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Year 3 - Surgery > Breast, Vasc, Anaesthetics > Flashcards

Breast, Vasc, Anaesthetics Flashcards

1
Q

What is the gold standard for breast investigation?

A

Triple Assessment

  1. Clinical Hx and Ex
  2. Imaging (Mamogram/USS)
  3. Pathology
    A. FNAC
    B. VAC-B
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2
Q

Breast cancer:

  1. Surgical Sites
  2. Surgeries
A
  1. Breast excision
    • WLE (Wide local excision)
    • Mammoplasty/lumpectomy
    • Mastectomy
  2. Breast Reconstruction
    - Implant
    - LD
    - TRAM/DIEP
  3. Axilla
    • SLNB (Sentinel biopsy for staging)
    • Clearance (Therapeutic)
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3
Q

How is a sentinel biopsy carried out?

A

SLNB

Guided sample

- Peri-areolar Isotope

- Blue Dye infusion
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4
Q

WLE Pros and Cons

A

WLE

  1. Cosmetic procedure
  2. 10-20% need further surgery and radio
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5
Q

Mastectomy

  1. Decision making
  2. Follow up?
A

Mastectomy

  1. Decision making
    • Tumour:breast ratio
    • Multifactorial
  2. Follow-up
    • Chest wall radio
    • Management of seroma (from lymph)
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6
Q

Breast reconstruction - 4 options

A
  1. Implant only
  2. LD (Lat Dorsi)
  3. TRAM (Transverse rectus abdominus)
  4. DIEP (Deep inferior epigastric perforator)
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7
Q

Breast cancer radiotherapy

Options and indications

A

Breast cancer radio therapy

  1. Supraclavicular
  2. Breast
    • following BCS
  3. Axilla
    • following SLNB
  4. Chest Wall
  • Young patient
    • Advanced disease
    • Node positive
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8
Q

Breast cancer

-	Chemotherapy options
A

Breast cancer
- Chemotherapy options

  1. Taxanes and anthrocyclines
    - Paclitaxel/docetaxel
    - Epirubicin/Doxorubicin
  2. Combination
    • Cyclophosphamide
    • 5FU
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9
Q

Breast cancer

- Endocrine agents

A

Breast cancer
- Endocrine agents

  1. Tamoxifen
    - Pre-menopause
    - Receptor modulator
  2. Aromatase inhibitors
    - Post-menopause
    - Prevent androgen aromatisation
    • Letrozole (Femara)
    • Anastrozole (Arimidex)
    • Exemestane (Aromasin)
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10
Q

Breast Cancer

- Biological agents

A

Breast Cancer
- Biological agents

  1. Herceptin (Trastuzumab)
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11
Q

Local Anaesthesia Techniques

A

LA Options

  1. Central neuraxial
    • Spinal
      • Intrathecal/subarachnoid
    • Epidural
      • Between ligamentum flavum and dura mater
  2. Plexus blocks
  3. Nerve blocks
  4. Local anaesthesia
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12
Q

General Anaesthesia

- Pre-operative assessment moments

A

GA: Pre-operative steps

  1. Risk assess
  2. Consent
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13
Q

Triad of anaesthesia?

A

Triad of anaesthesia

  1. Analgesia
  2. Hypnosis
  3. Muscle relaxation/spinal reflexes
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14
Q

IV Induction Dx

A

IV Induction Dx

  1. Propofol
  2. Etodomite
  3. Thiopental sodium
  4. Ketamine
  5. Midazolam
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15
Q

Inhaled Inducers

A

Inhaled Inducers

  1. Sevoflurane
  2. Assistance from NOS
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16
Q

General anaesthesia

- Muscle relaxants

A

GA Relaxants

  1. Atracurium besilate
  2. Rocuronium bromide
  3. Suxamethonium chloride
    • Succinylcholine
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17
Q

GA Drugs

- Analgesia

A

GA Analgesia Dx

  1. Morphine
  2. Alfentanil
    95 min terminal HL
  3. Remifentanil
    - Highly potent
    - Rapid clearance 35min terminal HL
  4. Fentanyl
  5. Lidocaine
  6. Bupivacaine
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18
Q

Phases of anaesthesia

A

Anaesthesia phases

  1. Induction
  2. Maintenance
  3. Emergence
  4. Recovery
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19
Q

Definitive airway?

  1. Surgical Indication
  2. Types
A

Definitive airway

  1. Surgical Indications
    • Emergency surgery (on a full stomach)
    • Major or long surgery
  2. Types
    • Endotracheal tube
    • LMA (laryngeal mask airway)
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20
Q

Pain

- Painful situations

A

Incidences of pain

  1. Post-op
  2. Infected, inflamed, injured
  3. Chronic pain
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21
Q

Approach to managing pain? (RAT)

A

RAT approach

R ecognise
A ssess
T reat

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22
Q

Three pain binaries

A

Pain binaries

  1. Acute vs chronic
  2. Cancer vs non-cancer
  3. Nociception vs neuropathic
    • Tissue injury/illness (sharp and well-localised or visceral)
    • Sensational disease
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23
Q

Pain pathway

A

Pain pathway

  1. Injury
  2. Neurotransmission
    • Substance P
    • Serotonin
  3. Nerve synapses
    • A Delta
    • C fibres
  4. ST Tract
  5. Thalamus
    • Cortex
    • Limbic system
    • Brainstem (modulatory)
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24
Q

WHO Pain Ladder

A

WHO Pain Ladder

  1. Step 1
    • Paracetamol
    • Aspirin
    • NSAIDs
  2. Step 2
    • Mild opioids eg. Codeine
  3. Step 3
    • Strong opioids eg. Morphine
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25
Q

Paracetamol

  1. Dosing
  2. ADRs
A

Paracetamol

  1. Dose
    • 15mg/kg
  2. ADRs
    • Liver failure
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26
Q

NSAIDs

- ADRs

A

NSAID ADRs

  1. GI effects
  2. GI Bleeding
  3. Asthma bronchospasm
  4. Caution in renal failure
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27
Q

Morphine

- Routes used in different settings

A

Morphine

  1. Wards
    • Oral
  2. AE
    • Oral or IV
  3. Theatres
    • IV
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28
Q

Oramorph

  1. Regimen for dosing
  2. Doses
A

Oramorph

  1. Regimen for dosing
    • Age-based
  2. Dosing
    • 20-40: 0.3 mg/kg
    • 40-60: 0.2 mg/kg
    • 60+: 0.1 mg/kg
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29
Q

Tramadol

  1. Indication
  2. ADRs
A

Tramadol

  1. Indication
    • Comparable to codeine
  2. ADRs
    • Serotonin overdose in the elderly (delirium)
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30
Q

Morphine

- ADRs

A

Morphine ADRs

- N+V
- Delirium
- Constipation
- Itching
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31
Q

What class of drugs is good for muscle spasm?

A

Muscle spasm

- Benzodiazapines

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32
Q

Ketamine

  1. Indication
  2. Route/dose
A

Ketamine

  1. Indication
    • Induction
    • Short procedures
  2. Route/dose
    • IM 6.5-13 mg/kg for 12-25 minutes
    • IV 2mg/kg for 5-10 minutes
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33
Q

Amitriptyline

  1. Indications
  2. Dose
A

Amitriptyline

  1. Abdo pain
    - 5-10-30mg PO
  2. Neuropathic pain
    • 25-75mg PO
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34
Q

Gabapentin

  1. Four Indications
  2. Dosing
A

Gabapentin

  1. Focal seizures
    • 300mg OD - 1.2g TDS
  2. Neuropathic pain
    • 300mg OD - 1.2g TDS
  3. MS Oscillopsia or Spacisity
    • 300mg OD - 900mg TDS
  4. MND muscular symptoms
    • 300mg OD - 900mg TDS
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35
Q

Pregabalin

  1. Indications
  2. Doses
A

Pregabalin

  1. Neuropathic pain (peripheral and central)
    • 150mg in 2-3 divided doses
    • 600mg in 2-3 divided doses
  2. Focal seizures
    • 25mg BD to 600mg in 2-3 DDs
  3. GAD
    • 150mg in 203 divided doses
    • 600 mg in 2-3 divided doses
36
Q

Buscopan (Hyoscine butylbromide)

  1. Indications
  2. Doses
A
  1. GI or GU smooth muscle spasm
    • PO 20mg qds
  2. IBS
    • 10mg tds to 20mg qds
  3. Acute spasm
    • IM 20mg 30 minutes apart, max 100mg/day
  4. Palliative care
    • Respiratory secretions
    • Bowel colic
37
Q

TENS Machine mechanism?

A

Transcutaneous Electrical Nerve Stimulation

38
Q

Fascia Iliaca Block

- Effects

A

Fascia Iliaca Block

- Sciatic
- Femoral
- Obturator
39
Q

NEW Score

  1. Specialist alternatives
  2. Scales 1 and 2?
A

NEW Score

  1. Specialist alternatives
    • MEWS (Maternal)
    • PEWS (Paediatric)
  2. Scales 1 and 2?
    • CO2 retention
    • COPD Patients
40
Q

A-E Assessment

- Airway

A

Airway assessment

  1. Talking
  2. Strider/wheeze
  3. O2 Sats
  4. Secretions
41
Q

A-E Assessment

- Breathing

A

Breathing assessment

  1. Look
    • RR
  2. Feel
    • Expansion
    • Trachea
  3. Listen
    • Sounds
42
Q

A-E Assessment

- Disability

A

Disability assessment (A-E)

  1. AVPU
  2. Pupils
  3. Temperature
  4. DEF glucose
43
Q

Emergency Assessment

- Named protocol

A

ATLS

- Advanced Trauma Life Support
- American college of surgeons
44
Q

Sepsis definition?

A

Sepsis (WHO)

  1. Life-threatening organ dysfunction
  2. Dysregulated host response to infection
45
Q

SOFA Score

  1. Definition
  2. Components
A

SOFA Score
- Sequential Organ Failure Assessment

  1. PaO2 and FiO2
  2. Platelets
  3. GCS
  4. Bilirubin
  5. MAP
  6. Creatinine
46
Q

Septic shock

  1. Definition
  2. Treatment
A

Septic shock

  1. MAP < 70
  2. Norepinephrine (gold standard)
47
Q

SIRS

  1. Definition
  2. Components
A

SIRS

  1. Severe inflamatory response syndrome
  2. Components
    i) RR
    ii) HR
    iii) Temp
    iv) WCC
  3. Severe Sepsis
    v) Suspicion of infection
    vi) Lactic acidosis
    vii) Severe sepsis
  4. Multiple organ failure syndrome
    viii) Multiple organ failure
48
Q

Sepsis 6

A

Sepsis Six

  1. Take
    • Culture
    • Urine
    • Lactate
  2. Give
    • Oxygen
    • Fluid
    • ABx within 1 hour
49
Q

ABGs

  1. Indications
  2. Results
A

ABGs

  1. Indications
    • Suspected sepsis - Lactate
    • Electrolytes
  2. Results
    • pH, pCO2, pO2, HCO3
    • Sats
    • Electrolytes
50
Q

The Leg

- Five indications for vascular scans

A

Scans of the Leg

  1. Stenosis/occlusion
  2. Varicose veins
  3. DVT
  4. Vein mapping
  5. Vein marking for bypass
51
Q

The Abdomen

- Vascular scans

A

Vascular scans of abdomen

  1. AAA screen
  2. EVAR follow-up
52
Q

Vascular scanning

- Arm indications

A

Vascular scans of arm

  1. Thoracic outlet
  2. Stenosis
  3. Emboli/occlusions
  4. DVT
  5. Vein mapping/marking for bypass
53
Q

Head and neck

- Vascular scans

A

Head and neck scans

  1. Carotid artery disease
  2. TCD monitoring
    - Trans-cranial doppler
54
Q

Vascular USS

- Six pathways

A

Vascular USS Pathways

  1. Lower limb ischaemia
  2. ABPI measurements
  3. Varicose veins
  4. DVT
  5. AAA
  6. Carotid disease (TIA/Stroke pathway)
55
Q

Lower limb ischaemia

  1. Hx
  2. Ex
  3. Mx
A

Lower limb ischaemia

Hx

  1. Intermittent claudication
  2. Rest pain
  3. Cold

Ex

  1. Weak peripheral pulses
  2. Slow cap refill
  3. Ulceration/gangrene

Mx.

  1. Exercise/lifestyle
  2. BMT (best medical)
  3. Surgery
56
Q

Lower limb ischaemia

-	Surgical mx
A

Lower limb ischaemia surgery

  1. Angioplasty (+/- stenting)
  2. Endarterectomy (CFA)
  3. Bypass grafting
  4. Amputation
57
Q

Varicose vein

  1. Hx
  2. Ex
  3. Mx
A

Varicose vein

Hx

  1. Visible varicosities
  2. Ulceration
  3. Skin changes (haemosiderin)

Ex

  1. Venous eczema
  2. Thrombophlebitis
  3. Lipodermatosclerosis

Mx

  1. Hosiery/compression
  2. EVLT (endovenous laser therapy)
  3. Vein stripping and avulsions
58
Q

Thrombophlebitis

  1. Definition
  2. Presentation
  3. Management stratification
A

Thrombophlebitis

  1. Clot in superficial veins
  2. Presents with dolor, calor, rubor, tumor
  3. Management

<5cm: Treat conservatively

  • NSAIDs
  • LMWH with risk factors

> 5cm: Treat as DVT

  • Anticoagulate
  • Sapheno-femoral ligation if CI’d
59
Q

AAA

  1. Hx
  2. Mx
A

AAA

Hx

  1. Asymptomatic
  2. Back pain
  3. Pulsatile abdominal mass >3cm
  4. FHx
  5. Trashed foot (embolic occlusion)

Mx

  1. USS surveillance till 5.5 cm
  2. EVAR (endovascular aneurysm repair)
  3. Open repair
60
Q

Carotid disease

  1. Hx
  2. Mx
A

Carotid disease

Hx & Ex

  1. Bruit
  2. TIA/Stroke
  3. Amaurosis fugax

Mx

  1. Trans-cranial doppler monitoring
  2. Carotid endarterectomy
61
Q

ABPI

  1. Indication
  2. Calculation
A

ABPI

  1. Severity of lower limb vascular disease
  2. Ankle systolic pressure / brachial systolic pressure
    >1.0 - no diease
    0.8-0.5 - mild disease
    <0.5 - Severe or critical disease
62
Q

Spinal anaesthesia

-	Layers crossed
A

Spinal anaesthesia layers

  1. Skin
  2. Subcutaneous and connective tissue
  3. Supraspinous ligament
  4. Interspinous ligament
  5. Ligamentum flavum
  6. Posterior epidural space
  7. Dura mater
  8. CSF
63
Q

Breast disease

- B-Coding

A

Breast Needle Core Biopsy

B1 Normal
B2 Benign

B3a Uncertain
B3b Without epithelial atypia
B3c With epithelial atypia

B4 Suspicious for malignancy

B5a Malignant IS
B5b Invasive
B5c Non-assessable

64
Q

Breast pain

- Assessment

A

Benign lump pain

  1. Pattern
    - Cyclical
    - Non-cyclical
65
Q

Breast lumps

- Benign examples

A

Benign breast lumps

20yo Fibroadenomas
45yo Fibrocystic change
45yo Lipomas
55yo Cysts

66
Q

Fibrocystic change

  1. Age
  2. Presentation
A

Fibrocystic change

  1. Peak at 45
    >20% of pre-menopausal
  2. Discomfort
  3. Cysts
67
Q

Fibroadenoma

  1. Age
  2. Presentation
  3. Management
A

Fibroadenoma

  1. Peak at 20
  2. Benign lump
    - Can be multiple
  3. Excise if large/growing
68
Q

Phyllodes tumour

  1. Histology
  2. Presentation
  3. Management
A

Phyllodes Tumour

  1. Fibro-epithelial (stromal)
    - Mostly benign
    - Borderline/malignant
  2. 40-50 yo
    - Firm and painless lump
    - Weeks to months
    - Existing fibroadenoma
  3. Surgery
    - Lumpectomy
    - WLE
    - Chemo if malignant
69
Q

Breast Cyst

  1. Histology
  2. Treatment
A

Breast cyst

  1. Benign
    Usually multiple
  2. Aspirate
    - Usually recurs
70
Q

Duct ectasia

  1. Pathophysiology
  2. Presentation
  3. Management
A

Duct ectasia

  1. Duct blockage
  2. Discharge
    - Bloody/non-bloody
    - Lump behind nipple
    - Nipple inversion/
  3. Warm compress/shower
    - Support bra
    - Gentle massage
71
Q

Breast malignancy

- Presentation

A

Breast malignancy

  1. 1/9 women
  2. Lump, often painless
  3. Change
    - Colour
    - Shape
    - Skin pitting
  4. Discharge
    - Can be bloody
72
Q

Breast lump

- Investigation

A

Breast investigation
- Triple Assessment

  1. Examine
  2. Image
    - Mammogram (45+)
    - USS (<45)
  3. FNA
    - Cytology
    - NCB
    • VACB (vacuum)
    • Stereotactic
      - Excision Biopsy
73
Q

Breast malignancy

- Findings  1. Imaging 2. Histology 3. S&G
A

Breast cancer findings

  1. Imaging
    - Irregularity
    - Spiculation (lil spikes)
    - Micro-calcification
  2. Histology
    - 80% Ductal
    - 10% Lobular
    - Tubular, papillary, medullary
  3. S&G
    - Malignant
    - Grade B3-B5
    - Receptor status
74
Q

Breast cancer

- Surgical Mx

A

Breast cancer mx

  1. Breast
    - Lumpectomy
    - WLE
    - Mastectomy
  2. Axilla
    - SLNB
    - Clearance
75
Q

Breast cancer

- Adjuvant therapy classes

A

Breast cancer adjuvants

    • DXT (Deep x-ray)
  2. Chemo
    - Anthracycline-taxane
    - Combination
  3. Biologic
    - Herceptin/Trastuzumab
    - Perjeta/Pertuzumab
  4. Endocrine
    Tamoxifen/Nolvadex
  5. Bisphosphonates
    - Zoledronic acid
    - Sodium clodronate
76
Q

ERAS

- Features

A

Enhanced recover after surgery

  1. Pre: Optimisation
    - Physiology
    - Smoking, fasting, carbs
    - Inform about post
  2. Intra: Reduced stress
    - Short acting agents
    - Epidural
    - Minimally invasive
    - Avoid drains and NGT
  3. Post: Early mobilisation
    - Pain and nausea
    - Physio
    - Oral intake (carb drinks)
    - Stop IVs
    - Remove drains
77
Q

Surgical haemorrhage

- Classifications

A

Surgical haemorrhage

  1. Primary
    - Starts in surgery
  2. Reactive
    - End of surgery
    - Early post-op
  3. Secondary
    - Usually infection
    - 24hrs+ post op
78
Q

Urinary retention

- Post-op causes

A

Post-op urinary retention

  1. Drugs
    - Opioids
    - Intrathecal
    - Anti-cholinergic
  2. Pain
    - Sympathetic sphincter
  3. Psychogenic
    - Environment
79
Q

Post-op urinary retention

- Mx

A

Post-op urinary retention

Conservative

  1. Privacy + running taps
  2. Ambulation
  3. Analgesia
  4. Catheterise
    - IV Gent
  5. TWOC
    - Or send with catheter
80
Q

Atelectasis

- Management

A

Atelectasis

  1. Analgesia
    - Aid cough
  2. Chest physio
81
Q

Wound infection

- Organisms

A

Wound infections

  1. SA
  2. Coliforms
82
Q

Wound dehiscence

- Mx

A

Wound dehiscence mx

  1. Sterile soaked gauze
  2. IV ABx
    - Cef + met
  3. Opioid
  4. Theatre
    - Wash
    - Debride
    - Deep sutures
  5. VAC dressing
83
Q

Appendicectomy

- Complications

A

Appie Complications

  1. Abscess
  2. Fallopian tube trauma
  3. Right hemi
    - Carcinoid
    - Necrosis
84
Q

Ileus

- Presentation

A

Ileus Presentation

  1. Distension
  2. Constipation
  3. Vomiting
  4. Absent BS
85
Q

Ileus

- Mx

A

Ileus Mx

  1. IV fluids + NGT
  2. TPN if long
86
Q

Arterial surgery

- Risks

A

Arterial surgery risks

  1. Thrombosis/embolism
  2. Anastomotic leak
  3. Graft infection
87
Q

Breast surgery

- Complications

A

Breast surgery complications

  1. Lymphoedema
  2. Skin necrosis
  3. Seroma

Year 3 - Surgery (7 decks)

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