● Resp depression
● Further evelation
○ Transtentorial herniation
■ Stupor to coma
■ Dilation ipsalateral pupil
■ 3rd nerve palsy
■ Hemiparesis
■ Devebrate posture
■ Resp arrest
○ Rx
■ ET intubation
○ Spinal cord level
■ L1-l2
● cremaster reflex
○ Common second to diabetic neuropathy even in trauma
● Hip flexion
 ● Adduction
■ L5-s2
● Dorsiflexion and plantar flexion
■ S2-s4
● Anal sphincter tone
■ Causa equina syndrome
● Severe lower back pain
● Urinary or bowel incontinence
● Motor weakness or sensory loss BILATERALLY
● Saddle anesthesia
○ Neuro
■ Aneurysms
● Posterior communicating artery aneurysm
○ CN 3
■ Ptosis
■ Anisocoria
○ Acute scrotal pain
■ pain predominant (testicular torsion, torsion of the appendix testis, and
epididymitis)
● Testicular torsion
○ Screening test
■ Cremasteric reflex test
■
■ swelling predominant (hydrocele, varicocele, spermatocele, and testicular
cancer)
● Clinical
 ○
● Stress fractures
○ Tibial
■ Lower lef pain
■ Tibial tenderness
● medial tibial stress syndrome ("shin splints") without tibial
tenderness
● further activity can cause progression to a complete or incomplete
fracture, resulting in tibial tenderness on palpation
■ Running
○ Initial plain x-rays of the tibia have low sensitivity and are negative during the first
few weeks in over half of the cases
○ Possible abnormalities on x-ray may take up to 4 weeks to become apparent and
include
■ bone sclerosis, cortical thickening, periosteal elevation, and visible
fracture line
● Complex regional pain syndrome
○ Usually occurring after an injury, CRPS presents with pain out of proportion to the
injury, temperature change, edema, and abnormal skin color
○ Type I CRPS (90% of CRPS cases) occurs without a definable nerve lesion,
while type II occurs with a definable nerve lesion
● diarrhea
○ Postcholecystectomy diarrhea
■ Bile salt-induced diarrhea
● Secondary bile acids
○ Also seen in ileal resection and short bowel syndrome
 ■ Rx
● Cholestyramine
○ Small intestine bacterial overgrowth
■ Malabsorbtion syndrome
● Surgically created blind loops
● Motility
○ Diabetes
○ Systemic sclerosis
■ Rx
● Rifaximin
○ Dumping syndrome
■ Complication of gastrectmy
● Rx high protien diet
●