Resident Readiness General Surgery by Debra Klamen, Brian George, Alden Harken, Debra Darosa Page B
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and the transfused blood specimens to the lab.
Acute DIC is most easily recognized as oozing at the IV site.
COMPREHENSION QUESTIONS
1. A 55-year-old male is still on the ventilator 3 days following an open aortobifemoral graft. His Hbg is 7 g/dL. You decide to give him 2 U of packed red blood cells. The most likely benefit will be an increase in which of the following?
A. P O 2 95 → 110 mm Hg
B. O 2 saturation 95% → 98%
C. CaO 2 by 25%
D. Hbg 7 → 14 g/dL
E. Hct 20% → 35%
2. DIC can be most easily recognized by which of the following?
A. Low platelet counts
B. Bleeding around a peripheral IV site
C. Low hematocrit
D. Elevated D -dimers
3. You should stop a transfusion if the patient develops which of the following?
A. A rash
B. Pruritus
C. Hoarseness
4. Pharmacologic treatment of an acute transfusion reaction could include any of the following except which of the following?
A. Acetaminophen
B. Epinephrine
C. Phenylephrine
D. Diphenhydramine
Answers
1. C . More red blood cells increase the content of oxygen being carried in the blood. The oxygen saturation of that blood remains the same, as does the partial pressure of oxygen. The Hgb should rise by 1 g/dL for each unit, while the Hct will rise just 3% for each unit.
2. B . While these other elements can also be present, they are nonspecific and require a lab test. It is worth first checking the peripheral IV site.
3. C . A rash and pruritus are CDC level I–type reactions. You should give an antihistamine and then monitor the patient while you continue the transfusion.
4. A . Antihistamines such as diphenhydramine are first-line pharmacologic agents for all levels of transfusion reactions. For more severe reactions, α- and β-agonists are also indicated.
A 37-year-old Man With a Painful Bulge Over His Left Forearm
Eric N. Feins, MD
A 37-year-old man presents to the emergency department complaining of a painful bulge over his left forearm. He states that he noticed some redness around the area 1 week ago, and then over the past few days it has become more swollen and painful, but it has not drained anything. He denies fevers, but thinks he’s had some occasional chills. He has no other medical problems and denies injecting drugs.
On physical exam, he is afebrile, HR 95, and BP 115/75. He has overall good hygiene and is well kempt. Over the dorsolateral aspect of his left forearm there is a 3-cm erythematous, fluctuant mass. It is extremely tender to light palpation and is mobile. Nothing can be expressed from the mass on palpation. There is also a 4- to 5-cm margin of erythema surrounding the mass without any evidence of streaking up the arm.
1. What, if any, additional imaging would you obtain?
2. Can you drain this abscess in the ED, or should it be done in the OR?
3. Is antibiotic therapy warranted for this patient?
SUPERFICIAL ABSCESS
Not all superficial abscesses are created equal and host factors often explain their etiology and severity. Superficial abscesses can arise in otherwise healthy individuals who develop skin breakdown (ie, abrasion, cut, surgical incision) that allows the entry of pathogenic bacteria. These are typically simpler to manage because the patient lacks risk factors and is immunocompetent. In contrast, patients with a history of injection drug use are at risk for recurrent superficial infections and abscesses. Immunocompromised patients (ie, diabetics) are also at risk for developing more severe infections due to their impaired host defenses.
Host factors influence the microbiology of superficial abscesses. Simple abscesses in immunocompetent patients are typically due to skin flora: Staphylococcus and Streptococcus , although gram-negative and anaerobic bacteria, can be involved. Methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly common in some regions and is particularly prevalent in recently hospitalized patients, injection drug users, and diabetics. Pseudomonas aeruginosa is common in diabetics with
Acute DIC is most easily recognized as oozing at the IV site.
COMPREHENSION QUESTIONS
1. A 55-year-old male is still on the ventilator 3 days following an open aortobifemoral graft. His Hbg is 7 g/dL. You decide to give him 2 U of packed red blood cells. The most likely benefit will be an increase in which of the following?
A. P O 2 95 → 110 mm Hg
B. O 2 saturation 95% → 98%
C. CaO 2 by 25%
D. Hbg 7 → 14 g/dL
E. Hct 20% → 35%
2. DIC can be most easily recognized by which of the following?
A. Low platelet counts
B. Bleeding around a peripheral IV site
C. Low hematocrit
D. Elevated D -dimers
3. You should stop a transfusion if the patient develops which of the following?
A. A rash
B. Pruritus
C. Hoarseness
4. Pharmacologic treatment of an acute transfusion reaction could include any of the following except which of the following?
A. Acetaminophen
B. Epinephrine
C. Phenylephrine
D. Diphenhydramine
Answers
1. C . More red blood cells increase the content of oxygen being carried in the blood. The oxygen saturation of that blood remains the same, as does the partial pressure of oxygen. The Hgb should rise by 1 g/dL for each unit, while the Hct will rise just 3% for each unit.
2. B . While these other elements can also be present, they are nonspecific and require a lab test. It is worth first checking the peripheral IV site.
3. C . A rash and pruritus are CDC level I–type reactions. You should give an antihistamine and then monitor the patient while you continue the transfusion.
4. A . Antihistamines such as diphenhydramine are first-line pharmacologic agents for all levels of transfusion reactions. For more severe reactions, α- and β-agonists are also indicated.
A 37-year-old Man With a Painful Bulge Over His Left Forearm
Eric N. Feins, MD
A 37-year-old man presents to the emergency department complaining of a painful bulge over his left forearm. He states that he noticed some redness around the area 1 week ago, and then over the past few days it has become more swollen and painful, but it has not drained anything. He denies fevers, but thinks he’s had some occasional chills. He has no other medical problems and denies injecting drugs.
On physical exam, he is afebrile, HR 95, and BP 115/75. He has overall good hygiene and is well kempt. Over the dorsolateral aspect of his left forearm there is a 3-cm erythematous, fluctuant mass. It is extremely tender to light palpation and is mobile. Nothing can be expressed from the mass on palpation. There is also a 4- to 5-cm margin of erythema surrounding the mass without any evidence of streaking up the arm.
1. What, if any, additional imaging would you obtain?
2. Can you drain this abscess in the ED, or should it be done in the OR?
3. Is antibiotic therapy warranted for this patient?
SUPERFICIAL ABSCESS
Not all superficial abscesses are created equal and host factors often explain their etiology and severity. Superficial abscesses can arise in otherwise healthy individuals who develop skin breakdown (ie, abrasion, cut, surgical incision) that allows the entry of pathogenic bacteria. These are typically simpler to manage because the patient lacks risk factors and is immunocompetent. In contrast, patients with a history of injection drug use are at risk for recurrent superficial infections and abscesses. Immunocompromised patients (ie, diabetics) are also at risk for developing more severe infections due to their impaired host defenses.
Host factors influence the microbiology of superficial abscesses. Simple abscesses in immunocompetent patients are typically due to skin flora: Staphylococcus and Streptococcus , although gram-negative and anaerobic bacteria, can be involved. Methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly common in some regions and is particularly prevalent in recently hospitalized patients, injection drug users, and diabetics. Pseudomonas aeruginosa is common in diabetics with
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