64.A.

Traige and transport after mass casualty incidents

64.B. Rectal Cancer
64.C.Chronic venous insufficiency , therapy
64.D.MRI-Lumbar disc herniation
64.A.Triage and transport after mass casualty incidents
Triage:
- The systematic assessment and categorization of patients by severity and likelihood of survival with available resources, for the greatest number
of patients in the shortest period of time.
- Maximizing survivability — in a mass causality incidence (MCI) the emphasis shifts from the individual to the population.
- Triage situations mandate the individual autonomy be placed secondary to the collective good.
- Sorting of patients to provide for the survival of the most patients. Assignment of resources in the most efficient method.
- Most severe survivable injuries receive rapid treatment.
Different models:
- Three main models:
- SACCO (STM) — by Bill Sacco PHD: To maximize the expected number of survivor. Analysis of respiratory rate, pulse and motor response
adjusted for age
- START/JumpSTART — «START: Simple Triage and Rapid Treatment» — do the greatest good for the greatest number. Used by most pre-
hospital professionals.
- SALT — «Sort, Assess, Lifesaving interventions, Treatment/Transport»
START/JumpSTART:
- START is a triage method used by first responders to quickly classify victims during a mass casualty incident (MCI) based on the severity of their
injury. The method was developed in 1983.
- Triage categories:
- Deceased/Expectant — black triage tag color:
- Victim unlikely to survive given severity of injuries, level of available care, or both
- Palliative care and pain relief should be provided
- Immediate — red triage tag color:
- Victim can be helped by immediate intervention and transport
- Requires medical attention within 60 minutes for survival (up to 60)
- Includes compromises to patient’s ABC — airway, breathing, circulation
- Delayed — yellow triage tag
color:
- Victim’s transport can
be delayed
- Includes serious and
potentially life-
threatening injuries, but
status not expected to
deteriorate significantly
over several hours
- Minor — green triage tag
color:
- Victim with relatively
minor injuries
- Status unlikely to
deteriorate over days
- May be able to assist in
own care «walking
wounded»

Treatment and evacuation:

- After all patients have been evaluated,
responders use the START
classifications to determine priorities
for treatment or evacuation to a
hospital. The most basic way to use
the START classifications is to
transport victims in a fixed priority
manner:
- Immediate victims, followed
by delayed victims, followed
by the walking wounded.
64.B. Rectal Cancer
Most colorectal cancers are adenocarcinomas (95%). Clinical signs are often non-specific and may include a change in bowel habits, rectal bleeding
and weight loss. Iron deficiency anemia in men > 50 years and postmenopausal women should be considered a warning sign for CRC.
Etiology:
- Predisposing factors:
- Colorectal adenomas (villous > tubulovillous > tubular)
- Family history and hereditary syndromes (e.g. Familial adenomatous polyposis, HNPCC)
- Inflammatory diseases of bowel (e.g. IBD)
- Diet and lifestyle, older age, obesity
Clinical features:
- Often asymptomatic, particularly during the early stages of disease
- Nonspecific symptoms (e.g. weight loss, fever, night sweats, fatigue, abdominal discomfort)
- Symptoms according locations — In general, right-sided tumors chronically bleed, and left sided tumors cause obstruction:
- Rectosigmoid > Ascending colon > Descending colon
- Right-sided carcinomas (10%) — cecum and ascending colon:
- Iron deficiency anemia, Melena, Diarrhea
- Left-sided carcinomas (10%) — transverse and descending colon:
- Changes in bowel habits (Size, consistency, frequency)
- Blood-streaked stools, Colicky abdominal pain due to obstruction
- Rectum (50%) and sigmoid (30%):
- Hematochezia, Decreased stool caliber (pencil-shaped stool), Rectal pain, Tenesmus-recurrent inclination to evacuate the bowels
- Flatulence with involuntary stool loss
- Symptoms according to stage of disease:
- Advanced disease — mass, intestinal obstruction
- Metastatic disease — liver, lung, lymphatics
Staging: TNM (Stage I-IV), Dukes (A-D)
Diagnosis:
- Work-up of colorectal cancer is indicated in symptomatic patients and asymptomatic patients with abnormalities detected during routine screening:
- Initial work-up:
- Digital rectal examination — up to 10% of cancers are palpable
- Colonoscopy — gold standard If colonoscopy is incomplete: Barium studies (Apple core)
- Tumor marker — carcinoembryonic antigen (CEA) serum levels prior to initiating treatment — for monitoring disease recurrence and
response to therapy
Differential diagnosis:
- Small bowel neoplasms (e.g. adenocarcinoma, neuroendocrine tumors, lymphoma, gastrointestinal stromal tumors, leiomyosarcona, liposarcoma,
metastatic disease)
Treatment: Treatment primarily depends on the location of the tumor and the TNM stage:
Colon cancer:
- Curative approach:
- Any primary tumor with or without regional spread; resectable metastasis in the liver and/or lung. Treatment involves surgical resection
and adjuvant chemotherapy.
- Palliative approach:
- Distant metastases beyond the liver and/or lung or if the patient is not surgical candidate due to poor general health. Treatment involves
palliative chemotherapy.
Surgical management:
- Colectomy — extent of resection depends on the location of the tumor: Open approach or laparoscopic approach:
- Right hemicolectomy
- Left hemicolectomy
- Sigmoid colectomy
- Total abdominal colectomy — indicated for hereditary and multifocal carcinomas
- Regional lymph node dissection — for pathologic staging
- Resection of resectable metastases in liver and/or lung
Systemic therapy:
- Chemotherapy:
- Adjuvant chemotherapy if lymph nodes are positive (Stage III)
- Palliative chemotherapy for metastatic disease (Stage IV)
- Regimens:
- FOLFOX (Folinic acid, 5-FU, Oxaliplatin)
- FOLFIRI (Folinic acid, 5-FU, Irinotecan)
- XELOX (Capecitabine, Oxaliplatin)
- Biologicals: Anti-VEGF antibodies (e.g. bevacizumab) or EGFR antibody (e.g. cetuximab) may be added to the chemotherapy regimen for
metastatic disease
- Radiation therapy: Not a standard modality for treatment of colon cancer
Rectal cancer:
Surgical management:
- Transanal excision:
- Minimally invasive excision of small superficial tumors
- Indicated in early, localized disease (Stage I)
- Low anterior resection (LAR):
- Sphincter-preserving resection of the rectum and sigmoid
- Total mesorectal excision (TME) - en bloc excision of the mesorectum, regional lymph nodes and vasculature
- Abdominoperineal resection (APR):
- Resection of the rectum, sigmoid and anus with TME and permanent colostomy
Systemic therapy:
- Neoadjuvant radiochemotherapy — locally advanced disease (stages II-III) typically followed by surgery and postoperative chemotherapy
- Adjuvant chemotherapy after surgical resection depending on the pathology
- Palliative chemotherapy — indicated in inoperable, metastatic disease (stage IV)
Prevention:
- Screening for colorectal cancer: adenomatous polyps is performed in asymptomatic men and women > 50 years of age:
- Low-risk individuals:
 - Complete colonoscopy (gold standard) — repeat every 10 years if no polyps or carcinomas are detected
- Annual fecal occult blood test — screening for occult bleeding, which may indicate colorectal cancer
- Sigmoidoscopy every 5 years and FOBT every 3 years
- Annual fecal immunochemical testing
- CT colonography every 5 years
- High-risk individuals:
- Complete colonoscopy 10 years earlier than the index patient’s age at diagnosis or no later than 40 years of age
64.C.Chronic venous insufficiency , therapy Definition:
Chronic venous insufficiency — increased venous pressure due to malfunctioning valves in the veins resulting in fluid accumulation in
the lower extremities, which leads to alterations in the skin and veins.
Classification:
- CEAP:
- Clinical classification (no visible signs to active ulcer — C0 - C6)
- Etiological classification (congenital, primary, secondary, idiopathic)
- Anatomical classification (superficial, deep, perforator)
- Pathophysiological classification (reflux, obstruction, thrombosis)
Etiology:
- Risk factors — factors leading to increased venous pressure:
- Age, females, family history, sedentary lifestyle, prolonged standing
- Obesity, Pregnancy, Smoking. Prior thrombosis (post-thrombotic syndrome), Prior extremity trauma
Pathophysiology:
- Elevated venous pressure —> Incompetence of venous valves —> Reflux of blood into superficial veins of extremity —> Elevation of venous
pressure —> Varicose veins —> extravasation of protein and leukocytes —> release of free radicals —> damage to capillary basement membrane
—> leakage of plasma proteins —> edema formation —> decreased oxygen supply —> tissue hypoperfusion and hypoxia —> inflammation and
atrophy —> possible ulcer formation
- Virchow triad of VT: (1) venous stasis, (2) activation of blood coagulation, and (3) vein damage.
Clinical:
- Chief complaint:
- Generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
- Worsened by heat
- Worse while standing, relieved by walking and raising legs — opposite to PAD
- Pruritus, tingling, numbness
- Skin findings:
- Edema formation
- Telangiectasis
- Yellow-brown or red-brown skin pigmentation of medial ankle; later of the food and lower leg — due to RBC breakdown (hemosiderin
release)
- Varicose veins
- Lipodermatosclerosis — localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg
- Atrophie blanche — white, coin-to-palm sized atrophic plaques due to absent capillaries in the fibrotic tissue
Diagnosis:
- Based on history and clinical findings. Imaging is only used in diagnosis of chronic venous insufficiency.
- Test of choice — duplex USG:
- Presence of venous reflux confirms diagnosis of CVI
Treatment:
- Conservative measures:
- Indications: Superficial disease with no correctable cause of reflux, Postoperative period
- Measures:
- Compression stockings, avoid long periods of standing and sitting, avoid heat
- Frequent elevation of legs, physical therapy, manual lymphatic drainage
- Definite treatment:
- Vein ablation therapies:
- Interventional:
- First-line — endovenous thermal ablation (laser and radiofrequency)
- Alternative — chemical ablation (sclerotherapy)
- Open surgery with partial or complete removal of a vein — only for veins that are not accessible by interventional techniques.
- Vein ligation
- Vein stripping
64.D.MRI-Lumbar disc herniation