AS Flashcards
Management Hyperpyrexia
Dantrolene and cooling
Inidcations for emergency thoracotomy
> 1.5L drained on insertion
> 200ml/hr for 2-4 hours
Definition of flail chest
Fractures of 2 or more adjacent ribs
With 2 or more fractures on each rib
Mx: epidural and PCA –> need good respiratory effots
if conservative fails –> PPV
Kussmaul’s sign
Increased JVP on inspiration
=cardiac tamponade
Pulsus paradoxus
Systolic blood pressure FALLS >/10 mmHg on inspiration
=cardiac tamponade
Beck’s triad
Hypotension
Raised JVP
Muffled heart sounds
=cardiac tamponade
low voltage QRS ± electrical alternans
= cardiac tamponade
+ve diagnostic peritoneal lavage
> 100,000 RBCs/mm3,
Bile/intestinal contents
Anterior urethral injury
Spongy urethra: penile + bulbar
Saddle injuries / instrumentation
Posterior urethral injury
Membranous injuries
Pelvic fractures
High-ridingm prostate
Blood at meatus
Indications for intubation with head injury
GCS <8
PaO2 <9 on RA
PaO2 <13 on O2
PaCO2 >6
Spontaneous hyperventilation –> PaCO2 <4
Management of achalasia
Med: CCBs, nitrates
Int: botox injection, endoscopic balloon dilatation
Surg: Heller’s cardiomyotomy (open or lap)
Plummer Vinson
Severe iron deficiency anaemia
- -> hyperkeratinisation of upper 3rd oesophagus
- -> web formation
Pre-malignant: 20% risk of Squamous cell carcinoma
Management oesophageal cancer
Neo-adjuvant chemo: 5-FU + cisplatin
Ivor-lewis: 2 stage. abominal and R thoracotomy
McKeown: 3 stage, abdominal + R thorocotomy + L neck
Indications for Nissen fundoplication
Severe symptoms
AND
Refractory to medical therapy
AND
Confirmed reflux
Antrectomy with vagotomy
Billroth 1: directly to duodenum
Billroth 2 /Polya: to small bowel loop with duodenal
stump oversewn
Metabolic complications of by-pass
Dumping syndrome
- Abdo distension, flushing, n/v, fainting, sweating
- Early: osmotic hypovolaemia
- Late: reactive hypoglycaemia
Blind loop syndrome → malabsorption, diarrhoea
-Overgrowth of bacteria in duodenal stump
Vitamin deficiency
- ↓ parietal cells → B12 deficiency
- Bypassing proximal SB → Fe + folate deficiency
- Osteoporosis
Wt. loss: malabsorption of ↓ calories intake
Indications for surgical intervention in upper GI bleeding
Re-bleeding
Bleeding despite transfusing 6u
Uncontrollable bleeding at endoscopy
Initial Rockall score ≥3, or final >6.
Ramstedt pyloromyotomy
Divide down to mucosa
Mx for pyloric stenosis
Blood group A
Risk factor for GASTRIC CANCER
- Atrophic gastritis (→ intestinal metaplasia)
- Pernicious anaemia / AI gastritis
- H. pylori
- Diet: ↑ nitrates – smoked, pickled, salted (↑ Japan)
- Nitrates → carcinogenic nitrosamines in GIT
- Smoking
- Blood group A
- Low SEC
- Familial: E. cadherin abnormality
- Partial gastrectomy
Sister Mary Joseph nodule
Transcoelmic spread to umbilicus from gastric carcinoma
OGD: well-demarcated spherical mass c¯ central
punctum
= GIST
Management of GIST
Medical: Imatinib (tyrosine kinase inhibitor)
Surgical: resection
Rigler’s triad
= gallstone ileus
Pneumobiliia
Small bowel obstruction
Gallstone in RLQ
Tc pertechnecate scan +ve in 70%
Meckel’s diverticulum
Detects gastric mucosa
Carcinoid syndrome
=by-pass of first pass metabolims
= Live rmetastasis
Usually appendix primary
Increased serotonin:
- Flushing: paroxysmal, upper body ± wheals
- Intestinal: diarrhoea
- Valve fibrosis: tricuspid regurg and pulmonary stenosis
- whEEze: bronchoconstriction
- Hepatic involvement: bypassed 1st pass metabolism
- Tryptophan deficiency → pellagra (3Ds)
Tx carcinoic crisis
High dose octreotide
Cope sign
Flexion + internal rotation of R hip → pain
= Appendix lying close to obturator internus
Psoas sign
Extension of hip –> pain
= Retrocaecal appendicitis
Appendix mass
=complication of appeniditis
Omentum and small bowel stuck to appendix
Mx:
- NBM and ABx
- Interval appendectomy
- 6 week colonoscopy to r/o malignancy
If doesn’t resolve –> appendix abscess
- -> percutaneous driange
- -> ultimate management in failed cases –> R hemicolectomy
Components of Truelove and Witts
Grading UC
Motions PR bleed Temp HR Hb ESR (<30, >30)
Day 3 Acute UC
On day 3: stool freq >8 or CRP >45
Predicts 85% chance of needing a colectomy during
the admission
Emergency medical Mx:
-ciclosporin, infliximab or visilizumab (anti-T cell)
UC 1st lien management
Induction:
sulfasalazine or mesalazine AND prednisolone
Mainteance:
sulfasalazine or mesalazine
2nd line: azathioprine or mercaptopurine
Emergency surgery for UC
Total / Sub-total colectomy + End-ileosotmy
+/- mucous fistula
3 months later:
a) Completion proctectomy + Ileal-pouch anal anastomosis (IPAA) or end ileostomy
b) Ileorectal anastomosis (IRA)
Maintaining remission Crohns
1st line: azathioprine or mercaptopurine
2nd: methotrexate
(Note difference, no 5-ASAs)
Induction Crohn’s
1st line
- Ileocaecal: budesonide
- Colitis: sulfasalazine
2nd line: prednisolone (tapering)
3rd line: methotrexate
4th line: infliximab or adalimumab
Hinchey Grading
Diverticulitis perforation
I- IV
III and IV –> surgeyr
-indicated by peritonitis (III: purlent, IV: faecal)
Gardeners
TODE
Thyroid tumours
Osteomas of the mandible, skull and long bones
Dental abnormalities: supernumerary teeth
Epidermal cysts
5q21`
= APC gene –> FAP
Autosomal dominant
Lynch 1
HNPCC
AD
Lynch 1 = right sided CRC
Lynch 2
HNPCC
AD
Lynch 2 = colorectal cancer
+endometrial
+prostate
+breast
Diagnosis of HNPCC
3, 2, 1 rule
≥3 family members over 2 generations c¯ one <50yrs
STK11 gene
Peutz-Jeghers syndrome
AD
Mucosal hyperpigmentation
CRC, pancreatic, breast, lung, ovaries, uterus
Peutz-Jeghers
AD - STK11 gene
Mucocutaneous hyper-pigmentation
Multiple GI hamartomatou spolyps
–> intussusception
–> haemorrhage
Cancer:
- CRC
- Pancreatic
- Breast
- Ovarian
- Uterine
- Lung
Cowden syndrome
AD
Macrocephaly + skin stigmata
Intetsinal hamartomas
Increased risk of extra-intestinal cancers
Goodalll’s Rule
Posterior fistula drian –> 6
Anterior fisture drain radially
Anal lymph drainage
Above dentate line → internal iliac nodes
Below dentate line → inguinal nodes
HPV oncogenic strains
16, 18,
31, 33
McEvedy Approach
High approach
Inguinal
EMERGENCY in obstruction
–> allows inspection for ischaemic bowel
Lockwood Approach
= LOW
Elective
Low incision over hernia c¯ herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt.)
Classification of malignant melanoma
Superficial Spreading: 80%
- Irregular boarders, colour variation
- Commonest in Caucasians
- Grow slowly, metastasise late = better prognosis
Lentigo Maligna Melanoma
- Often elderly pts.
- Face or scalp
Acral Lentiginous
- Asians/blacks
- Palms, soles, subungual (c¯ Hutchinson’s sign)
Nodular Melanoma
- All sites
- Younger age, new lesion
- Invade deeply and metastasis early = poor prog
Amelanotic
-Atypical appearance → delayed Dx
Malignant parotid tumours
Malignant (CN7 palsy + fast growing)
1st: Mucoepidermoid
2nd: Adenoid cystic
Transverse rectus abdominis myocutaneous flap
Gold-standard
Pedicled (inf. epigastric A.)
Or free: attached to internal thoracic A
CI if poor circulation: smokers, obese, PVD, DM
Risk of abdominal hernia
Latissimus dorsi myocutaneou sflap
Pedicled flap: skin, fat, muscle and blood supply
Supplied by thoracodorsal A. via subscapular A.
Usually used c¯ an implant
Definiton of chronic limb ischaemia
Ankle artery pressure <50mmHg
Toe <30mmHg (diabetics)
And either:
- Persistent rest pain requiring analgesia for ≥2wks
- Ulceration or gangrene
Critical limb ischaemia
Rest pain
- Especially @ night
- Usually felt in the foot
- Pt. hangs foot out of bed
- Due to ↓ CO and loss of gravity help
Ulceration
Gangrene
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
Leriche’s syndrome
Buerger’s angle
≥90: normal
20-30: ischaemia
<20: severe ischaemia
Fontaine classification
A: asymptomatic
B: intermittenet claudication
A = >200m
B = <200M
C: rest pain
D: ulceration or gangrene
Doppler waveforms
Normal: triphasic
Mild stenosis: biphasic
Severe stenosis: monophasic
ABPI values
Asymptomatic / Fontaine 1 = 0.8-0.9
Claudication / Fontaine 2 = 0.6-0.8
Rest pain / Fontaine 3 = 0.3-0.6
Ulceration and gangrene / Fontaine 4 = <0.3
Exercise test important:
ABPI measured before and after: 20% ↓ is sig
Indicationds for end-arterectomy
Symptomatic
+ >70% occlusion = major indication
>50% occlusion if low operative risk <75 years age
Asymptomatic
≥60% benefit if low risk
Aneurysm monitoring
UK Small Aneurysm Trial suggested that AAA <5.5cm
in maximum diameter can be monitored by US (/CT)
<4cm: yearly monitoring
4-5.5cm: 6 monthly monitoring
Indications for aortic aneurysm intervention
Symptomatic (back pain = imminent rupture)
Diameter >5.5cm
Rapidly expanding: >1cm/yr
Causing complications: e.g. emboli
