ABSITE Flashcards
Mechanism of Action:
-Pembrolizumab
-Cyclophosphamide
-Paclitaxel
-Ipilimumab
-Monoclonal Ab against PD1
-Alkylating agent of DNA
-Microtubule inhibitor
-CTLA-4 Inhibitor
Treatment for hydrofluoric acid burn
Topical calcium gluconate gel & copious irrigation
Treatment of perianal abscess with fistula tract in patient with Crohn’s colitis
surgical drainage
placement of noncutting seton
short course of antibiotics
Necrotizing Enterocolitis:
-presenting age
-medical management
-surgical management
-Within 1 month of birth
-NPO, IVF, transfuse prn, Abx. 50% resolve within 7-10 days
-Surgery: only with perforation. Perform resection with stoma as anastomotic leaks & stricture are common
Mechanism of action:
-Aztreonam
-Ceftriaxone
-Ciprofloxacin
-Metronidazole
-Tetracycline
-Erythromycin, Clindamycin, Linezolid
-Monobactam blocks cell wall synthesis. Resistant to beta-lactamase. Low PCN cross-reactivity.
-Beta-lactam. Blocks cell wall synthesis.
-Inhibit DNA gyrase & topoisomerase
-Creates free radicals
-Blocks 30S ribosome for protein synthesis
-Blocks 50S ribosome
Step up treatment of Shatzki’s ring
Dilation
Steroid injection before dilation
Endoscopic incision
Surgical intervention
These are mostly mucosal without muscular involvement.
Protective against Barretts esophagus
Always have associated hiatal hernia
Dopamine effect at doses:
Low
Med
High
LOW: Dopamine receptor
-renal, mesenteric, cerebal vasodilation
MED: Beta 1
-increased cardiac contractility & HR
HIGH: Alpha 1
-vasoconstriction
Top two causes of morbidity in the elderly:
- Falls
- MVC
Young male, fever, elevated WBC and ESR, “Onion peel” on xray. Dx?
Ewings sarcoma
MC: pelvic location
T: radiation to pelvis/spine, chemo and surgery for long bones
Treatment of CMV infection
Ganciclovir, Foscarnet, Cidofovir
Inhibit DNA polymerase
[valganciclovir is a po med]
Burn medication side effects:
-mafenide acetate
-silver nitrate
-silver sulfadiazine
-polymyxin B, neomycin, bacitracin
-mupirocin
-metabolic acidosis (moa: carbonic anhydrase inhibitor) penetrates eschar
-methemoglobinemia, hyponatremia, hypochloremia
-neutropenia (good for candida coverage though) cannot penetrate eschar
-nephrotoxicity
-(treats MRSA)
Caprini Risk Assessment
5 points
3 points
5 points: poly-trauma, >6hr surgery, stroke, hip/pelvis/leg fracture, spinal cord fx/ paraplegia, major LE arthroplasty
3 points: age >75, personal/family hx of VTE, on chemotherapy, thrombophilias (inherited or hep induced)
Caprini Risk Assessment
2 points
1 point
Women specific
2 points: age 60-74, surgery >45 min, diagnosis of cancer, bedbound, central line, plaster cast, minor arthroplasty
1point: age 40-59, minor surgery, BMI>30, COPD, MI, CHF, IBD, swollen legs/varicosities, hx of major surgery, medically bed bound
Women: pregnant, hx spont abortions, OCP/hormonal therapy
Pancreas exocrine function tested by secretin test:
Effect on volume, bicarb, & enzyme
-cancer
-chronic pancreatitis
-malnutrition
Cancer: volume low, bicarb/amylase normal
Chronic: volume nml, bicarb low, amylase nml
Malnutrition: volume nml, bicarb nml, amylase low
End stage pancreatitis: all low
Zollinger Ellison: volume high
62F abd pain and diarrhea
CT scan: mass in ileum with desmoplastic reaction tethering small bowel and mass in liver
Diagnosis and next steps in work up
Carcinoid tumor
Obtain urinary 5-HIAA
(chromogranin A elevated w/ PPI use)
Imaging: 68Ga-Dotatate PET CT
Grade: Ki-67
Sx control: octreotide or lanreotide
GI neuroendocrine tumors originate from what cells?
enterochromaffin cells (Kulchitski cells)
Pain medication with little histamine release
Fentanyl & Tramadol
Bleomycin side effect
Pulmonary toxicity = fibrosis
Decreased lung volume and decreased DLCO
Hypothermia
Mild, Moderate, Severe, Profound
MILD- shivering, mental changes, tachycardia
MODERATE- agitation, combative, pupil dilation, muscle spasm, slowing respirations, decreased PVR leads to Afib and hypotension
SEVERE- flaccid, comatose, EKG w/ prolong QRS, osborne waves, leads to V fib and arrest
PROFOUND- loss of vital signs, cardiac activity, EEG
Gastrintestinal Stromal Tumor (GIST)
Diagnosis and management
Express CD117
mutation in KIT proto-oncogene
If >2cm, segmentally resect w/ R0 margin without lymphadenectomy
Can consider imatinib to shrink if needed
Prognosis based on size and mitotic count
Barretts Esophagus
long segment vs short segment disease
short segment < 3cm
long segment >3cm
Barretts without dysplasia repeat endoscopy 3-5 years
Barretts Esophagus surveillance intervals
No dysplasia: 3-5 years
Low grade dysplasia: 6-12 months +/- endoscopic ablation
High grade dysplasia: endoscopic ablation, 3 months
Rectal cancer indication for neoadjuvant chemoradiation
T3, T4, or node positive
If shrinking can make it sphincter sparing
Rectal cancer indication for transanal excision
T1 (submucosa) cancer in mid/distal rectum with:
tumor <3cm in diameter
tumor <30% of bowel lumen circumference
mobile & nonfixed
need clear margins, favorable features, no nodes
aggressive postop screening
Workup for proximal rectal cancer
CT CAP, CEA, pelvic MRI
Workup for colon cancer
CTCAP, completion colonoscopy, CEA
Brooke Resuscitation formula
2 x kg x %TBSA = total resuscitation
First half in 8 hours, Second half in 16 hours.
For >15% burns
Absolute contraindications for BCT + radiation
radiation during pregnancy
diffuse appearing microcalcifications
positive pathologic margins
disease involving >1 quadrant
Absolute contraindications for PEG tube
active infection at skin site
hemodynamic instability, peritonitis, sepsis
peritoneal carcinomatosis
uncontrolled ascites
uncontrolled coagulopathy or inability to stop anticoagulation
severe malnutrition
completely obstructing mass
Surgical treatment of parathyroid carcinoma
parathyroidectomy, en bloc ipsilateral hemi-thyroidectomy
only take central nodes if nodes appear positive
Imaging radiation risk (low to high)
chest xray
mammogram
CT head
CT Angiogram
PET CT
Nuclear Med cardiac stress test
Indication for radioactive iodine after total thyroidectomy for papillary thyroid cancer
extrathyroidal extension
primary tumor > 4cm
bulky or >5+ lymph nodes
*follow with levothyroxine to avoid hypothyroid state
What disease is association with genetic mutations:
KRAS, SMAD, p53, CDKN2A
pancreatic adenocarcinoma
Colonoscopy surveillance guidelines with 1 first degree relative with colon cancer
Start at age 40 or ten years prior to diagnosis, repeat q5 years
Average risk is 45yo start w/ q10 years repeat
FFP components
vs.
Cryoprecipitate components
FFP: Factor V, 7, 9,10,11,12, vWF, fibrinogen, thrombin
Cryo: Factor 8, 13, vWF, fibrinogen
Ulcerative colitis screening colonoscopy recommendations
8 years after diagnosis
High risk: q1 year vs Low risk: 2-5 year
Random biopsies
Management of ulcerative colitis with invisible high grade dysplasia or multifocal low grade dysplasia
total proctocolectomy
WAGR syndrome
Wilms tumor
Aniridia
Genitourinary anomalies
Mental Retardation
Chromosome 11
Neurogenic shock parameters
PCWP nml
Cardiac output LOW
SVR LOW
Patient in cardiac arrest is hypothermic, what is the best active rewarming technique and warm to what temp?
Warm lavage of chest or abdomen
Warm to 90F (0C)
Epidemiology of pediatric intussusception
Between 3month and 3 years
MC: ileocolonic
Only 1/3 get abd pain, palpable mass, & currant jelly stool
Transplant medications MOA:
-Tacrolimus & Cyclosporine (maintenance)
-Sirolimus (alternate maintenance)
-MMF & Azathioprine (antiproliferatives)
-Calcineurin inhibitor, bind FK binding protein, inhibit T cell proliferation. SE: headache, gallstones, nephrotoxic
- binds FKBP, blocking mTOR, blocking cell proliferation
-Interfere w/ DNA synthesis (de novo purines & alkylate) SE: GI upset
Risk factors for gastric polyps:
H pylori and atrophic gastritis
MC: hyperplastic
Adenomatous can be tubular, tubulovillous, villous
Fundal polyps have no malignancy risk
Most common tumor of the appendix
Carcinoid
<2cm at tip, just appendectomy
>2cm, at base, high risk features, needs hemicolectomy
Colorectal surgery perioperative Abx regimen
SCIP recommendations
&
PCN allergy alternatives
Cefoxitan, Cefotetan, Ancef +Flagyl, Unasyn
PCN allergy:
Clinda or Vanc WITH
gentamicin, ciprofloxacin, levofloxacin, aztreonam
Treatment for metastatic carcinoid
Lanreotide (somatostatin analog) for sx relief
Tumor debulking +/- embolization
MC location for carcinoid: rectum, ileum, appendix
First sign of uncal herniation
anisocoria w/ normal motor exam
compression of CN III
Surgical speciality most likely to cause postoperative delirium
Cardiothoracic
Medical management of gastroparesis
Metoclopromide (Reglan) Dopamine receptor antagonist
Domperidone (motilium)
w/ small frequent low fat, low fiber diet
Abnormal gastric emptying study
> 60% at 2 hours
10% at 4 hours
Type I Error
vs
Type II Error
Type I: no statistically significant difference exists but you think there is one. The null hypothesis is rejected (incorrectly).
Type II: a difference exists but you do not detect it. The null hypothesis is accepted.
Primary lymphoid organs
Secondary lymphoid organs
1: liver, bone, thymus
2: lymph nodes, spleen, peyer patch, tonsil, adenoid
Principles of resection in colon cancer
total mesocolic resection w/ >12 lymph nodes
5cm margins
ligation of primary vessel at origin
Pancreatic fistula initial management
NPO, TPN, resuscitation
NPO, nasojejunal feedings, skin care
After 4-6 weeks ERCP w/ sphincterotomy and stent
High output is >200mL/day and indicate octreotide use
Most common tumor of the anterior mediastinum
Adult: Thymoma (Tx: resection)
Children: teratoma
Most common tumor of the posterior mediastinum
Neurogenic tumor
Signs of frostbite
1st degree
2nd degree
3rd degree
4th degreee
1st: no permanent damage, white plaque
2nd: to dermis, blisters
3rd: subcutaneous tissue, hemorrhagic blisters, eschar, may need skin graft or amp
4th: muscle/bone, mummification, necrosis, amputation
Superficial mass biopsy: spindle cells w/ CD34 staining
Dermatofibrosarcoma- high risk local recurrence.
Arises from fibroblasts.
Need core needle or incisional biopsy
Prognosis: grade, size, depth
Most common benign salivary gland tumor
Initial treatment
Treatment for recurrence
Pleomorphic adenoma
Treat w/ superficial parotidectomy
Treat recurrence with radiotherapy and observation if multifocal and poor surgical candidate.
Describe each type of fundoplication
Nissen
Dor/Toupet
Watson
Hill
Belsey Mark IV
-Full 360 degree wrap
-Anterior/Posterior 180-200 degree wrap
-Fix esophagus in abdomen and plicate fundus along left anteriolateral border
-Lesser gastric curve to R esophagus and pexy to median arcuate ligament
-transthoracic anterior fundoplication
Nigro protocol
Squamous Cell Carcinoma of the anus
5-flurouracil, mitomycin C, external beam radiation
Surveillance for recurrence or residual disease
10-30% need salvage APR
Patient w/ ITP undergoing elective splenectomy
what is desired preop platelet count
when to transfuse platelets if needed
> 50,000 platelets
Transfuse after ligation of splenic artery
Can give IVIG preop to boost platelets too
Screening test for Cushings syndrome
24 hour urine cortisol x2
if equivocal, can get nighttime salivary cortisol
Treatment of pituitary prolactinoma
Cabergoline- dopamine agonist therapy
or Bromocriptine
Repeat MRI in 6 months
Surgery reserved for failure or women wanting pregnancy
Most common tracheoesophageal fistula
Type C: prox esophageal atresia w/ distal TE fistula
Describe each treatment of Hirschprungs
Swenson
Soave
Dahumel
-resection w/ end to end anastomosis
-normal colon anastomosis to anus within aganglionic cuff
-colon brought through retrorectus w/ end to side anastomosis
T-test
ANOVA
Chi square
significant difference between means of 2 groups
significant difference between means of 3+ groups
is there difference in the expected frequency vs observed frequency in 1+ categories
Mechanism of action of ketamine
NMDA antagonist
Most common inherited hypercoagulable disorder and mechanism
Factor V Leiden
Factor V can no longer be inactivated by Protein C leading to hypercoagulable state
Hepatorenal syndrome
Dx by decreased GFR
Postassium lost, sodium held..?
Torsades de Pointes in stable patient
First line:
IV magnesium
if unstable, synchronized cardioversion
if V fib develops then defibrillate
Most common organism for
Early graft infection
Late graft infection
early: staph aureus
late: steph epidermidis
Pregnant patient with papillary thyroid cancer treatment
US surveillance w/ thyroidectomy post-partum
If medullary cancer, node positive, growing on US do thyroidectomy in second trimester
If anaplastic or compressive, do immediate thyroidectomy
Treatment of small bowel lymphoma
wide excision with lymph node dissection and adjuvant chemoradiation
Male patient w/ 1cm invasive ductal carcinoma ER+ HER2-, node negative, post surgical chemo treatment
Tamoxifen 5 years post mastectomy
Risk factors for peri-operative pulmonary complications
Age >50
active smoking
COPD/ asthma / OSA
interstitial lung disease
pulmonary hypertension
heart failure
current pulmonary infection
Albumin <3
Risk factors for gastric adenocarcinoma
cigarette smoking, alcohol
gastric surgery
gastric adenomatous polyps
nitrates
H.pylori and EBV infections
Pernicious anemia, Type A blood
Function of MHC class II molecules
Activate cytotoxic and helper T cells
Found on: dendritic, B-cells, monocytes, and APCs
Subtypes: DR, DP, DQ
Two chains, four domains
Reversal agents for DOAC
-Dabigatran (Pradaxa)
-Apixaban (Eliquis) & Rivaroxaban (Xeralto)
-Idarucizumab (Praxbind)
-Andexanet alfa (Andexxa)
Sodium Deficit Equation
Na deficit = (Desired Na- Patient Na) x TBW
TBW = Kg x gender factor
women: 0.5
men: 0.6
Prophylactic Abx for colon surgery options
Ancef + Flagyl
Cefoxitin
Unasyn
Cefotetan
Treatment of marginal ulcer after RNYGB
PPI, first. 90% effective.
surgical intervention, second
Contents of lactated ringers
NA: 130
K: 4
Cl: 109
Ca: 2.7
lactate:28
Primary indication for liver transplant
Hep C infection
Adrenocortical carcinoma biochemical workup
urine androgens
plasma metanephrines
aldosterone: renin ratio
dexamethasone supression test
What foramen does the vagus nerve exit
Jugular foramen
Spinal accessory nerve innervates:
SCM and trapezius
Motor function only: shoulder shrug
Exits jugular foramen
Treatment of condyloma accuminata by:
Patient
Clinician
Patient: imiquimod, podophyllotoxin, sinecatechin
Clinician: crytherapy, acetic acid, surgery, and laser
Second line: podophyllin resin and topical 5 fu
Treatment of esophageal cancer by T staging
Tis, T1a- endoscopic mucosal resection
T1b (submucosa), T2 (muscularis propria) - upfront esophagectomy
*unless high-risk, then give neoadjuvant
T3, T4 - neoadjuvant chemorads
High Risk: >3cm, LVI, poorly differentiated
Treatment of adrenal crisis
IV Hydrocortisone
(mineralocorticoid)
Branchial cleft cysts
MC: 2nd type. Anterior border of SCM. Near hypoglossal nerve and glossopharyngeal nerve
1st type- auditory canal to submandibular area near parotid/facial nerve
Benefit of splenectomy in patient with ITP
Removes source of anti-platelet antibodies and site of destruction
Risk factors for cholangiocarcinoma
primary sclerosing cholangitis
choledocal cysts
ulcerative colitis
biliary tract infections
Aldosterone:Renin ratio in aldosteronoma
> 30 confirms diagnosis
BP control w/ spironolactone before adrenalectomy
MC cause of pyogenic liver abscess
MC species
cholangitis
gram neg facultative anaerobes: Ecoli, Klebsiella, proteus with enterococcus species
Hypertrophic pyloric stenosis on US findings
thickness of >3-4 mm
length of >15-18 mm
Post transplant lymphoproliferative disorder
After chronic immunosupression
Epstein-Barr Virus
Prothrombin Complex Concentrate
3 factor
4 factor
3 factor: Factor II, IX, X
4 factor: Factor II,VII, IX, X
What is autonomic dysreflexia?
Effect in patient with spinal cord injury at or above T6.
Increased parasympathetic above level of injury
Increased sympathetic below level of injury
HTN, Bradycardia, Diaphoresis
Li-Fraumeni syndrome
TP53
Sarcoma, Phyllodes, adrenocortical cancer, brain tumors
Phyllodes of the breast management
1 cm margin and radiate
Function of mineralocoricoids
Promote sodium and water retention
Lower serum potassium concentration
by increasing sodium channels in distal convoluted tubule of the kidney
What are normal findings in a colonic transit study
<20% of radiopaque markers at 5 days after ingestion
MEN 1 findings
pituitary lesion, parathyroid lesion, pancreatic lesion (MC: gastrinoma)
MENIN gene mutation
Present with primary hyperparathyroidism
What class of bacteria is C. diff?
Anaerobic, gram positive bacilli
Treatment of rectocele
Identified by bulging of the rectum into the vagina.
Initial: High fiber diet, water intake, stool softener, pelvic floor PT
Surgical: transvaginal repair where vaginal muscularis and rectovaginal tissues are plicated
Infection with pneumocystis jiroveci:
Imaging findings
Treatment
Bilateral infiltrates in lung, can be disseminated
prophylaxis with bactrim
After total thyroidectomy, what do you check for thyroid hormone status
TSH
Treatment for unresectable hilar cholangiocarcinoma with no lymph node or metastatic spread
Neoadjuvant chemotherapy and liver transplant evaluation for R0 resection
What cells make TNF-alpha
Macrophage
*Infliximab is a TNF-alpha monoclonal Ab used in autoimmune disease like Crohns
What test is needed to diagnose GERD in a patient with typical symptoms and normal EGD
Esophageal pH monitoring
Structures located in each compartment of the lower leg
Anterior: anterior tibial artery and deep peroneal nerve
Deep Posterior: peroneal artery, posterior tibial arter
First line treatment of bleeding in uremic patients with platelet dysfunction
Desmopressin - vasopressin analog that causes vWF and Factor VIII release from vascular endotheliumF
Esophageal Cancer TNM staging
T1a - lamina propria or muscularis mucosa
T1b - submucosa
T2 - mucularis propria
T3 - adventitia
T4 - invades neighbor structure
N1 - 1-2 nodes
N2 - 3-6 nodes
N3 - >7 nodes
ASA Classification system
I - healthy
II - mild systemic disease
III - severe systemic disease
IV - severe systemic disease that is constant threat to life
v - moribund
Genitourinary injuries during surgery
MC: bladder
Ureter injuries occur at the pelvic brim, when gonadal and ovarian vessels cross, and lateral to the uterus
Most common bacteria in infected abdominal aortic aneurysm
1 is Staph Aureus
Treatment of dumping syndrome after Billroth II reconstruction
1st: diet modifications
2nd: somatostatin analogs
Early dumping :hyperosmolar load into duodenum
Late dumping: rapid glucose absorption leading to insulin surge
What order does bowel function return?
Small bowel, stomach, colon
When to use 21 gene Oncotype Dx
When to give adjuvant chemo
Hormone positive, HER2 negative, node negative
Recurrence score >26 gets adjuvant chemo
Breast cancer postoperative radiation
Not referencing BCT
Node positive, >5cm, positive pathologic margins
Treatment of pseudomyxoma peritonei
Resection of as much tumor as possible
-Debulk anything >2mm
Intraperitoneal chemotherapy
-HIPEC is best at 41C
Treatment of pseudomyxoma peritonei
Resection of as much tumor as possible
-Debulk anything >2mm
Intraperitoneal chemotherapy
-HIPEC is best at 41C
Soft tissue sarcoma
Staging
Best prognostic indicator
Stage IV criteria
TNM + G (mitosis, differentiation, necrosis)
Prognostics: histologic grade
Stage IV if regional lymph nodes or distant mets
What patients should not get PPI
severe osteoporosis
When do you I&D a breast abscess
Very large, overlying skin changes, loculations, recurrent
Treatment of squamous cell carcinoma of the anus
If < 2cm, no sphincter involvement, no nodes, can perform wide local excision
Nerves & innervations during axillary dissection
Medial pectoral nerve - pec major & minor muscles
Lateral pectoral nerve (branch of above) - pec major
Long thoracic nerve - serratus muscle
Thoracodorsal - latissimus dorsi
Maneuvers during IOC to remove duct stone
Flush with saline
Give 1.0 mg of glucagon
Flush again
( best for small 3-4mm stones)
Fogarty balloon catheter or stone retrieval basket for larger stones
QT prolonging medications
&
Treatment of Torsades
ABX: Macrolides (clarithromycin) & Fluoroquinolones
Antipsychotics: haldol,
Antidepressants: amitryptiline
Methadone, Zofran
Magnesium and supportive care
Melanoma findings requiring SLNB
ulceration or mitosis >1
upstages from T1a to T1b and needs SLNB
Also if lesion is >0.8mm thick needs SLNB
Melanoma T staging
T1 = <1mm
T2 = 1-2mm
T3= 2-4mm
T4 is >4mm in depth
Any node makes it stage 3.
How to perform repair of the trachea
single layer repair with interrupted absorbable suture
can buttress with strap muscle or SCM
trach should be placed elsewhere
Bacteria involved with lymphangitis
MC: Strep pyogenes
Cancers associated with Epstein Barr Virus
Burkett lymphoma
Hodgkin lymphoma
immunosuppresion related lymphoma
nasopharyngeal carcinoma
some gastric cancers
Merkel Cell Carcinoma
Treatment
Aggressive skin cancer in 65+ yo sun exposed areas
Neuroendocrine carcinoma (blue cells )
Stain for CK 20.
wide local excision with SLNB
followed by radiation
Mediastinal tumors
MC anterior: thymoma
MC posterior: neurogenic
Treatment of hemodynamic instability during pheochromocytoma removal
Hypertensive crisis - give nitroprusside infusion
Tachyarrhythmias - give iv esmolol or lidocaine
Hypotension- give fluids, blood product, phenylephrine
MC complication after liver transplant
bile leak 2/2 ischemia of donor biliary tree
eval for hepatic artery stenosis or thrombosis
What is the respiratory quotient?
CO2 produced / O2 consumed
> 1: overfeeding
1: normal
0.7: pure fat metabolism
Most common type of skin cancer
MC type of skin cancer after transplant
Basal cell carcinoma
tumor islands from the epidermis with peripheral palisading of nuclei and stromal retraction
*MC cancer of the upper lip
squamous cell carcinoma
*MC cancer of the lower lip
MOA of vasopressors
Norepinephrine
Phenylephrine
Vasopressin
Epinephrine
Dobutamine
Norepi: alpha and beta 1
Phenyl: pure alpha
Vaso: V1
Epi: alpha, beta1, beta2
Dobutamine: mostly beta
MENII
RET gene
2A: medullary thyroid, hyperparathyroidism, pheochromcytoma.
Thyroidectomy before age 5
2B: medullary thyroid, pheochromocytoma, mucosal neuromas, marfinoid habitus
Thyroidectomy before age 1
Pancreatic Endocrine Neoplasms location
Insulinoma: throughout pancreas
Glucagonoma: body and tail
- necrolytic migratory erythema, diabetes
VIPoma: tail
Gastrinoma: head in gastrinoma triangle
Somatostatinoma: head
Hepatic lesion management
Hemangioma- peripheral to central enhancement. Leave alone
Focal Nodular Hyperplasia- central scar, take up sulfur colloid. Leave alone.
Adenoma- hypervascular. Stop OCP or steroids. Resect due to malignant transformation potential.
Hepatitis C curative treatment
Sofosbuvir and Ribavirin
Wound healing timeline
4-5 days: collagen formation and wound contraction
Local anesthestic max dose
How much lidocaine is in 1% solution
Lido without 5; lido with 7
marcain without 3; marcaine with 5
1% lido has 10mg per 1 mL
Action of cytokines
IL 1
IL 4
IL 6
IL 8
TNF alpha
TGF beta
IFN gamma
IL1- proinflammatory marker
IL4- secretes IgE from B lymphocytes = anaphylaxis
matures B cells
IL 6- proinflammatory marker
IL8- migrate & activate neutrophils
TNF alpha - promotes inflammation, cachexia, TSS
TGF beta - decreases inflammation
IGN gamma - NK cells for immunity
ARDS criteria
Acute onset, non-cardiac, b/l infiltrates, hypoxia:
PaO2: FiO2 < 300 mild
PaO2: FiO2 < 200 mod
PaO2: FiO2 < 100 severe
BAL with high neutrophils and large protein count
Most common malignant salivary gland tumor
mucoepidermoid
Adenoid cystic carcinoma is slow and insidious and can have lung metastasis, spreads along nerves, poor prognosis.
Signs of acute elevation of ICP
bradycardia, hypertension, respiratory depression, double vision, pain, CN VI palsy (one cross eye)
Upper extremity nerve palsy
Ulnar nerve- cannot extend 4th and 5th digit
Median nerve - cant flex 2nd and 3rd digit or extend 1-3.
MC lymphoma type in patient with AIDS
B cell lymphoma
Indication to administer tetanus
If immunized within 10 years and small wound: none
If immunized within 5 years and large risk wound: none
otherwise, give tetanus toxoid
if not immunized and small wound: tetanus toxoid
if not immunized and high risk wound: tetanus toxid and tetanus immunoglobulin
Thrombectomy reveals tan, gelatinous myxoid material
Concern for atrial myxoma, needs TTE
Treatment for acute radiation proctitis
vs
chronic radiation proctitis (more often has bleeding)
Hydration and butyrate (SCFA) enemas
Sucralfate enemas
Describe the 3 types of vWF disease
Type I: low circulating vWF (can give desmopressin)
Type II: poor quality vWF, needs cryo
Type III: complete abscence of vWF, needs cryo
What is Stewart Treves syndrome
cutaneous angiosarcoma from chronic lymphedema
Highly malignant. Can occur 10 years after mastectomy.
Wide local excision.
Indication for stress dose steroids
> 20mg prednisone for > 3weeks see below:
Minor: AM meds.
local anesthesia, hernia repair, scopes
Mod: AM meds, 50 hydrocortisone + 25q8
hemicolectomy, open chole, LE revasc,
Major: AM meds, 100 hydrocortisone, 50q8 w/ taper
esophagogastrectomy, total proctocolectomy,
whipple, liver resection
[Any dose <3 weeks or <5 mg daily just AM meds]
Types of vagotomy
Truncal vagotomy - just above GE junction
Selective vagotomy- preserve nerves to liver, pancreas, small intestine
Highly selective vagotomy - spares nerves of Laterjet. Does not need drainage procedure.
Colonoscopy follow up intervals
Normal, low risk : 10 years
Personal hx of cancer, hx of adenomatous polyp, 1st degree relative w/ cancer: 5 years
large sessile polyp, removed piecemeal, malignant adenoma, multiple adenomas, or incomplete scope: repeat within 6 months
After cancer resection: H&P w/ CEA q3-6 months for 3 years, annual CTCAP for 3 years, colonoscopy within 1 year and then q5 years
Pagets disease of the anus
intractable pruritus
Needs full workup with Cscope, CTCAP to look for underlying malignancy
Tx: wide local excision or APR if underlying malignancy is found
Indications for CEA
Symptomatic disease >70%
Asymptomatic disease >80% (actually >60 on studies)
Indications to resect IPMN
All main duct
>30mm in size or growing
thickened wall or mural nodule
duct dilation >10mm
pancreatitis
intraductal mucin
change in duct caliber w. distal atrophy
GI peptides
Gastrin- from G cells, promotes histamine release from enterochromaffinlike cells which then promote acid release from parietal cells.
Somatostatin- from D cells, stops ECL and parietal cells.
Pancreatic cystic neoplasms
pseudocyst- benign, high amylase, low CEA
serous cystadenoma- benign, low amylase, low CEA
mucinous cystic neoplasm- low amylase, high CEA, distal pancreatectomy
IPMN- high CEA, high amylase
Pulm function testing for lobectomy
DLCO
FEV1
Predicted postop FEV1 needed for lobectomy
DLCO >60%
FEV1 >60
Predicted postop FEV1 >35-40%
Treatment of May-thurner syndrome
iliofemoral DVT
anticoagulation and endovascular thrombolysis and iliac vein stenting
Goal rate of urine output in burn resuscitation adults vs children
Adult 0.5-1ml/kg/hr
Kids 1-2mL/kg/hr
