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What is the difference between an open and closed fracture?
- Open: the skin is broken
- Closed: The skin is intact
What is the difference between complete and incomplete fracture?
- Complete: Bone is broke all the way through
- Incomplete: Bone is fractured but not all the way
What is a 45 degree fracture to long axis of a bone?
What two things cause an oblique fracture
- Compressive force
What type of fracture is described as a break in 2 or more fragments
A pt reports to the clinic and you suspect they have a fracture, what symptoms lead you to this conclusion?
- Unnatural alignment
- Muscle spasm
- Impaired sensation
What is it called when there is a dislocation in which contact between the surfaces are only partially lost?
Where are subluxations most common
The spinal column
What is the difference between a strain and a sprain
- Strain is a tear in the tendon
- Sprain is a tear in the ligament
What is painful inflammation of the tendon
What is painful inflammation of the bursae?
At what age is Bursitis most common and what causes it?
- Middle age
- Repeated trauma (softball players)
What is bursae?
A fluid-like sac that acts as a cushion at joints
What is a degradation of collagen fibers that results from trauma and repetitive stress?
What is complete separation of a tendon or ligament from its attachment
What is another name for Tennis elbow
What is inflammation of tendon where it attaches to a bone (olecranon process - elbow)
What is it when there is a sudden, forceful motion causing the muscle to become stretched beyond its normal capacity
What is a complication of localized muscle injury caused by scar tissue calcification and subsequent ossification?
What is a life-threatening complication caused by severe muscle trauma manifested by excess myoglobin, and intracellular muscle protein in the urine?
What is the most severe form of rhabdomyolosis
WHat can cause rhabdomyolosis
Drug overdose and Long term immobility
What disease what first seen in injuries after london air raids in WWII
What is a less severe and more localized form of myoglobinuria which can lead to Volkmann ischemic contracture of forearm or leg
What precipitating factors can lead to osetoporosis
- Decreased estrogen/testosterone
- Reduced physical activity
- Inadequate Vit C and D
- Insufficient dietary Ca+ and Mg+
What diseases is characterized by reduced bone mass or density and imbalance of bone resorption and formation
What disease is characterized by inadequate and delayed mineralization, causing radiolucent bands and bone fractures? Can cause Vertebral collapse?
What is osteomalacia in children called
What does deficiency in Vitamin D lead to in osteomalacia
decreased calcium absorption from intestines and low serum phosphate
What bacteria is the most common cause of osteomyelitis
What 3 things cause Osteomyelitis
- Contaminated open wound
- Hematogenous Bone Infection
What can osteomyelitis lead to and why?
Necrosis due to impaired blood supply
Name 5 places bone tumors may originate from
- Bone cells
- Fibrous Tissue
- Vascular tissue
What type of tumors destroy small areas of bone, tend to be limited to anatomical confines, has a uniform and well defined border with a geographic pattern easily separated from normal bone
What type of tumors have a moth eaten pattern with permeative pattern bone destruction that is not easily separated from normal bone and has the adjacent areas partially destroyed
Name four common types of bone tumors
- Giant Cell
Malignant bone-forming tumor found in the marrow that is large and destructive and has a moth-eaten pattern
What type of bone tumor is common in middle-aged and older adults
What malignant collagenic bone tumor is found in middle aged adults
What type of bone tumor is from myelogenic tissue that occurs between ages 20 and 40?
What is the pathology of shock
Cells are not receiving adequate oxygenation or are unable to use the oxygen
Name 3 compensatory mechanisms that happen when there is no glucose available for cells to use for energy
What is the breakdown of glycogen to glucose
What is glycogen formation from fatty acids and proteins rather than from glucose
What is fat breakdown used for alternative for fuel generation?
Describe the pathophysiology of cardiogenic shock
An injury to the heart muscle causes decreased cardiac output which causes back-up in blood flow leading to pulmonary congestion. Because the blood is not being pumped out of the heart effectively, the cells are deprived of oxygen.
What is the number one cause of cardiogenic shock?
Describe the pathology of hypovolemic shock
Due to a loss in blood or fluids, the heart has less oxygen to eject to the rest of the body leading to cell deprivation of oxygen
What can cause blood loss that leads to hypovolemic shock
What can cause fluid loss that leads to hypovolemic shock
- Third spacing (Liver/Renal failure)
What does someone with hypovolemic shocks skin feel like and why?
cool and clammy, pale due to blood being shunted to the critical organs and subsequently away from the skin
Pt comes into the clinic c/o chest pain and difficulty breathing. Upon assessment you note JVD, cool, clammy skin, and crackles in the lung fields. BP measures 90/47. HR is 112. What type of shock do u suspect the pt has and why?
Cardiogenic shock, The tale tale sign is crackles and JVD as these indicate fluid overload which is consistent with this type of shock.
What type of history would a man suspected of having cardiogenic shock most likely have?
Hx of: MI, valve issues, arrhythmias, atherosclerosis, and heart infections
Describe the pathophysiology of neurogenic shock
Nervous system malfunction leads to decreased vascular tone which causes blood to pool.
What things can lead to neurogenic shock
Brain injury and SCI
What is the NUMBER ONE symptom that differentiates neurogenic shock from all other types of shock and why
Bradycardia because the nervous system is also responsible for stimulating the heart to beat effectively, with it being impaired, the heart rate slows dramatically
What is the skin like for a person suffering from neurogenic shock and why
warm and flushed. With neurogenic shock, all the vessels in the body are dilated causing blood rush to the skin
Name two different mechanisms that can lead to shock and examples of each
1. Cells are starved, so all available oxygen is taken by the tissues and very little is returned to the heart. (Cardiogenic/Hypovolemic)
2. Oxygen has a hard time getting to the tissues due to inflammation or other barriers, so most of the oxygen returns to the heart (Distributive: Anaphylactic, septic)
What cellular compensatory mechanisms occur to counteract decreased oxygenation?
Aerobic switches to anaerobic leading to increased lactic acid production which decreases the pH and causes increased respiration
What is progressive failure of 2 or more organ systems caused by SIRS after a severe illness or injury
Name the four different parameters in which there needs to be at least 2 apparent to diagnose SIRS
- Temp <96.8 or >100.5
- HR >90
- RR >20 or PaCo2 <32
- WBC <4000 or >10,000, Bands >10%
What criteria must be met for a pt to be diagnosed with Sepsis
2 criteria of SIRS and confirmed infection
What criteria must be met for severe sepsis to be diagnosed
Sepsis + Sx of end stage organ damage + Hypotension <90 + Lactate >4 mmol
What criteria is needed for a person to be in septic shock
Sepsis + Hypotension that is unrelieved by fluids + Organ damage + Lactate >4 mmol
When does a person transition from Septic shock to MODS
When there is severe septic shock, organ FAILURE, and a build up of metabolic waste (due to liver failure)
What type of burn affects only the epidermis?
What type of burn affects the epidermis and dermis but tactile and pain sensors stay intact
Second Superficial Partial Thickness
What type of burn affects the epidermis and dermis but the tactile and pain sensors are diminished
Second Deep Partial Thickness
What type of burn affects the epidermis, dermis, and subq tissue, tactile and pain sensors are absent
3rd degree Full thickness
What does a first degree burn look like? When does the symptom appear
Blisters may be present within 24 hrs
What does a second degree superficial partial thickness burn look like and when does the symptom appear
Blisters present within minutes
What does a second degree deep partial thickness burn look like
- Blisters may or may not appear
- Flat, dehydrated layer lifts off in sheets
What does a third degree burn look like
- Blisters are rare
- A flat dehydrated layer lifts off easily
Describe cellular and cardiovascular response to a major burn injury
- Within minutes, capillary beds open
- There's an increase in capillary permeability
- There is an increase in hypermetabolic state
- Hypercoagulable state develops
What can Increased capillary permeability lead to for a burn patient
Hypovolemic shock and massive edema
Why does a burn patient have a persistent elevated body temperature?
Due to the hypermetabolic state
What will the labs look like for a burn patient
- Elevated fibriniogen
- Decreased PT and PTT
Besides hypovolemic shock, what other type of shock is a burn patient at risk for and why
Septic, due to the ability for microbes and endotoxins to translocate across intestinal wall, the complement system is deactivated which decreases opsonization and the body can no longer tell self from nonself allowing bacteria to multiply
What is Small unmyelinated C polymodal nociceptors responsible for
Transmission of diffuse burning or aching sensations (slow pain)
What is Medium-sized A-delta fibers responsible for
Carrying well-localized sharp pain important in initiating rapid reactions to stimuli (fast pain)
What is responsible in the spinal cord for regulating transmission of pain impulses that proceeds cephalad for further processing and interpretation in the brain?
What needs to be stimulated in order to close pain gates?
Large, fast, heavy myelinated Alpha-Beta fibers
Where are large, fast, heavy myelinated Alpha-Beta fibers located
synapse at dorsal horn of spinal cord along with their nociceptive Alpha-Delta and C counterparts
What two neurotransmitters located in the medulla and pons contribute to pain modulation
Norepinephrine and Serotonin
What are morphine-like neuropeptides that act as transmitters by binding to one or more opioid receptors?
What do endogenous opioids do??
Inhibit transmission of pain impulses in brain and spinal cord
Name 4 types of endogenous opioids
Name 3 types of acute pain
What type of acute pain is near on on the surface of the skin that is sharp and localized
What type of acute pain is located in the internal organs, abdomen, and skeleton
What type of acute pain is an area removed or distant from point of origin
How does pain get referred in the body
Cutaneous and visceral neurons converge on same ascending neuron and brain cannot distinguish between the two
Describe the process of thermoregulation
Hypothalamus > TSH-RH
Anterior Pituitary > TSH
Thyroid > Thyroxine
Adrenal Medulla > Epinephrine
= Vasconstriction, Glycolysis, Increased Metabolic Rate
How does fever occur?
Introduction of Exogenous pyrogens/endotoxins
Phagocytes engulf bacteria
IL-1, IL-6, interferons, and TNF released
Raises Set point of hypothalamus
What is a potential complication of fever?
What occurs during a heat stroke
- Regulatory center ceases to function
- Sweating ceases causing rapid increase of body temp
- Skin if dry and flushed due to vascular collapse
- Altered LOC due to cerebral edema, degeneration of CNS, and Renal tubular necrosis
At what temperature is someone at risk for heat stroke
What does hypothermia do to the body
- Slows chemical reactions
- Increases blood viscosity
- Slows blood flow
- Facilitates blood coagulation
- Stimulates profound vasoconstriction
At what temperature a person at risk for hypothermia?
What are sx of hypothermia
- Decreased HR, RR, CO
- Decreased coordination
- Moderate to severe acidosis
What is consciousness
Alertness with orientation to person, place, and time
What is altered perception of stimuli (time, then place, then person)
What is orientated X 3 but slow vocalization and decreased motor skills
What LOC occurs when pt awakens in response to stimulation, continous stimulation is needed for arousal, and eyes are usually closed
What LOC does a pt exhibit who only responds to painful stimuli
What LOC is a pt who has no arousal to any stimulus but brainstem remains intact
Name the components of the diencephalon
thalamus and hypothalamus
What occurs in the diencephalon as a person progresses into nonresponsiveness
- agitated, dull, lethargic, obtundation
- Pupils respond briskly
- Dolls eyes
- No Caloric posturing
What is caloric posturing
When there is no eye movement in direction on or after injection of hot/cold water in ear canal
What three things take place in the midbrain as a person become unresponsive
- Neurogenic hyperventilation
- Midposition fixed pupils (MPF)
What is the difference between brain death and cerebral death
- Brain death is when cardiac and resp cannot be maintaned (death of brainstem/cerebellum)
- Cerebral death is an irreversible coma but brain stem is not yet affected so brain can maintain cardiac and resp function
What is caused by abnormal excessive hypersynchronous discharges of CNS neurons characterized by sudden transient alterations of brain functions
Name and describe two types of partial seizures
- simple: Motor, sensory, somatosensory sx (aura)
- Complex: Loss of consciousness w/ automastisms
What type of seizure has a partial onset and evolves into a generalized seizure
What type of seizure is bilaterally symmetric, without local onset, and loss of consciousness
Define clonic phase in seizure
Alternating contraction/relaxation of muscles
Define tonic phase of seizure
Muscle contraction with excessive muscle tone
What is the occurrence of a second, third, of multiple seizures before the person has fully regained consciousness from preceding seizure causing cerebal hypoxia
What phase of seizure follows tonic-clonic seizure usually involving sleeping
What disease is charecterized by loss of neurotransmitter stimulation by choline acetyltransferinase
What is late-onset FAD linked to?
a defect on chromosome 19
What is an accumulation of insoluble amyloid beta peptides that is also a protein found in AD
What is neurofibrillary tangles?
Twisted and distorted protein fibers in the neurons
Where is neurofibrillary tangles more concentrated
cerebral cortex and hippocampus
What is the inability to perform coordinated acts in addition to cognitive
What is the difference between blunt and open brain injuries
- Blunt - closed - dura remains intact
- Open - penetrating - Break in dura
What can cause Blunt force trauma
head strikes hard surface or rapidly moving object strikes head
What does open brain injury result to
Focal brain injury
What involves specific, grossly observable brain lesions seen in cortical contusions, epidural hemorrhage, subdural hemorrhage, intracerebral hematoma, and open head trauma
Focal Brain Injury
What is a bruise on the brain from force of impact
What is coup in regards to brain injury
direct impact area
What is an area that lies opposite of the line of force, lesions where brain strikes hard tissue on the opposite side
What is the most common source of bleeding for an extradural hematoma
What is the tearing of bridging veins major cause of rapid and subacute development
What can subdural hematoma lead to
Herniation due to blood filling subdural space
What type of hematoma is caused from small blood vessels traumatized by shearing forces
What results from inertial force to the head associated with high levels of acceleration and deceleration leading to memory loss, dizziness, HA, anxiety, and mood disorders
Diffuse brain injury or diffuse Axonal injury (DAI)
What type of DAI has decerebrate or decorticate posturing, prolonged stupor, or restlessness (concussion)
What type of DAI has a prolonged coma that lasts days or weeks with incomplete recovery most often
What type of DAI leads to immediate autonomic dysfunction (brainstem signs) that resolves in a few weeks. ICP appears 4-6 days after injury
Where do most spinal cord injuries appear?
What is caused by normal activity of SC cells at or below level of injury ceasing because of lack of continuous clonic discharges from brain or brainstem and impulses inhibited immediately after injury characterized by complete loss of reflex at or below level of lesion
How long does spinal shock usually last after onset symptoms?
What is associated with massive, uncompensated CV response to stimulation of the SNS usually occurring at T6 or above
What is autonomic hyperreflexia usually in response to?
bladder or rectum distention
What is the biochemical and biomechanical alterations of the tissue that comprise the intervertebral disk
Degenerative disk disease
What is a structural defect that involves the lamina (neural arch of the veterbra
Where is spondylolysis most common
What is caused when a vertebra slides forward in relation to an inferior vertebra
Where is spondylolythesis most common?
What is a protrusion of part of the nucleus pulposus through a tear in the fibrous capsule that encloses the gelatinous center of the disk
Herniation of vertebral disk
What causes pain in lumbosarcral area that radiates along the sciatic nerve over the buttocks and into the calf and ankle
Herniated intervetebral disk
Name some risk factors for CVA
HTN, Cigarettes, elevated LDL, DM, hyperchromocysteinemia
What type of stroke is caused by arteries supplying the brain and is most frequently attributed to atherosclerosis and inflammatory disease processes that damage arterial walls
What is thrombotic particles that cause an intermittent blockage of circulation?
What causes neuro deficits in TIA
focal disturbance of brain or retinal ischemic lasting less than an hour without an infarction
What type of stroke involves fragments that break from a thrombus that was formed outside of the brain?
What common sites are associated with embolic stroke
heart: MI, Afib, Endocarditis, Rheumatic heart disease, aorta, common carotid artery
What type of stroke is most commonly associated with HTN, ruptured aneurysms, arteriovenous malformation, and bleeding disorders
What types of symptoms does hemorrhagic stroke cause
HA, stiff neck, loss of consciousness, blood in CSF
What is a lacunar stroke
very small and only involves small arteries
What is a cerebral infarction
when an area of the brain loses blood
What do nociceptors respond too
mechanical, thermal, and chemical
Describe the pathway of nociceptors to the brain
Tissue injury > Substance P, Acetylcholine, Serotonin, and Prostaglandins > Nociceptor > Dorsal root ganglion > Spinothalamic Pathway > Thalamus > Somatosencory Cortex > pain
Name two afferent fibers that transmit pain signals from free nerve endings into the CNS
Myelinated A-delta fibers and Unmyeliated C fibers
Describe how myelinated A-Delta fibers transmit pain.
Myelinated A-Delta fibers is responsible for pain related to mechanical and thermal injury (fast pain), they respond to nociceptors and quickly relay the message to the dorsal root of ganglia where it travels through the neospinothalamic tract and onto the thalamus ending at the primary somesthetic cortex
Describe how unmyelinated C fibers respond to pain?
Unmyelinated C fibers respond to chemical stimuli or persistent mechanical or thermal injury and takes the paleospinothalamic tract to the brain stem (RAS) and onto the primary somesthetic cortex
What is the PAG (Periaqueductal grey region) of the midbrain referred to?
Endogenous Analgesic Center
What pathway is fast pain (sharp, stabbing) associated with?
What pathway is slow pain (dull, aching) associated with
What is the main biological difference between acute and chronic pain (besides the obvious)?
- Acute involves Autonomic response
- Chronic involves Psychological response
What type of pain is a more diffuse and throbbing pain that originates in structures such as muscles, bones, tendons, and radiates to surrounding tissues
Deep Somatic Pain
What type of pain is diffuse and poorly defined pain that results from stretching, distention, or ischemia of tissues in a body organ
What pain originates at a visceral site but is perceived as originating in the part of the body wall that is innervated by neurons entering the same segment of the nervous system?
What gland is responsible for temperature regulation?
Describe the 5 steps to fever
- 1. Release of PGE2 or cytokines from inflammatory cells
- 2. Resetting of thermostat set point
- 3. Vasoconstriction, shivering, Piloerection, Increased metabolism
- 4. Core body temperature reaches new set point
- 5. Once temperature has been met, vasodilation, sweating, and increased ventilation occur to return temperature to normal set point
Name and describe the four successive stages of fever
- Prodromal: HA, fatigue, achy
- Second (chill): Shaking, cold
- Third: Flush, skin warm and red
- Fourth: (devervescence): sweating
What disease is pathologically characterized by cerebral cortex atrophy and enlargement of ventricles
What are the hallmark symptoms of alzheimers
- Short term memory loss
- Impaired abstract thinking
- Behavior changes
What is the main difference between focal and diffuse brain injury
- Focal: neuro deficit without loss of consciousness
- Diffuse: Almost always includes loss of consciousness
What is characterized by flaccid paralysis, loss of tendon reflexes below the sit of injury, absence of somatic and visceral sensations below the site of injury, and loss of bowel/bladder function?
What are two types of SCI and describe them
- Primary neurological injury: occurs at time of mechanical injury and is irreversible
- Secondary injuries: Progressive neuronal damage following a primary injury that promotes the spread of injury
What is a temporary disturbance in cerebral bloodflow (lasting less than 1 hr) which reverses before infarction occurs
Name the steps that take place in MODS from Ischemic injury to Massive Systemic Immune/Inflammatory response
- 1. Ischemic Injury
- 2. <microcirculation, organ hypoperfusion
- 3. Macrophages release inflammatory mediators which damage endothelium systemically
- 4. Activation of complement, coagulation, fibrinolytic, kilkrein/kenin system
- 5. Massive systemic immune/inflammatory response
What causes hypoperfusion of tissue in MODS
Vasodilation, Increased capillary permeability, selective vasoconstriction, and microvascular thrombi cause a maldistribution of systemic and organ blood flow
What causes an increase in oxygen and substrate demand in MODS
Due to the immune/inflammatory response, the body goes into a hypermetabolic state and hyperdynamic circulation which leads to increased oxygen and substrate demands
What is the end result of increased oxygen and substrate demand as well as tissue hypoperfusion in MODS
There is now an oxygen supply/demand imbalance which leads to tissue hypoxia and eventually organ dysfunction
How does body fluids try to compensate for decreased cardiac output in regards to shock?
Due to intravascular deficits, there is vasodilation to allow fluids from the interstitial space to sequester into the vessels. Since there is now decreased interstitial fluid and oxygen, the body is forced to switch to anaerobic glycolysis which increases lactic acid, leading to acidosis
How does the heart and vessels respond to decreased cardiac output and intravascular deficits in regards to shock? What clinical manifestations would appear as a result?
- Heart: Pumps harder - weak, fast pulse
- Peripheral Vessels: constrict - cool, clammy skin
- Arterioles: dilate, Veins constrict: blood pools - increased clots
- Blood is shunted to critical organs
- Kidneys fail to eliminate H+ ions - oliguria
Name 6 stages of fracture healing process
- 1. Impact
- 2. Induction: Clot and bruise (1st stage-heal)
- 3. Inflammation: Cartilage formation
- 4. Soft Callous: bridge two bones together
- 5. Ossification: Callous turns to bone
- 6. Remodeling