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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
Paracetamol 1. Dosing 2. ADRs
Paracetamol 1. Dose - 15mg/kg 2. ADRs - Liver failure
26
NSAIDs | - ADRs
NSAID ADRs 1. GI effects 2. GI Bleeding 3. Asthma bronchospasm 4. Caution in renal failure
27
Morphine | - Routes used in different settings
Morphine 1. Wards - Oral 2. AE - Oral or IV 3. Theatres - IV
28
Oramorph 1. Regimen for dosing 2. Doses
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
29
Tramadol 1. Indication 2. ADRs
Tramadol 1. Indication - Comparable to codeine 2. ADRs - Serotonin overdose in the elderly (delirium)
30
Morphine | - ADRs
Morphine ADRs - N+V - Delirium - Constipation - Itching
31
What class of drugs is good for muscle spasm?
Muscle spasm | - Benzodiazapines
32
Ketamine 1. Indication 2. Route/dose
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
33
Amitriptyline 1. Indications 2. Dose
Amitriptyline 1. Abdo pain - 5-10-30mg PO 2. Neuropathic pain - 25-75mg PO
34
Gabapentin 1. Four Indications 2. Dosing
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
35
Pregabalin 1. Indications 2. Doses
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
Buscopan (Hyoscine butylbromide) 1. Indications 2. Doses
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
TENS Machine mechanism?
Transcutaneous Electrical Nerve Stimulation
38
Fascia Iliaca Block | - Effects
Fascia Iliaca Block - Sciatic - Femoral - Obturator
39
NEW Score 1. Specialist alternatives 2. Scales 1 and 2?
NEW Score 1. Specialist alternatives - MEWS (Maternal) - PEWS (Paediatric) 2. Scales 1 and 2? - CO2 retention - COPD Patients
40
A-E Assessment | - Airway
Airway assessment 1. Talking 2. Strider/wheeze 3. O2 Sats 4. Secretions
41
A-E Assessment | - Breathing
Breathing assessment 1. Look - RR 2. Feel - Expansion - Trachea 3. Listen - Sounds
42
A-E Assessment | - Disability
Disability assessment (A-E) 1. AVPU 2. Pupils 3. Temperature 4. DEF glucose
43
Emergency Assessment | - Named protocol
ATLS - Advanced Trauma Life Support - American college of surgeons
44
Sepsis definition?
Sepsis (WHO) 1. Life-threatening organ dysfunction 2. Dysregulated host response to infection
45
SOFA Score 1. Definition 2. Components
SOFA Score - Sequential Organ Failure Assessment 1. PaO2 and FiO2 2. Platelets 3. GCS 4. Bilirubin 5. MAP 6. Creatinine
46
Septic shock 1. Definition 2. Treatment
Septic shock 1. MAP < 70 2. Norepinephrine (gold standard)
47
SIRS 1. Definition 2. Components
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
Sepsis 6
Sepsis Six 1. Take - Culture - Urine - Lactate 2. Give - Oxygen - Fluid - ABx within 1 hour
49
ABGs 1. Indications 2. Results
ABGs 1. Indications - Suspected sepsis - Lactate - Electrolytes 2. Results - pH, pCO2, pO2, HCO3 - Sats - Electrolytes
50
The Leg | - Five indications for vascular scans
Scans of the Leg 1. Stenosis/occlusion 2. Varicose veins 3. DVT 4. Vein mapping 5. Vein marking for bypass
51
The Abdomen | - Vascular scans
Vascular scans of abdomen 1. AAA screen 2. EVAR follow-up
52
Vascular scanning | - Arm indications
Vascular scans of arm 1. Thoracic outlet 2. Stenosis 3. Emboli/occlusions 4. DVT 5. Vein mapping/marking for bypass
53
Head and neck | - Vascular scans
Head and neck scans 1. Carotid artery disease 2. TCD monitoring - Trans-cranial doppler
54
Vascular USS | - Six pathways
Vascular USS Pathways 1. Lower limb ischaemia 2. ABPI measurements 3. Varicose veins 4. DVT 5. AAA 6. Carotid disease (TIA/Stroke pathway)
55
Lower limb ischaemia 1. Hx 2. Ex 3. Mx
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
Lower limb ischaemia - Surgical mx
Lower limb ischaemia surgery 1. Angioplasty (+/- stenting) 2. Endarterectomy (CFA) 3. Bypass grafting 4. Amputation
57
Varicose vein 1. Hx 2. Ex 3. Mx
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
Thrombophlebitis 1. Definition 2. Presentation 3. Management stratification
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
AAA 1. Hx 2. Mx
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
Carotid disease 1. Hx 2. Mx
Carotid disease Hx & Ex 1. Bruit 2. TIA/Stroke 3. Amaurosis fugax Mx 1. Trans-cranial doppler monitoring 2. Carotid endarterectomy
61
ABPI 1. Indication 2. Calculation
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
Spinal anaesthesia - Layers crossed
Spinal anaesthesia layers 1. Skin 2. Subcutaneous and connective tissue 3. Supraspinous ligament 3. Interspinous ligament 4. Ligamentum flavum 5. Posterior epidural space 6. Dura mater 7. CSF
63
Breast disease | - B-Coding
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
Breast pain | - Assessment
Benign lump pain 1. Pattern - Cyclical - Non-cyclical
65
Breast lumps | - Benign examples
Benign breast lumps 20yo Fibroadenomas 45yo Fibrocystic change 45yo Lipomas 55yo Cysts
66
Fibrocystic change 1. Age 2. Presentation
Fibrocystic change 1. Peak at 45 >20% of pre-menopausal 2. Discomfort 3. Cysts
67
Fibroadenoma 1. Age 2. Presentation 3. Management
Fibroadenoma 1. Peak at 20 2. Benign lump - Can be multiple 3. Excise if large/growing
68
Phyllodes tumour 1. Histology 2. Presentation 3. Management
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
Breast Cyst 1. Histology 2. Treatment
Breast cyst 1. Benign Usually multiple 2. Aspirate - Usually recurs
70
Duct ectasia 1. Pathophysiology 2. Presentation 3. Management
Duct ectasia 1. Duct blockage 2. Discharge - Bloody/non-bloody - Lump behind nipple - Nipple inversion/ 3. Warm compress/shower - Support bra - Gentle massage
71
Breast malignancy | - Presentation
Breast malignancy 1. 1/9 women 2. Lump, often painless 3. Change - Colour - Shape - Skin pitting 4. Discharge - Can be bloody
72
Breast lump | - Investigation
Breast investigation - Triple Assessment 1. Examine 2. Image - Mammogram (45+) - USS (<45) 3. FNA - Cytology - NCB - VACB (vacuum) - Stereotactic - Excision Biopsy
73
Breast malignancy - Findings 1. Imaging 2. Histology 3. S&G
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
Breast cancer | - Surgical Mx
Breast cancer mx 1. Breast - Lumpectomy - WLE - Mastectomy 2. Axilla - SLNB - Clearance
75
Breast cancer | - Adjuvant therapy classes
Breast cancer adjuvants 1. - 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
ERAS | - Features
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
Surgical haemorrhage | - Classifications
Surgical haemorrhage 1. Primary - Starts in surgery 2. Reactive - End of surgery - Early post-op 3. Secondary - Usually infection - 24hrs+ post op
78
Urinary retention | - Post-op causes
Post-op urinary retention 1. Drugs - Opioids - Intrathecal - Anti-cholinergic 2. Pain - Sympathetic sphincter 3. Psychogenic - Environment
79
Post-op urinary retention | - Mx
Post-op urinary retention Conservative 1. Privacy + running taps 2. Ambulation 3. Analgesia 4. Catheterise - IV Gent 5. TWOC - Or send with catheter
80
Atelectasis | - Management
Atelectasis 1. Analgesia - Aid cough 2. Chest physio
81
Wound infection | - Organisms
Wound infections 1. SA 2. Coliforms
82
Wound dehiscence | - Mx
Wound dehiscence mx 1. Sterile soaked gauze 2. IV ABx - Cef + met 3. Opioid 4. Theatre - Wash - Debride - Deep sutures 5. VAC dressing
83
Appendicectomy | - Complications
Appie Complications 1. Abscess 2. Fallopian tube trauma 3. Right hemi - Carcinoid - Necrosis
84
Ileus | - Presentation
Ileus Presentation 1. Distension 2. Constipation 3. Vomiting 4. Absent BS
85
Ileus | - Mx
Ileus Mx 1. IV fluids + NGT 2. TPN if long
86
Arterial surgery | - Risks
Arterial surgery risks 1. Thrombosis/embolism 2. Anastomotic leak 3. Graft infection
87
Breast surgery | - Complications
Breast surgery complications 1. Lymphoedema 2. Skin necrosis 3. Seroma

Year 3 - Surgery (7 decks)

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