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כירורגיה > כירורגיה כללית > Flashcards

כירורגיה כללית Flashcards

1
Q

כריתת כיס מרה בחולה א-סימפטומטי

A
  1. פוליפ גדול מ1 ס״מ
  2. פורצלן
  3. אבן מעל 2.5 ס״מ
  4. חלק משותף ארוך של צינור המרה והלבלב
  5. אנמיה המוליטית כרונית
  6. מטופל שעובר ניתוח בריאטרי
  7. מטופלים באימונוסופרסיה לאחר השתלה
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2
Q

אינדיקציה לניתוח

Chronic calculous cholecystitis

A
  • התקפים חוזרים של קוליק + 2 בדיקות שמדגימות סלאדג׳
  • בד״כ לא רואים אבני מרה
  • נשים בהיריון - אפשר לנתח מהטרימסטר השני
  • סכרתיים - ניתוח בהקדם בגלל שיש סיכון מוגבר לנמק
  • ההעדפה היא ל laparoscopic cholecystectomy
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3
Q

Acute calculous cholecystitis

טיפול

A
  • טיפול ראשוני באנטיביוטיקה, נוזלים ומשככי כאבים
  • טיפול דפיניטיבי ע״י הסרה בלאפרוסקופיה תוך 7 ימים
  • אמפיאמה/פרפורציה יש לעשות הסרה דחופה
  • Inflammatory process in triangle of Calot –> partial cholecystectomy
  • אם יש סיכוי ניתוחי גבוהה, יש לעשות precutaneous transhepatic cholecystectomy ולאחר שלושה עד ארבעה ימים לעשות הסרה
  • אם מטופל מגיע לאחר הטיימיג שהוגדר כ72 שעות, צריך להכניס נקז
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4
Q

Choledocholithiasis

אבחנה

A
  • אולטראסאונד - קומון בייל מעל 8 מ״מ, או מעל 5 מ״מ עם הוכחת אבנים בכיס המרה
  • MRCP
  • ERCP
  • EUS פחות רגיש
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5
Q

Choledocholithiasis

טיפול

A
  • ERCP - in patients with gallstones, there is high risk for recurrence.
    • Recommended cholecystectomy within the same admission
    • Unless the patient is older then 70
  • Laparoscopic CBD exploration: intraopertaive cholangiogram is done
    • If cannot be done within surgery, place a tube within the cystic duct and do endoscopic cholangiogram one day later
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6
Q

Contraindications to LAP cholecystectomy

A
  • Coagulopathy, severe COPD, end-stage liver disease, congestive heart failure
  • The main contraindication - inability to isolate the biliary tracts
  • Do OPEN CHOLECSYTECTOMY when the patient cannot tolerate pneumoperitoneum (lung/heart disease) and if there is a suspicion for gallbladder tumor.
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7
Q

Post-cholecystectomy syndromes

Bile duct injury

A
  • The most common
  • Recognized within surgery:
    • If <3mm in size –> correct with t-tube
    • if >3mm in size:
      • If <50% of diameter –> ligate
      • if >50%/thermal injury –> remove and anastamose
  • Recognized after surgery: diagnose with US/CT (collection accumulation)
    1. Antibiotics, decompression and drain collections
    2. Cholangiogram
    3. Repair within surgery
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8
Q

Post-cholecystectomy syndromes

  1. Post-cholecystectomy pain
  2. Retained billiary stones
  3. Billiary leakage
A
  1. Asses for retained stones
  2. Treat with endoscopic sphincterotomy
  3. Occurs in about a week after the surgery
    • CT/US to asses for fluid collection
    • Later do PTC/ERCP for drainage
    • If there is a need re-operate to correct the anastamosis
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9
Q

Acute cholangitis treatment

A
  • Can be diagnosed with MRCP/ERCP or with cholangiogram
  • Hydration and antibiotics
  • If presents with septic shock –> vasopressors
  • 15% of the patients will need urgent decompression, which is usually done with ERCP or with PTC
    • If not available –> operate the CBD with insertion of T-tube
  • Definite therapy (cholecystectomy), when the infection subsides
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10
Q

Uncomplicated appendicitis treatment

A
  • Symptoms that last about 48h or no imaging of abcess or phlegmon
  • LAP appendectomy
  • Pre-operative treatment
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11
Q

Perforated appendicitis treatment

A
  • If very sick - fluid resuscitation
  • Perferred LAP appendectomy
  • Broad spectrum antibiotics before and after surgery
    • Drain all the pus and send for culture and Gram stain
  • If there is small bowel abcess –> place a drain after the surgery
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12
Q

Appendiceal abcess

A
  • Abcess > 4cm - drain (transvaginal/transrectal)
  • Abcess < 4cm - treat conservatively with antibiotics
    • If patient is still febrile/leukocytosis few days after the beginning of the treatment –> appendectomy
    • If recovers –> elective appendectomy after 2-4 weeks (6 weeks?)
  • Afther the operative treatment - colonoscopy is indicated to rule out intestinal malignancy (5%)
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13
Q

Appendectomy complications

A
  • Mortality - 1%
  • SSI
    • patients that suffer from fever/leukocytosis and clean looking surgical cut –> CT/US to rule out fluid collection/abcess
    • In this case - percutaneous drainage
  • SBO
  • Infertility
  • Fistulization
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14
Q

Internal hemorrhoids classification

A
  • 1st degree - bleeding, no prolapse
  • 2nd degree - prolapse with spont. reduction
  • 3rd degree - prolapse with manual reduction
  • 4th degree - prolapse that cannot be reduced
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15
Q

Non-surgical procedures for internal hemorrhoids

A
  • Rubber band ligation (via anoscope, with anasthesia)
    • In the absence of symptomatic external hemorrhoids, it is the first line of treatment in 2nd degree hemorrhoids
  • Alternative therapies - sclerotherapy, electrocoagulation, heating
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16
Q

Hemorrhoids - diagnosis

A
  • Via rectal examination and anoscopy
  • If there is rectal bleeding, colonoscopy is indicated when:
    • > 40 years old
    • Risk factors for colorectal malignancy
    • Bleeding that is inporportionate to the bleeding
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17
Q

Internal hemorrhoids - surgical treatment

A
  • Hemorrhoidectomy
  • Indications:
    1. Lack of response to conservative treatment
    2. 3rd degree
    3. Strangulation (4th degree)
    4. Additional fissure, fistula, ulcers
    5. Additional symptomatic extrenal hemorrhoids
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18
Q

External hemorrhoids - management

A
  • Creams
  • The therapy of choice for symptomatic hemorrhoids - hemorrhoidectomy
  • Thrombosed hemorrhoids - operate as soon as possible
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19
Q

Anal fissure - management

A
  • Acure fissure (3-6 symptomatic weeks) - Sitz bathes, psyllium
  • Chornic fissure:
    • Creams of nitroglycerin of CCB
    • Second line can be botox injections
      • Can lead to fecal incontinence
    • Surgical management - as last choice/patients with complications
      • Lateral partial internal anal sphincterotomy
      • Urine incontinence, bleeding, abcess, fistula, fecal incontinence
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20
Q

Anal abcess - types and management

A
  1. Intrasphincteric - hardest approach
  2. Perianal - drainage without stitches
  3. Intramuscular/supralevator - drain into the rectum via the internal sphincter
  4. Ischiorectal - drain to the skin

If there is recurrence - preform CT and do additional drain under anasthesia with antibiotics

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21
Q

Fistula - types

A
  1. Intersphincteric
  2. Trans-sphincteric
  3. Supra-sphincteric
  4. Extra-sphincteric

Remember that Goosall rule - applicable only for fistula that are smaller then 3cm

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22
Q

Fistula - treatment

A
  • Done under anasthesia, we need to recognize the both endings and clean all the way throguh
  • If small, and involves only a small part of the sphincter –> fistulotomy
  • Anterior fistula in women, fistula that involves more then 25% of the sphincter muscle –> Seton line
  • Newer therapy include biological glue
  • Endorectal flap can also be used
  • In addition - bandages, Sitz baths
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23
Q

Diverticulitis - diagnosis

A
  • LLQ pain, diarrhea/constipation, fever
  • Can present with sepsis
  • Can cause ileus
  • Test of choice is CT (allows also for diagnosing complications)
  • Barium enema and colonoscopy are contraindicated in acute episode
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24
Q

Uncomplicated diverticulitis - treatment

A
  • Antibiotics PO
  • For pain give mepiridine (avoid MO)
  • After the first episode - high fiber diet
    • 3 weeks after the event –> colonoscopy
  • After the second episode - consider sigmoidectomy
  • If immunocompromised - sigmoidectomy is indicated after the first episode
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25
Q

Diverticulitis complications

A
  1. Abcess
  2. Fistula
  3. Diffuse peritonitis
    • Hinchy classification:
      1. Localized abscess
      2. Pelvic abscess
      3. Purulent peritonitis
      4. Fecal peritonitis
  4. Obstruction
  5. Bleeding
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26
Q

Complicated diverticulitis - abcess

A
  • Mass in physical exam
  • Diagnosed with US/CT/MRI
  • If smaller then 2 cm –> antibiotics
  • If bigger –> antibiotics and percutaneous drainage
  • 6 weeks after - sigmoidectomy is indicated (elective)
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27
Q

Complicated diverticulitis - fistula

A
  • Most commonly with the urinary bladder (air in CT)
  • Treat with antibiotics
    • Colonoscopoy/cytoscopy is indicated to rule out malignancy
  • When recovers –> fistulectomy and sigmoidectomy
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28
Q

Complicated diverticulitis - peritonitis

A
  • Can be due:
    • Abcess spread - Hinchy 3 (purulent peritonitis)
    • Perforation and fecal spread - Hinchy 4 (fecal peritonitis)
  • Antibiotics IV and Hartmann’s procedure
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29
Q

Complicated diverticulitis - obstruction, bleeding

A
  1. Obstruction:
    • Small bowel (due to abcess) –> antibiotics and drainage
    • Sigmoid (rare, due to hypertrophy) –> surgical removal
  2. Bleeding:
    • Stabilze with blood infusions
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30
Q

Vovulus - management

A
  1. Sigmoid volvulus (70%)
    • Fluid resuscitation and de-compression with rectal tube
    • If fails, try to open with colonoscopy
    • If fails, Hartmann’s procedure
    • For all patinets, because there is high recurrence rate, elective sigmoidectomy is adivsed
  2. Cecocolic:
    • Treat with right hemicolectomy with primary anastamosis
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31
Q

Colon polyps - classification

A
  • Haggit classification:
    • Level 0: CIS
    • Level 1: carcinoma in the submucosa’s head
    • Level 2: carcinoma in the submucosa’s neck
    • Level 3: carcinoma in the submucosa’s stem
    • Level 4: carcinoma in the submucosa’s intestinal wall
  • Sessile polyps defined as level 4
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32
Q

Colon polyps - management

A
  • Pedunculated - removal in colonoscopy
  • Sessile - saline can be injected and then removed. In some cases there will be need for segmental resection
  • Malignant polyps at levels I-III –> removal, followed by colonoscopy 6 monthes later
  • Level 4/sessile/poorly differentiated polyp - needs more aggressive treatment
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33
Q

Colon carcinoma - patient management

A
  • Imaging gold standard - colonoscopy
    • Visualization of all the colon because in 3% of time there is synchronous tumor
  • For staging 12 lymph nodes are needed
  • Metastasis check-up: CXR, abdominal and plevic CT, liver function tests
  • CEA should be taken before intiating therapy
34
Q
A
35
Q

Post-operative management of CRC

A
  1. Stage 1: CEA follow up and colonoscopy
  2. Stage 2:
    • Chemotherapy when T4, poorly differentiated tumor, 12 nodes resected, perforation
    • CEA
    • Abdominal and thoracic CT (1 year)
  3. Stage 3: chemotherapy
  4. Stage 4:
    • If there is isolated metastasis to the liver/lung - it is possible to resected to metastatic lesions and the primary tumor
    • Chemotherapy/biologic therapy
36
Q

Rectal carcinoma - pre-operative assessment

A
  • Rigid proctosigmoidoscopy - assess the distance
  • MRI/EUS - depth of penetration
  • Colonoscopy - rule-out synchronous tumor
  • Cytoscopy - if there is suspicion for bladder invasion
37
Q

Transanal local excision

Rectal surgery

A
  • Removal of the tumor and the rectum wall distal to it
  • Done when:
    1. Diameter <4cm
    2. Involves <40% of the rectum wall
    3. Maximal distance of 6cm from the anal verge
    4. T1/T2 tumor
    5. Well differentiated tumor, without lymphatic or vascular invasion
38
Q

Abdominal perianal resection

Rectal surgery

A
  • Tumor in the bottom 1/3 of the rectum
  • Removal of the rectum and the anus, in abdominal and perianal approach.
    • Closure of the perineum and creating colostomy
  • Done when:
    1. Sphincter involvement
    2. Inability to create clear margins (2cm) without removing the anus
    3. Difficult pelvic anatomy
    4. Poor sphincter function before the surgery
39
Q

Low anterior resection

Rectal surgery

A
  • Tumor in the middle 1/3 of the rectum
  • Removal of the proximal rectum and the sigmoid, and creating anastamosis
  • If the anastamosis leaves less then 9cm –> J-pouch
  • If there is risk for the anastamosis (chemo./neo-adjuvant therapy) do colostomy
40
Q

Sphincter sparing APR with colonal anastamosis

Rectal surgery

A
  • For young patients, with functional sphincter
  • Includes:
    • Chemotherapy
    • Removal of the rectum with clean borders
    • Mucosectomy to the stump
    • Colonal anastamosis
41
Q

Complications of rectal surgeries

A
  • Anastamosis leak: occurs 4-7 days after the surgery
    • Diagnosed with physical examination and CT
    • Minor - treat with antibiotics
    • Major - treat with laparotomy
  • Impotence
  • Retrograde ejaculation
42
Q

Complications of ulcerative colitis

A
  1. Malignancy:
    • If cannot be ruled-out –> remove
    • Low grade dysplasia –> follow-up
    • High grade dysplasia –> total colectomy
  2. Fulminant colitis
    • Fast, NG tube, steroids, antibiotics
    • Lack of response in 48-72h –> total colectomy and ileostomy
  3. Toxic megacolon
  4. Bleeding
  5. Intraceability
  6. Strictures
43
Q

Indications for UC surgery

A
  1. Fulminant colitis with toxic megacolon
  2. Massive bleeding
  3. Lack of response to therapies
  4. Dysplasia/carcinoma
  5. In kids - FTT, malnutrition
  • Tendency for total colectomy
  • Total proctocolectomy + ileostomy
  • Total proctolectomy + IPAA
44
Q

Most common causes of colonic obstruction

A
  1. Malignancy (60%)
  2. Diverticulitis
  3. Volvulus
45
Q

Most common causes of SBO

A
  1. Adhesions
  2. Malignancies (peritoneal metastases)
  3. Hernias
  4. Crohn’s
  5. Intra-abdominal abcess
46
Q

Management of SBO

A
  1. Fluid resuscitation, antibiotics, catheter for measurment of urinary output
  2. NG tube - decreases the need for aspiration
  • This handels 70% of partial obstructions
  • Next choice is surgery
    • If there is full obstruction the patient should be operated within 12-24 hours
47
Q

Surgical management of SBO

A
  1. Terminal cancer - avoid as much as possible
    • If cannot be avoided –> bypass
  2. Adhesion separation
  3. Abcess –> drainage
  4. Crohn:
    • Acute - NG tube and steroids (remission)
    • Chronic - segmental resection or stricturoplasty
48
Q

Operative indications for SBO

  1. Laparoscopic
  2. Laparotomy
A
  1. Proximal obstruction, mild abdominal distention, partial obstruction with expected single strand obstruction
  2. Distal obstruction, complete obstruction, multiple adhesions, carcinomatosis
49
Q

Crohn’s disease indications for surgery

A
  1. Bowel obstruction:
    • No improvement with conservative treatment –> removal of the involved segment
    • Short strictures/operated before –> stricturoplasty
  2. Perforation with fistula/abcess:
    • Enteroenteric fistula only if symptomatic
    • Cutaneous fistula if there is no resolution with conservative treatment
    • Other organs –> removal of the intestine and closure of the deficit with omentum
  3. GI bleeding
  4. Urologic complications
  5. Lack of response to therapy
  6. Malignancy
    • In high grade dysplasia –> total colectomy
  7. Perianal disease
50
Q

Ranson criteria for gallstone pancreatitis

A
  • In the time of admission:
    • Age > 70
    • Glucose > 220
    • AST > 250
    • LDH > 400
    • WBC > 18,000
  • 48 hours after:
    • Hct decrease > 10%
    • Calcium < 8
    • BUN increase > 2
    • Base deficit > 5
    • Fluids > 4L
  • More then 3 accounts for severe pancreatitis
51
Q

Management of acute pancreatitis

A
  • Fluids and electrolyte balance
  • Pain management - MO is preferred
  • NG tube for symptomatic relief
  • Nutritional support (oral feeding is the best)
  • ERCP
    • In cases that there is no proof for choledocholithiasis –> EUS
  • Elective cholecystectomy (6 weeks after the acute episode)
52
Q

Late complications of pancreatitis

A
  1. Peripancreatic fluid collection
    • If there is suspicion for infection - antibiotics and drain
  2. Pancreatic necrosis
    • Diagnose with CT (air in the pancreas)
    • IV carbapenem
    • Surgical debriment
  3. Pancreatic pseudocyst
    • Diagnosed with CT/MRI
    • If asymptomatic –> follow-up (remission in 70%)
    • If symptomatic/suspected malignancy –> drain endoscoply/surgically/percutaneously
  4. Splenic vein thrombosis - splenectomy
  5. Pancreatic ascites
53
Q

Variceal bleeding - treatment

A
  1. Resuscitation and stabilization: 2 large bore needles and start with crystalloids.
    • Take blood for typing
    • NG tube and urinary catheter
  2. Medications:
    • Octerotide
    • Prophylactic antibiotics
  3. Endoscopy: done after the patient is stabilized.
    • Band ligation or sclerotherapy
    • After 2 tries, treatment failure is declared
  4. Balloon temponade: for non stable patients or when endoscopy fails
  5. TIPS
  6. Emergency operation: when everything else fails
    • Esophageal transection, portocaval shunt, splenorenal shunt
54
Q

Indications and contraindications for TIPS

A
  1. Indications:
    1. Failure of conservative treatment
    2. Briding before liver transplant
    3. Patients with poor liver function that are not candidates for transplant
    4. Non-compliance
  2. Contraindications:
    1. Right heart failure
    2. Polycystic liver
    3. Portal vein thrombosis
55
Q

Secondary prevention of esophageal bleeding

A
  • Long-acting nitrates, beta-blockers
  • Endoscopic treatment
  • TIPS
  • Portosystemic shunts
    • Non-selective/selective/partial
  • Non-shunt operations: closure of collaterals and variceal ablation
  • Transection and anastamosis of the esophagous
  • Extensive esophagogastric devascularization with esophageal transection and splenectomy
  • Splenectomy (only in portal vein thrombosis)
56
Q

Localization of GI bleeding

A
  • In massive bleeding always start from look at the upper GI
  • In massive bleeding even if the NG tube is negative for blood –> EGD is indicated
  • In slow lower GI bleeding - colonoscopy. If the colonoscopy is not diagnostic –> marked RBC’s
  • Obsecure bleeding –> capsule
57
Q

Causes of UGIB

A
  1. Peptic ulcer (most common)
  2. Mallory-Weiss tear
  3. Stress gastritis
  4. Dieulafoy’s lesion
  5. Malignancy
  6. Aortoenteric fistula
58
Q

Pepetic ulcer - risk for rebleeding

A
  • Forrest classification:
    1. Ia: active pulsatile bleeding
    2. Ib: active non-pulsatile
    3. IIa: non bleeding, visible vessel
    4. IIb: adherent clot
    5. IIc: ulcer with black spot
    6. III: clear, non-bleeding ulcer bed
59
Q

Peptic ulcer - management

A
  • Endoscopic: ablation/epinephrine injection/hemoclip
  • Drugs: PPI’s, treatment for HP, avoid drugs that induce ulcers
  • Surgical:
    • Duodenal - ligation of the ulcer and later, truncal vagotomy and pyloroplasty
    • Stomach - stop the bleeding and ligate.
60
Q

Peptic ulcer - indications for surgery

A
  1. Hemodynamic instability that requires more then 6U of blood transfusion
  2. Failure of endoscopic treatment
  3. Recurrent hemorrhage after initial stabilization
  4. Shock associated with recurrent hemorrhage
  5. Continuos slow bleeding that requires more then 3U per day
61
Q

LGIB - initial approach

A
  • All will start with EGD
  • Colonoscopy: for patient with mild-intermediate bleeding
  • Angiography: detects bleeding of 0.5-1ml/min
    • Allows treatment with embolization or vasopressin
  • RBC scan: detects bleeding of <0.1ml/min
62
Q

LGIB - diverticulitis

A
  • First try to stop in colonoscopy
  • If fails –> angiography
  • If fails –> segmentectomy

Same approach for angiodysplasia

63
Q

LGIB - mesenteric ischemia

A
  • Diagnosis with CT or CT-A
  • First - supportive with festing, antibiotics, cardiac support and treating the cause
  • In severe cases (leukocytosis, fever, fluid need, tachycardia, acidosis, peritonitis) –> segmental resection
64
Q

Overt obsecure GI hemorrhage

A
  1. Gastroscopy and colonoscopy (even if first time is negative)
  2. If negative GI imaging:
    1. RBC scan
    2. Angiography
    3. Meckel scan (recommended for intial work up in patients <30)
    4. Small bowel capsule
    5. Intra-operative endoscopy
65
Q

Surgical site infection

A
  • Up to 30 days from the operation, or up to a year with a foreign body
  • If doesnt involve organs –> open the stitches, debriment and let the wound heal/VAC
  • Cellulitis –> antibiotics PO
  • Organs involved/abcess –> drainage
  • Necrotizing faciitis –> debriment and antibiotics (ampicillin, gentamicin, clindamycin)
  • Chronic wound - doesnt resolve up to 90 days –> debriment and close with VAC or with flap
66
Q

Anastamosis leak

A
  • Usually 5-7 days after the surgery
  • Fever, abdominal pain, erythema in the area of the incision, leukocytosis
  • In the first step –> fluid resuscitation
  • Indications for repeat operation:
    • Diffuse peritonitis
    • Intraabdominal pain
    • Suspected intestinal ischemia
    • Evisceration
  • In non-stable patient - damage control with second look after 24-48 hours
  • In a stable patient - re-anastamosis
67
Q

Breast - indication for surgical biopsy

A
  1. In the FNA there is no cystic fluid or diagnosis of a solid mass
  2. Bloody fluid
  3. Fluid is drained, but the mass does not disappear
  4. Cystic reccurence in the same place
68
Q

Breast - diagnosis and assessment

A
  • Diagnosis is based on biopsy
  • Staging with CXR, blood work, CT, US and mammography of both breasts and axillae to rule out another lesion
  • PET-CT, bone scan, liver US - only in advanced diseases or in the presence of suspicious findings
  • MRI to asses the lesion and look for another lesions in the cases of lobular carcinoma
69
Q

Lumpectomy

A
  • When tumor can be removed with clear margin, and getting appropriate cosmetic result
  • 2-3 mm of clean borders
70
Q

Indications for mastectomy

A
  • Big tumor in relation to the breast
  • Diffuse clacifications
  • Cannot get clean margins
  • Contraindications for breast irradiation
71
Q

DCIS

A
  • Diffuse calcifications in mammography without a mass
  • Lumpectomy + irradiation + tamoxifen - have to lower rate of recurrence (10%) [only when ER positive]
72
Q

Locally advanced breast tumor

A
  • Needs to fulfill this 2 criteria:
    • One of the following: >5cm, skin/chest wall involvement, inflammatory, ulcerated
    • No signs of metastatic disease
  • Treat with neo-adjuvant chemotherapy + operation with dissection + irradiation
73
Q

Early bariatric complications

A
  1. Mortality
  2. Leak
    • Fever, abdominal pain, oral intolerance
    • Diagnose with CT
    • Stable –> percutaneous drain
    • Unstable/non-successful - exploration
  3. Marginal ulcer
    • Bleeding, melena, hematochezia
    • Dignosis with endoscopy
    • Treat with PPI’s
  4. Stenosis: endoscopic balloon dilation
  5. Stomal obstruction
    • Acute (edema) - NG tube decompression
    • Persistent - surgery
  6. SBO
  7. Biliopancreatic limb obstruction: percutaneous gastrostomy tube
  8. DVT/PE
  9. Pulmonary complications
  10. Nausea, vomiting, poor oral intake
74
Q

Indications for explorative laparotomy in blunt trauma

A
  1. Hemodynamic instability
  2. Free air
  3. Peritoneal signs
  4. Diaphragmatic rupture
  5. Postive CT
75
Q

Indications for intubation

A
  1. Person that cannot keep airway
  2. Aspiration protection
  3. Suspected impending obstruction
  4. GCS < 8 or, decrease in 3 points
76
Q

Indications for emergency thoractomy

A
  1. Cardiac arrest
  2. Massive hemothorax
  3. Cardiac temponade
  4. Big open wound of the rib cage
77
Q

Indications for explorative laparotomy in penetrating abdominal trauma

A
  1. Hemodynamic instability
  2. Peritoneal signs
  3. Evisceration
  4. Positive FAST/CT
  5. Gunshot wound
78
Q

Liver injury

A
  • Garding according to AAST if the patinet is stable and have to following criteria:
    1. Stable
    2. No other indications for laparotomy
    3. No peritoneal signs
  • Stable without contrast blush –> conservative
  • Contrast blsuh in stable patient –> embolization
  • Surgery –> packing/Pringle maneuver
79
Q

Spleen injury

A
  • Following criteria allows conservative management:
    1. Stable
    2. Rupture level 1-3
    3. No other indications for laparotomy
    4. Less then 2-4 blood infusions are needed in the first day
  • The surgical options are
    • Splenectomy
    • Partial splenectomy, covered with mesh for packing
    • Splenorraphy
80
Q
A
81
Q

Common causes for LGIB

A
  1. Diverticulitis
  2. Angiodysplasia
  3. Mesenteric ischemia
  4. IBD
  5. Malignancy

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