Answers to SESAP questions:
Question 1: The correct answer is B
Critique: Although arteriography is accurate in identifying the presence of a vascular injury, its accuracy about the specific type and extent of injury compared with operative findings may be less than once believed. Angiograms have been useful in determining the need for operation, and may have an even more important role as some centers recommend nonoperative management for minimal injuries. They are also helpful in planning the operative approach, but are contraindicated in patients who present with an obvious injury, as here, and a pulseless extremity in which viability is threatened.
Compartment pressures should be measured prior to operation. If the compartment pressure is elevated (>30-40 cm H20), it may be advantageous to perform a fasciotomy, which will decompress the compartment and may restore flow to the extremity.
A cold pulseless extremity in a trauma patient is an acute surgical emergency requiring an immediate operation. Blood should be available in the operating room in the event major blood loss occurs.
Systemic anticoagulation is often not feasible in many trauma patients because of associated injuries. For appropriate patients, early systemic anticoagulation may reduce distal thrombosis and should be considered for patients with isolated peripheral injuries with diminished distal circulation. When systemic heparin is contraindicated, local or regional anticoagulation can be achieved by infusing a 1:10 solution of heparin and saline cooled to 4oC into the distal circulation during the vascular reconstruction.
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Snyder WH III, Thal ER, Perry MO: Vascular injuries of the extremities, in Rutherford RB (ed): Vascular Surgery, ed3. Philadelphia. WB Saunders Co, 1989 pp 615-637
Critique: Full-thickness skin grafts provide thicker and more durable coverage than do partial or split-thickness skin grafts. They do not contract as much as do split-thickness grafts and consequently are useful for weight-bearing surfaces and to correct contractures. However, they require a better vascular bed for survival and do not tolerate wound contamination as well as thinner split grafts. Sensory return is generally better in split-thickness skin grafts.
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Question 3: The correct answer is C
Critique: Tissue damage after high-voltage electrical injury is mediated by heat at the cutaneous contact site and in tissues and organs in the path the current takes between entrance and exit sites. The generated heat is a function of current density or voltage drop and current flow per unit of cross-sectional area. This relationship to cross-sectional area and the frequent entry contact site on hands and feet makes severe extremity injury frequent and truncal injury infrequent. The current density is greatest at the contact points between skin and electricity, and the local skin injury further increases the resistance to the passage of current. The heated tissue acts as a radiator; the deeper tissues cool more slowly, making them subject to sever heat-generated injury. Extensive areas of devitalized muscle, a ready source for releasing myoglobin into the circulation or producing an extremity compartment syndrome, may lie beneath a seemingly mild skin burn.
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Question 4: The correct answer is D
Critique: Supplemental Vitamin A prevents acute radiation-induced defects in wound healing in rats. Local hypothermia increases subcutaneous tissue oxygen tension in patients with implanted tonometers. Increased environmental temperatures also increase local oxygen tension in the skin and the rate of wound healing.
Cortisone and its derivatives decrease the rate of protein synthesis and inhibit the normal inflammatory reaction. In most species studied, including man, high doses of corticosteroids limit capillary budding, inhibit fibroblast proliferation, and decrease the rate of epithelialization. However, even with high doses of corticosteroids, wound healing goes to completion; only the time scale is altered.
In experimental studies assessing the effects of cyclosporine, azathioprine, and prednisone on wound healing, cyclosporine in clinical dosages did not inhibit skin or fascial healing. Azathioprine and prednisone significantly retarded skin healing but did not affect musculofascial healing.
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