BRG Flashcards
Describe options for penetrating Zone II neck injury
I - observe with CTA, laryngoscopy, esophagosocopy and bronchoscopy.
II - Can explore in OR with full evaluation of carotid sheath, trachea and esophagus if you are there.
Operation for penetrating injury to Carotid.
Approach like a CEA
Have blood, shunt and bovine pericardium available.
- prep and drape with head turned.
- incision along the medial border of the SCM
- Obtain proximal and distal control of Carotid (ICE) and IJ
- open hematoma if present
- resect portion of injured carotid
- repair defect with bovine pericardium
- explore remaining structures in the neck beyond the injury.
Options for blunt carotid injury
If there is flow ith a grade IV or V injury, fix it. if no flow leave it alone. aspirin for low grade injuries.
what is reason to remove a carotid body tumor?
It will grow and develop neurologic symptoms. (minimal chance of malignancy)
Preop imaging and procedure for carotid body tumor?
Get CTA as a roadmap. consult IR for perioperative embolization.
Carotid body tumor resection?
Have a shunt and BP monitoring/meds available.
- Approach like a CEA getting control.
- clip the feeding vessel (look at yout CTA) coming off the external carotid.
- disect the tumor our at the subadventitial level of the vessel never entering the lumen if possible.
- close.
Patient stays for 24 hours of bedrest and BP monitoring.
recurrent GIST
resect all (if possible) add gleevec regardless of size/mitoses for recurrence.
Indications for resection of pancreatic cystic masses (IPMN)?
Any side branch >3cm
Any main duct.
How do you fix an Aorto-caval fistula?
Try calling Vascular for an EVAR stent.
If forced open then:
Approach like an AAA, also gaining proximal and distal control of the IVC.
Open the Aorta and “fix the fistula from the inside of the aorta”
Sew in tube graft.
FAP (multiple polyps seen on c-scope)
Send to genetics for APC
review colonoscopy to check rectum to plan the operation
Get CT scan to plan operation
upper GI.
Take to OR for pouch v ileorectal anastomosis depending on rectal sparing.
If your anastomosis doesn’t reach: high ligation of the IMA/SMA.
One medical treatment for desmoids?
Suldinac
What happens after resection for rectal cancer that got neoadjuvant?
Needs more Folfox.
see them every three months for physical exam and a CEA level.
CT scan and c-scope in one year.
Unstable patient with GSW to left colon: two options?
Give a colostomy and close.
Leave open and come back for primary anastomosis once stable.
Patient presents with anal condyloma with HIV
Make sure to check CD4 count, viral load and medical compliance.
Biopsy any irregularities as this may be a prompt for SCC of the anus (then go to that scenario)
One way to describe Cattel Brasch?
Lifting the root of the mesentery to the left shoulder to expose the IVC/Aorta.
Board answer for bad zone 3 pelvic vascular trauma. (illiac/aorta)
Ligate bleeding vessels as a damage control procedure.
Come back in <24 hours (hopefully stablilize) to perform an ax-bifem.
Infrarenal IVC injury? what can you do
can ligate.
Keep patients LE in ACE wraps to control the edema until they develop collaterals.
Suprarenal IVC injury?
cannot ligate, guerenteed renal failure.
If you can control then fix by harvesting a saphenous vein or possibly internal iliac. Fillet the harvested veinto create a rectangle, wrap that in a spiral around an appropriate sized chest tube. Sew the spiral together and use that as an interposition graft.
Cutuffs for when to perform a CEA.
Symptomatic
Asymptomatic
Symptomatic 50%
Asymptomatic 80%
Steps of a CEA
Make sure shunt and bovine pericardial patch are available.
- Incision along the anterior border of SCM
- carry down thru platysma, entering the carotid sheath protecting the vagus.
- Circumpherentially dissect the patient away from the carotid to expose the bifurcation
- divide the facial vein.
- identify disease free areas to place clamps.
- Heparinize with 80 U Heparin/kg.
- Place clamps I.C.E. (Internal, Common, External.)
- Open the area of disease longitudinally
- Place shunt, flashing out clots.
- Remove the plaque sharply taking care to leave a smooth surface.
- begin to close defect with bovine pericardium, initially over the shunt, then replacing clamps (ICE) completing anastomosis with a flash to celar potential emboli (ECI for clamps)
- Close
Two indications for carotid stent?
- recurrence of plaque after CEA
2. previous neck radiation.
Stroke in PACU after CEA?
Ultrasound to confirm blockage and reexplore neck.
Increasing hematoma in PACU after CEA?
Take back to OR for reexploration.
Venous stasis ulcer (medial malleolus)?
ABI/PVRs to rule out arterial disease. biopsy and culture order an ultrasound venous insufficiency test. venous ablation procedure. Unna boot.
Pulseless in the OR?
“I would have a direct conversation with anesthesia about the airway and adequate ventillation and stary chest compressions with ACS protocol”
Unidentified SSC of the neck (FNA of node result)
PET scan to look for source if nothing on full review of physical exam.
Triple endoscopy with blind biopsies
Base of tongue
tonsillar pillar
piriform sinus
If no source the ipsilateral modified radical neck and radiation therapy.
Moves for missing INFERIOR parathyroid?
Ipsilateral cervical thymectomy (do not need to do for missing upper)
Papillary thyroid cancer, when to do an thyroid lobectomy?
Any tumor less than 1 cm, all others do a complete.
board answer 2017, might change
One endocrine tumor not seen on an octreotide scan?
Insulinoma
Adjuvant treatment of gastric cancer?
Indiacations and Regimen
T3 or N+
5FU and radiation (MacDonald trial)
H and Ts of ACLS
Hypothermia Hypoxia Hydrogen ions (acidosis) Hyper or Hypokalemia Hypoglycemia
Toxins
Tension PTX
Thrombus (MI or PE)
Tamponade
ACLS
chest compressions
with pulse checks q2-3 mins
epinephrine every other cycle.
amiodarone for wide complex rhythms.
Steps for any vascular trauma case
- Make diagnosis
- Localize the lesion (just get a CTA!)
- go to the OR
- Get proximal and distal control
- Restore flow (argyle shunt)
- repair vessel
- shoot a completion angio
Zone I neck exploration: Left subclavian control
High left thoracotomy to clamp proximal
Axillary incision (think ALND) to clamp distal.
then control
Zone I neck exploration: Right subclavian control
Median sternotomy for proximal subclavian control
Axillary incision to clamp distally.
Hepatic artery laceration in trauma. How to repair?
Pringle manouver
clamp infrahepatic IVC
clamp thoracic IVC by making a hole in the diaphragm.
Steps to an esophageal repair
Perform a myotomy to expose the full mucosal injury
repair in two layers over a bougie
butress with a pleural flap
consider a distal. feeding tube.
Can you leave the esophagus in discontinuity?
Yes for unstable patient and return
Insulinoma cutoff for enucleation?
2CM.
If bigger then whipple/distal panc.
move to find a gastrinoma?
transiluminate.
Can kocher and hold up duodenum or pass an endoscope.
Adrenal incidentaloma, size cutoff?
4 cm
Adrenal incidentaloma, functional workup
Plasma metanephrines, VMA, check electrolytes and renin/angiotensin ratio.
Adrenal incidentaloma with previous cancer history, what is work up?
PET scan to see if avid (implies its a met)
GOO from likely ulcer disease but cannot rule out cancer.
Gastrojejunostomy with truncal vagotomy.
If having symptoms for >6weeks then subtotal gastrectomy with roux-en-y.
variceal bleed
- ICU, Octreotide, vasopressin
- SB tube with esophageal balloon up for 24 hours.
- TIPS
- Second TIPS
- Stapled the GE junction with an end to end anvil stapler. (good luck with this one…)
Pediatric spleen case: know one salvage operation
thrombin soaked vicryl mesh?
Pediatric post-splenectomy patients, what to give?
splenectomy vaccines (pneumococcus, meningitis) and penicillin prophylaxis until their teens.
three formulas you need to know for pediatrics
4/2/1 per kg for maintainance IVF
20cc/kg crystalloid; 10cc/kg blood for trauma bolus
age/4 +4 for ETT size
Ask for the breslow tape!!
alpha-blocker for a pheo
phenoxybenzamine
OR drip for a pheo
nitroprusside drip
screening test for MTC
calcitonin
MTC in newly diagnosed MEN2a patient what operation?
total thyroid with bilateral neck dissection
what age to start pheo screening in MEN2
18
When to get prophylactic thyroidectomy in MEN2
5
what is first test in any dysphagia case?
Upper GI
prevents an EGD perforation of a zenckers etc
Margins for a phylloides tumor
malignancy for a phylloides tumor
1 cm
>5 mitoses/hpf
mammography guidelines.
every other year at age 40
high risk family mammography guidelines
10 years before youngest familial diagnosis.
reccomend genetic councilling.
High risk radiology screening?
yearly MRI
what age to stop mammograms
age 75 or when to frail for an operation.
duration of herceptin
1 year post-op
pleiomorphic adenoma, why to remove?
will enlarge and cause neurologic symptoms
risk of permanant facial nerve injury with parotidectomy?
less than 1%, most deficits in PACU will resolve if you visualized the entire nerve.
how to identify facial nerve.
In relation to the tragus
What does faicial nerve arise from?
stylomastoid foramina
Procedure for pagets?
Central segmentectomy including the nipple.
procedure for recurrent breast cancer?
basically always gets a mastectomy since you cant redo radiation, but can redo SLNB.
Stage three breast cancer, two things to do before neoadjuvant therapy?
Make sure there is a clip in the lesion in case it dissapears.
Stage the whole body with a PET and bone scan.
Office test for Frey’s syndrome?
Current cure
give lemon drops to reproduce.
give botox injections.
Horners syndrome after paraotidectomy
Expectant management.
chyle leak after neck surgery.
ligate the thoracic duct thru the chest.
when to do a R hemicolectomy for a carcinoid?
if it involves the base, >2cm, high grade
tests to send for a carcinoid?
5HIAA and chromogrannin
Screening for barretts?
no dysplasia - start at 1 broaden to 3 years.
low grade dysplasia - start at 6 months, broaded to yearly.
high grade dysplasia - every 3 months, refer for ablation or consider surgery.
Anal fissure treatment
topical diltiazem for 6 weeks.
botox
partial lateral internal sphincterotomy.
What do you do for a lateral anal fissure?
C-scope to rule out crohns.
HER2 drugs
HERCEPTIN and PROGETTA, drop doxorubicin
concern for breast cancer in pregnant woman?
I would get a mammogram shielding the uterus
Who can get immediate breast reconstruction?
No stage 3 since they will need post-op chest RT.
perianal abscess - order of procedures?
- I&D with EUA
- rubber seton
- cutting seton
- consider an advancement flap, especially female/anterior.
Parkland formula
4 mL/kg x %tbsa over the next 24 hours
give first half over 8 hours
give secnod half over the next 16.
Thrombosed aortobifem in PACU, what do you do?
Go back in thru the abdomen,
gain proximal and distal control on the graft and make an opening on the graft for balloon thrombectomy. close the graft. shoot a completion angio.
Amount of renal ischemic time with suprarenal aortic cross clamping.
45 mins
Clinical presentation: machine like murmur in the abdomen with massive lower extremity edema
Aorto-caval fistula
Replaced left hepatic artery; what do you do?
Clamp and carry on for a few minutes. If the left lobe turns dusky then you have to work around it.
Cuttoffs for pulmonary lobectomy
FEV1 40%
DLCO 40%
Steps to a pneumonectomy
appropriate thoracotomy dissect out the pulmonary artery vein and bronchus. Complete the appropriate fissue TEST CLAMP THE BRONCHUS Take out the lobe.
Who should get upfrom pneumonectomy for blebs?
Pilot, scubadiver, other professions that change pressure.
HIV with spontaneous pneumothorax?
Test for PCP and get viral loads
HITT
Platelets <100 or down by 50%
argatroban
send of PF4 antibody and confirm with seratonin assay
Heparin for DVT, starting settings
80 U/kg bolus
18 U/kg maintainance
cutoff for AV fistula
3 mm in upper arm
2.5 mm below the elbow
Procedures for AV fistula in best order
radiocephalic
brachiocephalic
brachiobasilic
graft
Extreme hand pain post AV fistula?
Back to OR ligate the fistula
Steal syndrome procedure
Distal revascularization and interval ligation.
Failing fistula, what to look for on fistulagram?
early failure, then balloon proximally
late failure, balloon distally
When do you know broadening of the mesentery is complete in a LADDs
When you can completely visualize the SMA and SMV
description for reduction of an intussusception?
“milk it retrograde”
How do you confirm air contrast enema worked for intussussception?
passage of contrast freely into ileum
When do you take pyloric stenosis baby back to the OR?
When electrolyte replacement is sufficient with bicarb <28
Do you extend your pyloromyotomy onto the duodenum (pyloric stenosis)
No, stop short, look for pooching of the mucosa.
ultrasound criteria for pyloric stenosis?
length of 15 mm
treatment of ischemic orchitis?
ice packs and scrotal elevation
Operation for occlusive SMA atherosclerosis?
R common iliac to distal SMA with ringed PTFE graft.
Knee dislocation in trauma prompt?
CTA all to look for popliteal injury
Incision and approach for popliteal bypass.
interposition graft from contralateral saphenous
medial incision above and below the knee approching the popliteal behind the femur and behind the Tibia.
retroperitoneal sarcoma encircling the kidney. (preop planning)
Get a pyelogram to evaluate the ureter and function of the contralateral kidney.
Swann numbers
CI 3-4 CVP 10-12 PAP 10-25 (dimes to quarters) SVR 1000 Wedge 6-18
Moves for ARDS?
Low tidal volumes 6-8 cc/kg
Low peep 10-18
permissive hypercapnia - pH 7.2
Call the ICU fellow to talk about oscillatory settings
High airway pressures on vent?
Check the tube and for PTX first
Then think ARDS
High v low fistula output
~500cc per day.
amyloid on thyroid FNA
MTC
Finding on FNA for MTC
Amyloid
rule of 10% for pheos
10% familial
10% bilateral
10% malignant
Criteria for TTP?
FATRN
fever, angiopathy, thrombocytopenia, renal insufficiency, neuropathy
Therapy for TTP?
plasmaphoresis
Duodenal exploration
Open on a diagonal, slide a pediatric feeding tube in
