Abdomen, Perioperative Care, Burns & Wounds Flashcards
Define an abdominal aortic aneurysm.
Localized weakness of blood vessel wall with dilation
Where are abdominal aortic aneurysms most commonly found?
Infrarenally
A 61 yo male patient comes in with abdominal/flank/back pain. He reports he smokes. On exam, you auscultate an abdominal bruit. What is the most likely diagnosis? How would you treat it?
Abdominal aortic aneurysm
Tx:
Immediate surgery if symptomatic/ruptured.
Beta-blockers
A patient comes in with hypotension. He reports he had a syncopal event prior to coming in. On exam, you notice a flank ecchymosis. What is the next best step in management and what is the most likely diagnosis?
Abdominal aortic aneurysm
If hemodynamically stable + symptomatic: Contrast CT
If hemodynamically unstable OR asymptomatic: bedside U/S
What patient population meets the requirement for an abdominal aortic aneurysm screening?
One time screening via abdominal U/S in men 65-75 yo who ever smoked
You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is greater than/equal to 5.5 cm. What is the next best step in managing this patient?
Immediate surgical repair–even if asymptomatic
You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that increased by 0.5 cm. What is the next best step in managing this patient?
Immediate surgical repair–even if asymptomatic
You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is >4.5 cm. What is the next best step in managing this patient?
Vascular surgeon referral
You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is 4-4.5 cm. What is the next best step in managing this patient?
Monitor by U/S q 6 months
A patient comes post abdominal surgery. She complains of abdominal pain and vomiting. On exam, you note abdominal distension and visible peristalsis. What is the most likely diagnosis and how would you treat it?
Small bowel obstruction
NPO, IVF, NG suction (bowel decompression)
If strangulated: surgery
A patient comes in with a history of Crohn disease. She reports abdominal pain and obstipation. What are you most likely to hear on auscultation of the abdomen?
Small bowel obstruction
High pitched tinkles
A patient comes in with a current incarcerated hernia. You determine she has a small bowel obstruction with obstipation being a huge giveaway. What would best help you to definitively determine this diagnosis?
Abdominal XR - multiple air-fluid levels in a step ladder appearance/string of pearls sign. Dilated bowel loops.
CT: most sensitive.
- transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast
A patient comes in with abdominal pain and a low-grade fever. They describe having changes in their bowel habits. PE is normal while labs show leukocytosis. What is the most likely diagnosis and how would you treat it.
Diverticulitis
Sigmoid colon MC area
Metronidazole + Cipro/Levofloxacin
A patient comes in with epigastric pain that is exacerbated by fatty and large meals. On exam, the patient demonstrates a positive Boas sign. What is this sign and what is the most likely diagnosis?
Acute cholecystitis
Boas sign: referred pain to the R shoulder/subscapular area
A patient comes in with nausea and fever. You note a positive Murphy’s sign and determine this patient has acute cholecystitis. What is the most likely causative microorganism? What is the initial test of choice and how would you treat it?
Microbe: E. coli
U/S - initial
HIDA scan - most accurate
Tx: NPO, IVF, Ceftriaxone + Metro –> cholecystectomy
A patient comes in complaining of epigastric gnawing pain. He notes he has been taking ASA for 3 months daily for his R knee pain. What is the most likely diagnosis and how would you treat it?
Peptic ulcer disease
Tx: Bismuth subsalicylate + Tetracycline + Metro + PPI x 14 days
A patient comes in with an upper GI bleed. On exam, you notice the patient lays extremely still. You note rebound tenderness, guarding and rigidity on palpation. What is your next best step in managing this patient?
Peptic ulcer disease
Upper endoscopy + bx - testing for H. pylori
What is a complication of portal vein hypertension?
Esophageal varices
A patient comes in with hematemesis, melena, and hematochezia. The patient notes he has alcohol use disorder. What is the next best step in managing this patient?
Esophageal varices
Upper endoscopy - both diagnostic and therapeutic
A patient comes in to the ED with a massive upper GI bleed. How would you best stabilize this patient?
Esophageal Varices
2 large bore IVs and IVF
Endoscopy
Octreotide
Nadolol/Propranolol (nonselective beta blockers) for prevention of a rebleed
A patient comes in with GERD. What is the pathology of this disease?
Incompetent lower esophageal sphincter
A patient comes in complaining of chest pain. She notes the pain increases when she is lying down. She also reports hoarseness. What is the most likely diagnosis and how would you treat it?
GERD
Tx:
- Lifestyle modifications: elevate head of bed, avoid laying down for 3 hours after eating, avoid fatty/spicy foods, chocolate, caffeine
- If <2 episodes/week (mild or intermittent) Antacids and H2 receptor antagonists
- If severe or moderate (>2 episodes/week): PPI
A patient comes in with dysphagia, odynophagia, weight loss and bleeding. What are you most concerned for? How would you diagnose it?
GERD
Concerned for Barrett’s esophagus –> esophageal adenocarcinoma
Clinical diagnosis. If confirmation needed: 24-hr ambulatory pH monitoring
A patient comes in with epigastric pain hat radiates to the back. It is worsened when she is laying down and is relieved when she leans forward. What signs should you look out for on your exam? Tx?
Acute pancreatitis
Cullen’s sign (periumbilical ecchymosis) + Grey Turner Sign (flank ecchymosis)
Tx: NPO, IVF
A patient comes in with acute pancreatitis. What are you looking for in labs/imaging?
Labs:
- Increased lipase>amylase
- Hypocalcemia
Imaging:
- abd CT
- XR: sentinel loop
What’s the sequence of preoperative care?
Diagnostic workup
Preoperative eval
Preoperative prep
What’s the sequence of postoperative care?
Postanesthetic observation
Intensive care
Intermediate care
Convalscent care
A patient comes in to the ED. You determine they require surgery ASAP. What are the most important questions you should ask them prior to them starting surgery?
AMPLE
A: allergies M: meds P: past medical history L: last meal E: events preceding the emergency
What would make someone have delayed wound healing, thus increasing their postsurgical risks?
use of corticosteroids
severe anemia
diabetes
smoking
decreased perfusion
What classification tool helped determine the correct anesthetic to be used prior to surgery?
ASA Physical Status Classification
1: patient is fit and healthy
2: patient has mild systemic disease
3: severe systemic disease, not incapacitating though
4: incapacitating disease that’s a constant threat to life
5: patient isn’t expected to live with/without surgery
E: emergency surgery
NOT USED TO PREDICT OPERATIVE RISK
What is a postop complication that presents within 24-48 hrs of postop?
Atelectasis
Pneumonia
What is a postop complication that presents within 48-72 hrs of postop?
UTI
What is the most common cause of fever 72 hrs postop?
Wound infection
When is a thrombotic event concerning postop?
72 hrs postop
How does COVID pathophysiologically enter the human body?
By attaching to the ACE2 receptor, found in alveoli, the intestines, kidney, and heart, which allows it to enter host cells.
What are the primary signs and symptoms of COVID19?
Cough
Fever
Dyspnea
Anosmia (loss of smell) & ageusia (loss of taste)
Pernio-like lesions (COVID toes)
Palmar erythema
Livedo reticularis - netlike pattern of reddish/blue skin discoloration
A patient presents with sxs of COVID19. You decide to test them and get some labs. What is the gold standard for diagnostic testing of COVID19? What lab anomalies should you expect?
Test: reverse-transcription PCR
Labs - low:
- low lymphocyte count
- low albumins
- low platelets
- low Hg
Labs - high:
- Lactate dehydrogenase
- Ferritin
- D-dimer
- ALT & AST
A patient presents with sxs of COVID19. You decide to get a CXR. What are you most likely to find on CXR? What about a chest CT?
CXR: Multifocal pneumonia
CT: ground glass opacities
A patient presents with sxs of COVID19. They are an obese 67 yo male with a history of smoking. He reports a history of CHF and TDM2. Which of his characteristics put him at risk for developing COVID19?
Not age: must be over 75 yo
Not CHF. The only cardio risk factor is HTN.
Not smoking - not listed in PPT.
Diabetes
Obesity!!
A patient presents with sxs of COVID19? You decide to treat them in the outpatient setting. How would you proceed?
Supportive care
DEF NO STEROIDS or ABX!!!
If high risk for disease progression: consider monoclonal antibodies (Bamlanivimab or casirivimab+imdevimab)
A patient presents with sxs of COVID19? You decide to treat them in the inpatient setting. How would you proceed?
If needing O2: Decadron
Monoclonal antibodies: Bamlanivimab or casirivimab+imdevimab
Anticoagulation/DVT prophylaxis
In what kinds of burns should the Rule of Nines be considered?
Partial thickness burns or deeper areas
Why are we more concerned about a geriatrics or pediatrics patient being burned that we would be for a young adult?
Kids and the elderly have a thinner dermal layer, so burns can be deeper than they appear
What is the Rule of Nines?
Head - 9% Each arm - 9% Anterior torso - 18% Posterior torso - 18% Anterior leg - 9% Posterior leg - 9% Genitalia - 1% Palm - 1%
A patient presents with a burn to her arm. It is erythematous without blistering. How would you categorize the burn? Tx?
1st degree/Superficial
Tx:
- lotion/emollients
- analgesia OTC
- oral hydration
Under what conditions MUST the burn center be contacted?
If the burn occurs on a child or over a joint
A patient presents with a burn to her arm. It is erythematous and wet with blistering and dermal loss. When you push against the burn, it blanches. The patient is in pain. How would you categorize the burn? Tx?
2nd degree/partial thickness
Tx:
- Face: ALWAYS bacitracin. Quickly switch to a facial lotion once healing is evident
- Other areas: silver gel/Xeroform/Petroleum gauze
Which treatments should not be used on a burn and why?
Silver sulfadiazine
Triple antibiotics
These will stain the skin
A patient comes in with an arm that appears pale in some areas and cherry red in others. It is dry, no blanching, and no pain. How would you categorize the burn?
3rd degree/full thickness
What is a 4th degree burn?
Full thickness burn (dry, pale, cherry red) + loss of body part
What category of burns require an immediate referral to a burn center?
Partial thickness burns >10%
Full thickness burns
List the order of normal wound healing
Hemostasis - coagulation
Inflammation - removal of debris - minor:24 hrs, major: 48 hrs
Proliferation - fill and cover
Remodeling/Maturation - scar - can take 2 years!! - increases tensile strength!
Scars increase __% per week and are __% stronger after 5 weeks.
10.
50.
How long does it take in weeks for a scar to reach full healing strength?
10 weeks (3 months)
Normally, a scar will be thickest __ weeks after the skin cells have closed and sealed the surface. Then they soften by __ back to normal in another 6 weeks (3 months after wounding) and 80% in 6 months. It takes a full year for the thickness to soften all the way.
6
50%
What are the most common etiologies of a small bowel obstruction?
- adhesions
- hernias
- Meckel’s diverticulum
- Mesenteric ischemia
A patient presents with a small bowel obstruction. What sxs would he present with?
Crampy abdominal pain
Abdominal distension
Vomiting (bilious)
Obstipation
You hear high-pitched tinkles on auscultation and visible peristalsis on PE. What is the most likely diagnosis and how would you tx it?
Small bowel obstruction
NPO, IVF, Bowel decompression
What is the most common etiology of a large bowel obstruction?
Fecal impaction
What is SIRS?
2 or more of the following:
- Temp >38C (100.4) or <36C
- RR >20 or PaCO2 <32
- HR >90
- WBC >12,000, <4,000, or >10% Bands
What is sepsis?
SIRS + source of infection
What is severe sepsis?
Evidence of organ dysfunction
- lactic acidosis >2
- Systolic BP <90
What is septic shock?
Severe sepsis + hypotension despite adequate fluid resuscitation (30mL/kg of crystalloid)
A patient comes in with sepsis. What are some common sources of infection?
- Pneumonia
- Intrabdominal
- Primary bacteremia - IV drug use, catheter
- Urinary
A patient comes in with sepsis. How do you treat? (4 steps)
- Blood cultures –> Early antibiotics (within 3 hours)
- Early crystalloids (30 mL/kg within first 3 hours)
- Initial and repeat lactic acid if >2 within the next hours
- Early vasopressors (NE)
A patient presents with sepsis. You treat with empiric antibiotics. What does this include?
Ceftriaxone/Cephipim
Pip/Tazo
Ampicillin/Sulbactam
Levofloxacin
NEVER VANCOMYCIN (this only treats gram positive)
What’s the difference between a direct and an indirect hernia?
Direct hernia - origin of the sac is MEDIAL to the inferior epigastric artery (direct message = DM))
Indirect hernia - origin of the sac is LATERAL to the inferior epigastric artery
- MC of hernia in both sexes, young kids, and young adults
This is often congenital due to a persistent patent process vaginalis.
indirect hernia
A patient comes in with swelling at the lower abdomen. It enlarges with valsalva. It is extremely painful and is irreducible. What is the most likely diagnosis?
Incarcerated indirect hernia
- key words: painful, irreducible
A patient comes appearing extremely toxic. They complain of fullness at the lower abdomen and severe painful bowel movements that make them refrain from defecating. What is the most likely diagnosis?
Strangulated indirect hernia - surgical emergency!
- key words: toxic, painful BM
A patient comes in with a painless growing lump in her midabdominal region. It’s been there for as long as she can remember but reports it’s getting bigger. What’s the most likely diagnosis and how would you treat it?
Umbilical hernia
This is congenital.
Usually resolve by 2 years of age
Surgery if persistent in 5+ years of age to avoid incarceration or strangulation
What medical problems must be addressed prior to a hernia repair, why?
Morbid obesity
DM
Smoking
Hernia recurrence
If any of these are present, this is considered a complex hernia.
Getting these taken care of help to reduce recurrence risks.
A patient comes in with a bulge at the superior portion of a vertical incision. He reports it is painful and notes obstipation. What is the next best step?
Incisional (ventral) hernia
CT/MRI
