Basilar Skull Fractures

Basilar skull fracture are commonly seen in blunt trauma. These fractures are usually managed conservatively and do not require surgery. They present with the following:

1. Racoon’s eyes (periorbital edema)
2. Battle’s sign (postauricular ecchymoses)
3. Hemotympanum (blood behind the ear canal)
4. Cerebrospinal fluid otorrhea (drainage through the ear canal)
5. CSF rhinorrhea (drainage through the nostrils)
6. Cranial nerve deficits

Nasogastric tubes should not be placed in cases of suspected or confirmed basilar skull fractures as the tube can be inadvertently placed intracranially.

Metastatic Tumors To The Lung

The cancers that are most commonly metastatic to the lung are:

1. Colon
2. Breast
3. Renal (kidney)

In many cases, these tumors can be resected (surgically removed) if the following criteria are met:

1. There is no other metastatic disease in the body.
2. The amount of lung resection leaves adequate pulmonary reserve.
3. The primary tumor is adequately controlled.

Electrocardiogram Findings in Pericarditis

Pericarditis (inflammation of the sac around the heart) is associated with several ECG findings:

1. Low voltage (i.e., “small”) QRS complexes.
2. Electrical alternans.
3. ST segment elevations with a “concave up” morphology more common.
4. Depression of the PR wave.
5. T wave inversion, but usually only after the ST segment has normalized

Killip Classification

This classification predicts risk of mortality after a ST-segment elevation myocardial infarction (STEMI.)

Class 1 – absence of congestive heart failure – 6% risk of mortality.
Class 2 – presence of an S3 murmur and/or bibasilar rales – 17% risk of mortality.
Class 3 – presence of pulmonary edema – 30-40% risk of mortality.
Class 4 – presence of cardiogenic shock – 60-80% risk of mortality.

Sgarbossa Criteria

The presence of a left bundle branch block (LBBB) makes it difficult to determine if there are ischemic changes on an electrocardiogram (ECG.)

The Sgarbossa scoring system can determine with a 90% specificity if cardiac ischemia is present on an ECG in the setting of a LBBB if the score equals 3 or greater.

The criteria are:

1. Elevation of the ST segment of 1 mm or greater that is concordant as the QRS in any lead – 5 points.

2. Depression of the ST segment of 1 mm or greater in any lead from V1 to V3 – 3 points.

3. Elevation of the ST segment of 5 mm or greater that was discordant with the QRS complex – 2 points.

Amaurosis fugax is a classic sign (more often described than actually seen) for an acute embolus to the ophthalmic artery, a branch of the internal carotid artery

It presents as an acute descending blindness in one eye, as if a shade is being pulled down over the eyelid. It is considered an indication for carotid endarectomy (surgical removal of atheromatous plaque in the carotid artery.)

Treatment of Kidney Stones

The development of kidney stones (aka urinary calculi) is a common condition seen by family practice doctors, emergency room physicians, and urologists. There are several considerations when treating kidney stones:

1. Most small calculi (< 4mm) pass spontaneously on their own without intervention.
2. Treatment of stones < 4mm consists of pain medication, vigorous hydration, and straining of the urine.
3. Stones larger than 4 mm but less than 2.5 cm are treated by extracorporeal shock-wave lithotripsy (ESWL).
4. Stones larger than 2.5 cm require percutaneous nephrolithotomy (PCNL).
5. Staghorn calculi require PCNL.
6. Stones that do not pass spontaneously typically obstruct the urinary system at three points: the ureteropelvic junction, the area where the ureter crosses the iliac vessels, and the ureterovesical junction.

Caloric Yield of Basic Nutrients

Adequate surgical nutrition is critically important in recovering from injury or illness. When calculating the energy yield from nutritional substances, the following caloric determinants are used:

Fat – 9 kcal/gm
Protein – 4 kcal/gm
Carbohydrate – 3.4 kcal/gm

The goal in any nutritional therapy is to provide sufficient calories in fat and carbohydrate to prevent protein breakdown.

Criteria For Referring Patients To A Burn Center

Burn wounds are distressingly common and can be dangerous for the patient and difficult to treat. It is generally acknowledged that the following criteria are indications for referral to a burn center:

Inhalation Injury
Burns to the face, feet, hands, or perineum
Electrical burns
Chemical burns
Burns involving more than 10% of total body surface area
Burns in patients with co-morbidities (ex. HIV)

Umbilical Hernias In Infants

Umbilical hernias (aka belly button hernias) are extremely common in infants and toddlers and occur in 10% – 30% of newborns.

Management of the hernia at time of discovery is dependent on the size of defect in the abdominal wall. Small hernias (< 2.0 cm) frequently close on their own and repair should be delayed until age 4.

Defects larger than 2 cm should be repaired at time of diagnosis, although this is typically scheduled on an elective basis as incarceration (i.e., tissue or bowel becoming trapped in the hernia) is rare.