Boblin's Review PPT Flashcards
A serious a potentially life-threatening condition that arises when a considerable mass of body tissue dies after an injury, infection or ischemia
gangrene
a collection of pus within a naturally existing anatomical cavity, like the lung pleura
Empyema
bacteria in the blood that often occurs with severe infections and may be life threatening
septicemia
A collection of pus in a newly formed cavity in any part of the body that is accompanied by swelling and inflammation
abscess
the presence of viable bacteria in the circulating blood that may or may not have any clinical significance.
bacteremia
A diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin
cellulitis
a surgical complication in which a wound breaks open along the surgical suture. Risk factors are age, DM, obesity, poor suture technique, trauma to wound s/p sx.
dehiscence.
What are the 3 most common primary sources of infection that result in sepsis?
1) lungs (50%)
2) abdomen
3) UTI
You estimate your patient will need surgery for an ectopic pregnancy within 36 hours. This would be an example of ________________ surgery.
(elective, urgent, or emergency)
urgent (life-saving sx to be done within 24-48 hours)
Any unanticipated event in a healthcare setting resulting in death or serious physical/psych injury to a person which is not related to the natural course of the patient’s illness. Ex: loss of limb, gross motor fxn, etc.
Sentinel Event
What are some of the most common Sentinel Events?
1) wrong pt/procedure/site
2) retention of medical equipment
3) medication error
4) fall
5) delayed treatment
6) suicide (no “fault” example)
Most surgeries are performed in the _________ position. Ex: abdominal, chest
Supine
Spinal procedures are typically done in the _________ position
Prone
Orthopedic procedures of the extremities are typically done in the _________ position
R/L lateral
OBGYN and urology procedures are typically done in the ___________position
Lithotomy
Colorectal and anorectal procedures are typically done in the ___________position
Jackknife
Neurosurgery and some ortho sx of neck and shoulders are typically performed in the ___________position
sitting
What are the pre-op labs that are generally ordered?
CBC, BMP, LFT, PT/PTT, UA, blood type (not all of these are ordered for asymptomatic patients without comorbidities)
In addition to labs, what other screening tests are commonly ordered pre-op?
CXR, EKG
What is one of the most common causes of delay for surgery?
Get your consent signed!
Your 55 year old WM patient has a h/o CHF and DM. You are going to perform a periumbilical hernia repair. When discussing his medications, you advise him that he should __________ his Metoprolol and _________ his Lasix.
a) hold, hold
b) hold, continue
c) continue, hold
d) continue, continue
c) continue BP meds and hold diuretics
Your 55 year old WM patient has a h/o CHF and DM. You are going to perform a periumbilical hernia repair. When discussing his medications, you advise him that he should __________ his Levemir (Long acting insulin) and _________ his Metformin.
a) hold, hold
b) reduce, continue
c) continue, continue
d) reduce, hold
b) reduce long acting insulin by 1/2 dose and hold oral DM medications on day of surgery
How many days before surgery should you stop ASA?
7 days
What is your pre-op advise for a surgical patient who is taking Coumadin for afib?
Convert from Coumadin therapy to Lovenox injections 4-5 days prior to surgery. (No anticoagulation on the day of)
What 4 factors predict pulmonary complications s/p sx?
1) smoking
2) lengthy sx
3) sx near diaphragm
4) current infection
Which of the following patients has the least risk for developing a blood clot following sx?
a) a patient with a prolonged intubation
b) a patient who underwent excision of cancer
c) a patient with PVD
d) a patient who underwent orthopedic surgery
e) a patient who had a spinal cord injury
c) a patient with PVD (I just made that one up, the rest are on the list)
If you are worried about the risk of hypoglycemia in your diabetic patient during surgery, what is your target range for glucose during the procedure?
120-180
When can diabetic patients resume their home medication regimen?
As soon as they can eat normally.
Studies show that smoking cessation for ___(#) _____ (days/weeks/months) prior to sx reduces risk for post op pulmonary infections
8 weeks
A 27 year old female is pregnant with twins. They do not have a cephalic presentation, so she and her OBGYN opt for a cesarean. She has no significant PMH. What classification would you give her on the ASA PS system?
ASA PS2 (pregnancy is considered a mild systemic disease when there are no complications)
A 64 year old man requires a coronary bypass (CABG) for a 96% occlusion. His blood pressure is poorly controlled, and he has unstable angina. What is his ASA PS score?
ASA PS4 (severe systemic disease that is a constant threat to life)
What are the 2 examples of procedures that carry a high risk of cardiac complications? (>5% chance)
Major vascular surgery (aorta)
Peripheral vascular surgery
Which of the following is NOT considered a low risk procedure. (Low cardiac risk)
a) prostate surgery
b) endoscopic procedure
c) breast surgery
d) ambulatory surgery
e) cataract surgery
a) prostate surgery is an intermediate risk
What 3 benefits come from mobilizing your patient the day after surgery?
1) reduce DVT risk
2) prevent muscle wasting
3) return bowel function
What are the 5 W’s? When are they most likely to occur?
Causes of post op fever
1) day 1–wind, atelectasis
2) day 3–water, UTI
3) day 5–walking, DVA
4) day 7–wound, infection
5) day 7–weird drugs, reaction
What is commonly a surgical problem that presents with RLQ pain and bowel obstruction?
IBD: Crohn’s or ulcerative colitis
What is Charcot’s Triad?
fever, jaundice, RUQ pain which indicate ascending cholangitis 2nd to gallstone
Fever, jaundice, RUQ pain, _________, and ________ make up _________’s Pentad for a diagnosis of Ascending Cholangitis
mental status change, and shock.
Reynold’s Pentad
Normal range for WBC
4.5-11 cell/uL
Normal range for PLT
150-450 cell/uL
Normal range for Hb
15g/dL
Normal range for Hct
45%
Normal range for Na
135-145 meq/L
Normal range for K
3.5-5.1 meq/L
Normal range for Cl
98-106meq/L
Normal range for CO2
22-29mmol/L
Normal range for BUN
8-20mg/dL
Normal range for Creat
0.6-1.2mg/dL
Normal range for Glucose
70-115mg/dL
Normal range for Ca
8.4-10.2mg/dL
Normal range for Mg
1.3-2.1meq/dL
Normal range for Phos
2.7-4.5mg/dL
What’s the most important thing you should do when evaluating a patient for coagulation risk?
Ask about prior h/o bleeding
The _______test is used to evaluate coagulation for Heparin. And the _________test is used to evaluate coagulation for Coumadin.
PTT and PT/INR
Which tumor marker is used to detect pancreatic cancer?
a) CEA
b) CA19-9
c) AFP
d) PSA
b) CA19-9
CEA–colon
AFP–testicular and hepatocellular
PSA–prostate
Your female patient weighs 100kg. How much fluid would you estimate is in her plasma?
apprx 6 L
Your male patient weighs 120kg. How much fluid would you estimate is in his interstitial fluid compartment?
apprx 17 L
What fluid compartment expands with Normal Saline IV?
Extracellular, which is why NS is great for replacing blood volume.
How many liters of 1/2NS would it take to replace 2.5 liters of blood loss?
15L (which is ridiculous, so you’d use Isotonic crystalloids….but I digress)
Administering fluids for resuscitation aims to correct existing deficits in blood volume and/or electrolytes. What are the goals of Maintenance Therapy?
1) Maintain water/electrolyte balance for patients who are NPO
2) Account for insensible losses
What is the best choice of fluid replacement for a patient who needs to expand plasma volume as quickly as possible?
Isotonic crystalloids like Lactated Ringers, NS, plasma-lyte)
Your adult patient has tachycardia, hypotension, decreased urine output and altered mental status. You want to provide fluid resuscitation. You give 2L Bolus of NS and do not see the improvement you’d hoped for, so you re-bolus with 2 more liters. And still nothing. What might be going on?
tension pneumo, cardiac tamponade, bleeding
What is in normal saline (and 1/2NS)?
Na and Cl
Explain the 4:2:1 rule.
Formula for Maintenance IVF
4cc/kg/hr for the 1st 10kg
2cc/kg/hr for the 2nd 10kg
1cc/kg/hr for each additional kg
How much maintenance IVF would you order for a 130kg patient?
170cc/hr
How much maintenance IVF would you order for a child weighing 18kg?
56cc/hr
What is the best indicator of adequate volume replacement?
urine output >0.5cc/kg/hr
A 70kg patient needs about ____mEq of Na and ____mEq of K daily
Na–140-210
K–35-75
Why might you want to switch a patient from NS to D5 1/2 NS +20mEq KCl?
glucose stimulates insulin release, resulting in amino acid uptake and protein synthesis, which aids healing
What common symptoms causes low bicarb? What would you use to replace it?
Diarrhea depletes HCO3 and K, replace with LR
If your patient has a free water deficit, the Sodium levels become very concentrated. Why is it important to correct this slowly (10mEq/day)?
Sudden hyponatremia carries the risk of cerebral edema, specifically central pontine myelinolysis where osmotic forces cause water to move into brain cells.
Your patient is 65kg. She had GI surgery yesterday and now you want to switch her from NS to D5 1/2NS +20mEqKCl. She cannot have any food or drink by mouth. How much of the new MIVF should you give her?
2.5 L of D5 1/2NS +20mEq daily will provide 194mEq of daily Na, which is within the 140-210 range. And 2.5L x 20mEq of K is 40mEq/daily which falls in the 35-75 range.
(65kg means 60cc/hr for the first 20kg, then an additional 45cc/hr = 105cc/hr = 2.5L/day.
What is the potential complication of hyperkalemia? (>5.5) What are some possible causes?
dysrhythmia! (life threatening). Caused by renal insufficiency***in bold. Also by certain drugs or rhabdomyolysis
What does hyperkalemia look like on an EKG?
peaked T waves
How do you stabilize the cardiac membrane to prevent dysrhythmias in the event of hyperkalemia?
Give calcium gluconate,
Then D50 + insulin to shift K intercellularly and also Kayexalate to chelate over the next several hours
What does Mg do? What can happen if it is low (<2)?
Cofactor for enzymatic rxns, regulates movement of calcium into smooth muscle cells. Low Mg can also cause arrhythmias. (Replace as needed via IV)
What is the most common post-op cause for hyponatremia?
SIADH (Na<135)
Again, what happens when your sodium is too low?
Osmotic forces shift water into brain cells = cerebral edema
How do you treat mild hyponatremia?
water restriction
How do you treat severe hyponatremia (AMS)?
hypertonic saline (3% NaCl), but do not correct more than half the deficit in 24 hours….risk central pontine myelinolysis
What is the classification of a surgical wound that has no evidence of active infection, but is not completely sterile like the Respiratory, GI, or GU tracts?
Clean-contaminated (class II)
What would a contaminated class III surgical wound look like?
Acute inflammation (no purulence). Traumatic open wound. GI leak. Secondary closure.
(Major failure in sterile technique, often traumatic or emergent)
What is the classification of a wound that was actively infected or necrotic? Could also be the perforation of an organ, or a delayed wound closure
Dirty, class IV
If a wound looks red, it is at the __________stage of healing. Pink = __________________
Yellow = _________________
Red = granulated Pink = epithelialized Yellow = dirty
Burns localized to the epidermis, like a sunburns are considered _______________ (burn depth)
1st degree
A non-painful burn that appears pale/yellow/mottled and dry has reached the ______________ and is termed __________________
Reached the reticular dermis, this is a deep 2nd degree burn.
A painless 3rd degree burn that has gone the full thickness through the epidermis and dermis looks like what?
hard, leathery eschar
What type of burn reaches the 2nd papillary dermis, is extremely painful, with a blistering wet appearance?
Superficial 2nd degree
4th degree burns involve what?
muscle, bone, connective tissue
What are the ABC’s of burns?
Airway (burns and inhalation injury). When in doubt, intubate due to likely inflammation/edema. Breathing (breath sounds, chest eschar) Circulation (start LR, monitor closely) Disability (GCS, prepare to intubate) Exposure (remove clothing)
***Quench burns ASAP, “prior to administration of O2”
What is the Parkland Formula?
4 x wt(kg) x TBSA% = mL to give per day. Give half the total in the first 8 hours, give the other half over the next 16 hours. (No colloid/albumin/proteins in first 24 hours b/c increase in interstitial edema)
Calculate IVF for a 64kg woman who sustained burns over 18% of her body.
4 x 64 x 18 = 4608mL/day. So 2.3L in the first 8 hours and then 2.3L over the last 16 hours.
What is the most common organism to infect a burn?
Pseudomonas
What is a special consideration specifically for electrical burns?
arrhythmia if heart was in the conduction path, get EKG.
What labs are important to monitor electrical burns?
CPK and urine myoglobin to monitor for rhabdomyolysis
True or False, Electrical burns often cause eschar and require escharotomies to relieve edema that may cause circulation difficulties or compartment syndrome.
True
True of False, the most significant injuries during electrical burns are with the epidermis.
False, deep tissue
After performing your ABC’s during a chemical burn, what is the next thing you should do?
Irrigate x 30 min
True or False, Alkalis can often be used to quench acidic burns and vise versa.
False. No. Don’t do it, causes worse damage.
When assessing a burn, what are the 6 P’s?
1) pain
2) pallor
3) pulselessness
4) paresthesias
5) paralysis
6) poikilothermia (inability to maintain body temp)
What is the basic tx for burns?
Irrigate/clean and debride, then cover with topical abx. Use grafts PRN
What are the topical antibiotics and sites of use for burns?
Sulfamylon-ears (good eschar penetration)
Bacitracin-face
Silvadene-trunk, neck, extremities (no penetration of eschar)
What are some common image-guided interventions?
1) Drainage
2) Bx
3) Vascular access
4) Enteral access
5) Vascular intervention
Breast abnormalities occurring in women <_____years old are likely to be benign (cystic, fibroadenomas)
30
What are the 3 methods for breast bx?
1) Fine needle aspiration
2) Core needle aspiration
3) Open excisional
Where are the primary sites of lymphatic drainage for the breast? (First to get spread of breast cancer)
Axilla. (responsible for 75% of drainage)
Level 1 is distal toward arm, drains to
Level 2 is around pec minor, drains to
Level 3 is superior to pec minor
Which histological type of breast cancer is pre-invasive and tends to progress to invasive cancer after 10 years? Involves microcalcifications
Ductal carcinoma in situ (DCIS)
Which histological type of breast cancer is really considered more of a marker for increased risk of developing ductal or lobular carcinoma?
Lobular Carcinoma in Situ (LCIS)
Your mmg report came back showing a BIRADS 3. What does this mean?
Probable benign findings, 6 mo f/u recommended
BIRADS 0?
Re-test needed
BIRADS 6?
Known biopsy proven malignancy
BIRADS1?
Negative findings (normal)
BIRADS 2?
Benign Findings
BIRADS 5?
Highly suggestive of malignancy
BIRADS 4?
Suspicious, recommend bx
A __________healing wound spontaneously closes from the edges
Secondary
A _________ healing wound is closed actively with direct approximation
Primary
A____________healing wound is closed actively after a delay
Tertiary
Cut or wound intentionally produced by cutting with a sharp instrument, produced with wound healing in mind.
incision
wound with torn skin
avulsion
wound or hole in the skin caused by sharp object such as nail, stick, etc. Should not close these wounds.
puncture
superficial loss of the epithelial tissue layer
abrasion
wound caused by sharp object producting edges that may be jagged, dirty, or bleeding
LAC
area of soft tissue swelling and hemorrhage without violation of the skin. Hematoma or bruise.
contusion
What stage? Intact skin, localized redness usually over bony prominence
Stage I pressure ulcer
What stage? full thickness tissue loss with exposed bone, tendon or muscle. Eschar may be present. Includes undermining and tunneling
Stage IV pressure ulcer
What stage? Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed. May also present as intact or ruptured serum filled blister.
Stage II pressure ulcer
What stage? full thickness tissue loss. SQ fat may be visible. Bone, tendon, and muscle are not exposed. May include undermining and tunneling.
Stage III pressure ulcer
What stage? full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar
unstageable
The ____________phase of wound healing in which the PNM’s (polymorphonuclear NEUTROPHILS) and macrophages are mainly involved
Inflammatory phase
FYI, macrophages are essential to release cytokines which attract helper cells and growth factors which are critical for healing
What type of cell is involved in wound depridement?
Macrophages rock.
The ____________phase of wound healing is characterized by the production of collagen in the wound. (Fibroblasts)
proliferative phase
The __________phase of wound healing is characterized by the maturation of collagen. Wound scar flattens and becomes less prominent, more supple)
Remodeling or Maturation phase.
