Clinica Flashcards
What are the differentials for Abdominal pain post op (colectomy)
Anastomotic leak Septic shock Haemorrhagic shock Perforation Obstruction Wound infection
Differentials for post op shock
Haemorrhage Sepsis (depends how long after) PE MI Anaphylaxis
Post cholecystectomy Ix
Bedside: ECG, BM, Urine dip (+pregnancy)
Bloods: FBC, U/Es, LFTS, CRP, amylase/lipase +/-D-dimer
Imaging: Erect CXR, Abdo USS looking free fluid. If stable, consider CT abdo
If not stable may need Dx Laparotomy
Haemorrhagic shock classification
Ix for drop in urine output
Bedside: BM, ECG, Urine dip and Microscopy, bladder scan
Bloods: classic + lactate
Imaging: USS Kidneys (?hydro)
Special: paired urine and serum osmolality
Pre-renal causes of AKI
Local: renal artery stenosis or renal vein thrombosis
Renal causes of AKI
ATN
Post renal causes of AKI
Upper: - Intraluminal: stone - Extraluminal: retroperitoneal fibrosis, malignant compression Lower: - Urethral stricture - prostate - blocked catheter
Treatment of hyperkalaemia
- calcium gluconate 10%:10ml
- Insulin + Dextrose: 10 units in 50mls of 50% dextrose
- Nebulised salbutamol
- Resonium
Continued cardiac monitoring
Indications for dialysis
Resistant fluid overload
Resistant high K
High Urea (encephalopathy)
Resistant met acidosis
How haemodialysis different from haemofiltration
Dialysis: counter flow of blood and dialysate fluid separated by semi-permeable membrane
Filtration: High hydrostatic pressure pushing blood into semi-permeable membrane, forming ultrafiltrate (small molecules and electrolytes pass through the membrane). Ultrafiltrate is then disposed and replaced by normal fluid
Scoring system for AKI
RIFLE from KDIGO (Kidney disease, improving global outcomes)
Management of failed 12Fr catheter
Try a larger cath
If not try a tieman
If not consider suprapubic or percutaneous needle aspiration
Differentials swollen leg post op
DVT
Cellulitis
Lymphoedema
Fracture
Well’s DVT score
Wells DVT score interpretation
Duration of anticoagulation for DVT
3-6 months
3 months for unprovoked
3 months for provoked but the provoking factor no longer present (eg post op)
3-6 months for cancer
Complications of DVTs
PE
Post-thrombotic syndrome (pain, swelling, haemosiderin, varicose veins)
Prevention of DVTs
Compression stocking
Elevation
Early mobilisation
Anticoagulation
A to E assessment for post op tonsilar bleed
Airway C: Patency O: Suction Breathing C: RR, SpO2, expansion, Breath sounds O: 15L non-rebreathe Circulation C: HR, BP, peripheral and central cap refill, HS O: - 2 large bore cannulae, bloods (clotting, G+S, +/- Xmatch, culture, VBG), - IV hartmanns if tachycardic. - Consider catheter for fluid balance Disability C: BM, GCS, Pupils Exposure C:rash, abdo exam, wound site
Tonsillar bleed mx before operation
Inform senior
Abx
Fluids/blood
Control bleeding:
1. LA spray with adrenaline
2. If obvious bleeding point: Cauterise with silver nitrate stick
3. if no obvious bleeding point: gargle hydrogen peroxide 3% diluted 1:4
Manual reduction technique for paraphimosis
- apply general pressure
2. thumbs on the glans, index finger behind the prepuce slowly pushing back
Pathophysiology of paraphimosis
Retracted prepuce proximal to glans forms a constricting ring
Impedes venous and lymphatic return
Causing engorgement of vessels distally
Swelling causes further obstruction ultimately cutting the arterial supply
Analgesia for paraphimosis reduction
LA without adrenaline
penile block or ring block
Other non-operative approach to paraphimosis
Osmotic method: gauze soaked with 50% dextrose
Dundee method: making multiple needle tracts in the swollen glans to create path for fluid drainage under pressure
Mx of intra-abdominal abcess
- abx
2. drainage (percutaneous or surgical)
Possum scoring system
Physiological and operative severity score for enUmeration of mortality and morbidity
Developed in 1991 by Copeland et al, revised by Portsmouth in 1998
Anticoagulation mx for pt needing urgent operation on warfarin for metalic valve
Consult cardiology and trust guideline
Might reverse with vit K whilst starting on UFH
Sepsis 6
Take: culture, lactate, UO
Give: O2, fluids, Abx
SIRS def
Symptoms and signs of infection
2 or more of the following: HR:90, RR>20, WCC>12 or<4
SIRS vs Sepsis vs Septic shock
SIRS: systemic inflammation
Sepsis: SIRS + confirmed/suspected source of infection
Severe sepsis: Sepsis + organ dysfunction (eg low urine output or high lactate)
Septic shock: severe sepsis and persistent hypotension despite resus
Scoring system for UGI bleeding
Rockall or Blatchford
Pre and post endoscopy rockall scores
Predicts the need for endoscopy or risk of re-bleeding (post endoscopy rockall)
Mx of UGI bleeding
Depends on the cause
If peptic ulcer: IV omeprazole
If oesophageal varices: IV terlipressin to reduce splanchnic flow, reducing bleeding, and prophylactic abx
Endoscopy
Riglers sign
Air present on both sides of bowel wall
Sign of bowel perforation
Common causes of small bowel obstruction
Adhesions
Hernia
Common causes of large bowel obstruction
Malignancy
Volvulus
Diverticulitis
Causes of bowel obstruction
Intraluminal
Gallstone ileus, ingested foreign body, faecal impaction
Mural
Cancer, inflammatory strictures*, intussusception**, diverticular strictures, Meckel’s diverticulum, lymphoma
Extramural
Hernias, adhesions, peritoneal metastasis, volvulus
Mx of sigmoid volvulus
A-E, bowel decompression using riles tube and IVI + analgesia
1st line: Rigid Sigmoidoscopy and insertion of flatus tube
2nd line: flexi sigmoidoscopy
3rd line: Surgical ?sigmoidectomy
Types of necrotising fasciitis
Type 1: polymicrobial:aerobic and anaerobic
Type 2: Haemolytic group A strep: strep pyogenes
Type 3: Gas gangrene: clostridium perfringes
Special test for Necrotising fasciitis
Finger Sweep test:
an incision over the suspected area may reveal:
- dishwasher coloured fluid
- pus exudate
- necrotic tissue
If the tissue dissects easily with minimal resistance: positive finger sweep test
Risk factors for necrotising fasciitis
Immunocompromised eg DM, HIV, malignancy
Post op
Trauma eg IVDU, burn
Prognosis of necrotising fasciitis
Early diagnosis and debridement improves outcome
Mortality between 20-50%
Contraindications for skin graft
General: patient fitness for op
Local: vascularity, growth of micro-organisms, necrotic tissue
Signs of appendicitis
Rosving
Rebound tenderness
Psoas sign
Obturator sign
Rosving sign
LIF palpation causes pain in RIF
?appendicitis
Psoas sign
Extend hip causes RIF pain
Psoas sign
HIP Extension against resistance causes RIF pain
Complication of acute appendicitis
Sepsis - septic shock - multi-organ failure
Periappendicular abscess
Perforation of appendix
Death
Complication of acute appendicitis
Sepsis - septic shock - multi-organ failure
Periappendicular abscess
Perforation of appendix
Death
Why you have to operate on appendicitis but cholecystitis might be treated with ABX
Appendix supplied by appendicular artery (small end artery) which could get thrombosed with sepsis, leading to gangrene and perforation
Cholecystitis: gallbladder supplied by both cystic and right hepatic arteries, even if one thromboses, another likely to be able to supply the appendix
6 Ps of acute limb ischaemia
Painful Pallor Pulseless Perishingly cold Paralysis Paresthesia
Ix of acute limb ischaemia
Bedside: ECG, BM
Bloods: FBC, UEs, CRP, G+S, lactate, ?thrombophilia screen
Imaging: Areterial duplex or CT angio
Rutherford classification of acute limb ischaemia
> 6 hours likely to be irreversible
Mx of acute limb ischaemia
Heparinise whilst awaiting imaging
Rutherford I and IIa: conservative with
- heparin loading and infusion (monitor APTT)
Rutherford IIb or worse: surgical
Surgical mx for acute limb ischaemia
If the cause is embolic, the options are:
- Embolectomy via a Fogarty catheter
- Local intra-arterial thrombolysis*
- Bypass surgery (if there is insufficient flow back)
If the cause is due to thrombotic disease, the options are:
- Local intra-arterial thrombolysis
- Angioplasty (Fig. 3)
- Bypass surgery
If >6hrs: amputation
3 components of normal doppler waveform
Multiphasic
Pulsatile
Regular amplitude
Causes of acute limb ischaemia
Acute thrombotic in situ (60%): acute occlusion in a vessel with pre-existing atherosclerosis
Embolic (30%): Cardiac (AF, MI, prosthetic/damaged valve), malignancy
Others: trauma , infection, dissecting aneurysm
ABPI interpretation
>1.3: arterial calcification seen in DM, RA, vasculitis 0.8< -- <1.3 normal 0.5< -- <0.8 moderate PAD: claudication 0.3< -- <0.5 severe PAD: rest pain <0.3 critical limb ischaemia
Complications of ischaemic limb if left untreated
Loss of limb (40%)
Death (20%)
Complications of ischaemic limb when treated
Reperfusion syndrome ->compartment syndrome/chronic pain
Complications of thrombolysis: CVE, retroperitoneal bleed
Chronic limb ischaemia rutherford vs fontaine classification
Mx of critical limb ischaemia
Urgent vascular referral for consideration for surgical intervention :
- stent
- bypass
- amputation
ATLS acute assessment
C: triple c-spine immobilisation should be established until spine is declared clear
A: cant do head tilt chin lift or jaw thrust (c-spine). start with airway adjuncts if needed and call anaesthetists
B: Check for haemothorax, pneumothorax, cardiac tamponade, flail chest. Apply 15L non-rebreathe regardless of COPD
C:
IV access*2, Warmed crystalloid 30ml/kg initial bolus (10ml/kg if HF),
- look for bleeding: floor and 4 more
D: GCS, pupils, BM, temp. Analgesia as per WHO
E: expose,log roll, abdo exam, check integrity of pelvis and apply binder
AMPLE Hx
Secondary Survey
Ample hx
Allergies Medication PMHs Last meal Events
Imaging Ix for Trauma
Chest, c-spine, pelvic XR
FAST scan
Full trauma series CT TAP +/- head
How to differentiate between haemothorax and pneumothorax
Haem: dull percussion, no distended neck veins, deviated trachea
Pneum: hyper-resonant, distended neck veins, deviated trachea
Definition of massive haemothorax
Chest drain empties 1.5L or more than 200ml/hr for 2 hrs
Mx of massive haemothorax
Transfusion
Chest drain
Explorative surgery to control bleeding
Epigastric pain differentials
GI: - pancreatitis - Cholecystitis - peptic ulcer - GORD - obstruction Cardiac: - MI - pericarditis Vascular: - AAA Endocrine: - DKA
Normal amylase
<100
if it is 3 times or more is most likely pancreatitis
Risk factors for gallstones
Fat
Female
Fertile
Forty
Causes of pancreatitis
GETSMASHED Gallstones Alcohol Trauma Steroids Mumps Autoimmune eg SLE Scorpion High Ca, High Lipid, low temp ERCP Drugs: azothioprin, NSAIDs, thiazides
Severity of pancreatitis scoring
APACHE II
Glasow score
APACHE score
Glasgow pancreatic score
Criteria for CT scanning in pancreatitis patients
Not until after 48/72hrs: inflammatory changes are not radiographically present
Unless suspecting pancreatic carcinoma
If mild pancreatitis, unlikely to need CT
If severe pancreatitis, will definitely need CT for: assessing complications, provide prognostic info (risk of necrosis/infection)
Complications of pancreatitis
Necrosis +/- infection Pseudocyst ARDS Chronic pancreatitis Retroperitoneal haemorrhage: grey-turner/cullens Death
Mx of gallstone pancreatitis
MRCP + Cholecystectomy
If bile duct stones/or unfit for surgery: ERCP and sphincterotomy
Acute groin pain differentials
Gen Surg: - Hernia: femoral or inguinal and 2ndary small bowel obstruction Ortho: - Psoas abscess - OA flare Vascular: - femoral aneurysm - saphenous varix - AAA Others: - lipoma - lymphadenopathy
Commonest type of hernia
Gen population: Direct inguinal hernia
Paeds: indirect inguinal (patent process)
Elderly female: femoral
Femoral triangle anatomy
Femoral canal Femoral sheath (artery and vein)
Femoral canal boundaries
Medial: Lacunar lig
Ant: pectineal muscle
Post: Inguinal ligament
Lat: femoral vein
Note great saphenous coming in! common source of bleeding post herniotomy
Femoral canal content
Fat
Lymph nodes of cloquet
Differentials for testicular swelling
General: - direct inguinal hernia Uro: - torsion - hydrocele - varicocele Trauma - haematocele Malignancy - tumour Infective: - mumps - epididymo-orchitis
<p>Types of non seminoma</p>
<p>Teratoma</p>
<p>Yolk sac tumour</p>
<p>Choriocarcinoma</p>
<p>Testicular germ cell tumour types</p>
<p>Seminoma</p>
<p>Non seminoma</p>
<p>Seminoma vs non seminoma age group</p>
<p>Seminoma: ~ 40 yo</p>
<p>Non seminoma: 20-30 yo</p>
<p>Testicular germ cell tumour types</p>
<p>Seminoma</p>
<p>Non seminoma</p>
Blood test for testicular cancer
AFP
bHCG
LDH
Risk factors for testicular cancer
FHx
Down syndrome
Klinefelters syndrome
Cryptorchidism
Surgical approach for testicular cancer
Inguinal (not testicular) approach as minimised seeding
Presentation of testicular torsion
Hx: - Sudden onset severe pain - N+V +/- abdo pain O/E: - Globally tender, high riding/transverse - absence of cremasteric reflex
Blood supply to femoral head
Weight bearing status following Hemi/total/DHS/Cannulated hip screw
Hemi/total: weight bear as tolerated
DHS/Cannulated hip screw: minimally weight bearing/non weight bearing for 6 weeks to facilitate fracture healing
Hemi vs total for intracapsular NOF
Hemi if:
- immobile
- low AMTS
- Co-morbid/high risk of GA
How many hip fractures?
Mortality
30 day: 10%
1 yr: 30%
Surgical approach to hip replacement
Anterolateral for hemi
Posterior for total
Mx of pertrochanteric hip fractures
DHS
Mx of subtrochanteric fractures
IM nail
Assessment of neurovascular status in children with upper limb fracture
Median: ‘ok’ sign -> flexor policis longus (FPL) and flexor digitorum profundus (FDP) + sensation on the thumb
Ulnar: middle finger over index finger: intrinsic hand muscles + sensation of little finger
Radial: extend wrist + Sensation on the back of the hand
CRT + radial +ulnar pulses
Mx of radial fracture in children
Backslab + NBM
Discuss with senior
Consent and mark for TENS wires or plates and screws
Mx of spiral femoral fractures in kids
Plating or TENS nailing of femur
Signs of non-accidental injury
Multiple fractures at different stages of healing
Scapula, ribs, lateral clavicle, skull fracture
How long does it take for fractures to heal
4 wks for hard callus to appear on xray
4-6 wks start of mobilisation: 3 months completion of callus formation
3-6 wks of healing time in kids
Remodelling up to 6 months
BOA guidelines: compartment syndrome Ix and management
In pt with clear signs/sx,
- any circumferential dressing should be removed and pt reviewed after 30 mins
- If persists, needs urgent decompression
In pt with Dx uncertainty
- record intracompartmental pressures
- If diastolic blood pressure - the compartment pressure < 30 mmHg ; suggests positive
- Needs to D/w consultant if positive whether needs decompression
- If absolute compartment pressure >40mmHg, it is definitely compartment syndrome
BOA guidelines: compartment syndrome Hx and exam
- Time: of injury and evaluation
- Mechanism of injury/RFs
- Pain: out of proportion? on passive extension
- Analgesia: ?regional, response to analgesia
- Neurovascular status
- GCS
Treatment for lower leg compartment syndrome
2 incision 4 compartment fasciotomy
BOA guidelines: Spinal clearance principles in trauma
- Inclusion: unconscious, unable to cooperate or who have distracting injuries
- Examine the entire spine on arrival: any injury found requires urgent imaging
- If unlikely to be conscious in 48hr, need radiological imaging
- Radiological imaging: CT Head (extend to c spine), CT CAP for coronal view, AP and lateral xray of thoracic and lumbar. needs reporting by a radiologist before clearing the spinal immobilisation measures. MRI needed for cord injury
BOA Guidelines for open fractures
- Need orthoplastics
- Prophylactic abx
- Neurovascular exam before and after reduction
- Re-align and splint
- CT trauma +/- angio
- Informal debridement to remove gross contamination, take pics, then cover with saline soaked gauze and occlusive dressing
BOA guideline: Timing to debride an open fracture
Debridement should be performed using fasciotomy lines for wound extension where possible
— Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise
(compartment syndrome or arterial disruption producing ischaemia).
— within 12 hours of injury for other solitary high energy open fracture
— within 24 hours of injury for all other low energy open fractures.
When would you use haemofiltration or haemodyalisis
Dialysis: less expensive, less technical
Filtration: Less effect on BP, lower risk of hyperlipidaemia
BOA Guidelines on operating on Fraily trauma pts
1 . TEP
- Timing:
- orthogeries review within 72 hrs
- operate within 36 hrs, aim for FWB
- PT on day 1 post op - Orthogeries assessment includes:
- bone health
- anticoagulation
- Multifactorial fall assessment
- nutrition
- pain mx
Causes of hip fractures in elderly
Weakness caused by:
- osteoporosis
- met deposits
- metabolic conditions eg pagets
- rarely osteomyelitis
Ix for painless haematuria
Bedside: urine dip, bladder scan
Bloods; routine
Imaging: CT KUB
Special: flexi/rigid cystoscopy
Causes of D1 post-operative pyrexia
- Pulmonary atelectasis
- Infection prior to operation: catheter, cannula, LURTI/UTI
- PE
How to manage pulmonary atelectasis post op
- Analgaesia : PCA
- Oxygen if low sats
- Chest physio
- If issues with oxygenation, contact outreach
Risk factors for abdo wound dehiscence
Pre-op: wound healing impairment
RF: DM, anaemia, jaundice, malignancy, vit c deficiency
Peri-op:
- Surgical: poor suturing, increased bowel handling
- equipment: poor sutures
Post- op:
- anything that increases intra-abdo pressure: cough, high BMI, constipation
Jenkin rule
suture length should be at least four times the wound
sutures placed 1cm apart
1cm bites
Surgery for wound dehiscence
- debride non viable tissue around the wound edges
- repair with non absorbant sutures eg nylon 1.0 or PDS including peritoneum, rectus sheath, fascia layers but not skin
- separate skin closure
Difference between incisional hernia and wound dehiscence
Skin intact in incisional hernia
Complications of any fracture
Early: bleeding, infection, NV compromise
Intermediate: compartment syndrome, bleeding infection
Long term: malunion or non-union
Complications of any fracture
Early: bleeding, infection, NV compromise
Intermediate: compartment syndrome, bleeding infection
Long term: malunion or non-union
What nerve damaged in supracondylar fractures
Anterior interosseus nerve branches off median in the proximal forearm:
Innervates flexor pollucis longus and digitorum profundus (cant make the ok sign)
What nerve damaged in supracondylar fractures
Anterior interosseus nerve branches off median in the proximal forearm
How to classify supracondylar fractures
Gartland classification
How to prepare someone for theatre
NBM + maintenance IVF Mark and consent Anaesthetics: ECG and CXR Bloods: G+S + routine + INR Covid Swab TEP form VTE Inform: SpR, ITU, Emergency theatre staff
Differentials for UGI Bleed
Oesophageal varices Duodenal or peptic ulcers Malignancy Trauma Gastritis/Oesophagitis Mallory-weis tear Arterio-venous malformation
<p>Arterial supply of nose bleed</p>
<p>Internal and external carotid artery plexus (Little's area or kiesselbach's plexus)</p>
<p>Mainly sphenopalatine and greater palatine arteries (branches of the maxillary artery)</p>
<p></p>
<p></p>
<p>ENT Mx of epistaxis</p>
<p>If anterior:Simple anterior: 1st: silver nitrate cautery 2nd: packing</p>
<p>If posterior: balloon tamponade (if anterior packing has failed)</p>
<p></p>
<p>Abx post nasal packing</p>
Immediate mx of epistaxis
Press on the cartilagenous part of the nose for 15 to 20 mins whilst leaning forward to avoid the blood flow posteriorly and risk occluding the airway
When to give abx in epistaxis
If no source of bleed found, nose is usually packed for 48hrs.
Abx needed if pack is in place for more than 48 hrs
Toxic shock syndrome is a complication otherwise
What does grade 2 shock and abdo pain imply
Should be interpreted as ruptured AAA until proven otherwise
Most common site of AAA
Infrarenal 80%
Suprarenal 20%
RFs for AAA
Male Age >55 HTN Smoking High Cholesterol FHx
Differentials for bowel obstruction
- large bowel obstruction
- small bowel obstruction
- Pseudo-obstruction
- ileus
Pseudo-obstruction vs ileus
Both are acute distention of bowels in absence of any mechanical obstruction
Ileus (Ogilvie’s syndrome) includes both small and large bowel
Pseudo includes only large bowel (mainly caecum and ascending colon)
Causes of pseudo obstruction or paralytic ileus
Meds: opiates
Electrolyte imbalance
Neurological: MS, parkinsons
Trauma: including recent surgery
Mx of pseudo obstruction
NBM IV fluids 24-48hr
If not resolved, flatus tube decompression
Sometimes could give neostigmine to help reduce the secretions
Minority will need resection
Difference in history of Small bowel vs large bowel obstruction
Large bowel: constipation proceeds nausea
Small bowel: (profuse) vomiting proceeds constipation, spasmatic crampy abdo pain
Bowel sound in obstruction
Tinkling
Indications for AXR
Obstruction
Perforation
Volvulus
Toxic megacolon in acute IBD
Complications of small bowel obstruction if managed conservatively
Sepsis
Intra-abdominal abscess
Complications of small bowel obstruction if managed surgically
Early complications such as infection and haemorrhage
Intermediate such as bleeding, anastomatic leak, abdo wound dehiscence
Late: short gut syndrome, chronic pain
Different types of skin grafts
Split thickness:
- includes the germinal layer,
- leaves islands of germinal layer in the donor site, allowing it to heal by re-epithelisasation and is able to become a donor site in 6 wks
Full-thickness:
- includes all layers of dermis and epidermis
- needs to be sutured close (or closure by split-thickness skin graft)
Composite graft:
- includes special tissue like cartilage for nasal reconstruction
Criteria for Burns referral to a tertiary centre
- Partial thickness > 10%
- hands, feet, face, genitalia , or major joints
- full-thickness burns in any age group
- Electrical, chemical, inhalation burns
- Burns injury in patients with co-morbidities that could affect recovery
• Any patient with burns and concomitant trauma (such as fractures) in which the burn poses the greatest risk of morbidity or mortality.
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients requiring special social, emotional or long term rehabilitative support.
DDx for hip pain in 13 yo
SUFE
Undiagnosed Perthes
Muscular injury
Trauma
Examination findings for SUFE
Shortened, externally rotated hip
Reduced internal rotation
Waldling gait with external rotation
Mx of SUFE
May require a period of bed rest
May need fixation with a cannulated hip screw
Transpyloric plane landmark for?
Hilum of the left kidney SMA Fundus of gallbladder Neck of pancreas 1st part of deuodenum portal vein
Calot triangle borders
Cystic duct
Common hepatic duct
Inferior hepatic border
Inguinal canal borders:
- superficial ring
- deep ring
- anterior wall
- posterior wall
- roof
- floor
- superficial ring
- deep ring
- anterior wall: ext oblique
- posterior wall: transversalis fascia + conjoint tendon medially
- roof: int oblique, transversus abdominus
- floor: inguinal ligament
6 Ps of acute limb ischaemia
Pulseless Parasthaesia Pain Perishingly cold Paralysis Pallor
Major haemorrhage definition
Loss of entire blood volume in 24 hrs (eg 5 L in 70kg man)
Loss of 50% in 3 hours
Beck’s triad
Muffled heart sounds
Hypotension
Raised JVP
Factors increasing risk of hip dislocation post replacement
Patient:
- F >M (*2)
- Age
- obesity
- alcohol
Surgical:
- posterior approach>antero-lateral
- capsular excision
- smaller femoral head size
Anterio-lateral vs posterior approach risk vs benefit
A-L: increased risk of
- sciatic n palsy,
- trochanteric bursitis
- post op bleed
Posterior:
- increased risk of dislocation
Risk factors for anastamotic leak
Patient:
- age (old)
- gender (male)
- malnutrition
- long term steroids
- Smoking and alcohol
Operative:
- poor operative technique
- increased bowel handling
- level of anastemosis (left sided worse than right sided)
Post op:
- sepsis
- constipation
Operative mx of anastemotic leak
- faecal diversion
Washout + Loop ileostomy or colostomy - Hartmanns procedure
Resection of anasetomsis and closing the proximal stump
(difficult to reconstruct later)
Alternative to erect CXR if patient cannot sit up
Left lateral decubitus film (lean on the left side)
Air between liver and abdo wall
Operative mx of a perforated ulcer
Omental patch repair if large through a upper midline laparotomy incision
(could sometimes self seal with conservative mx)
<p>Intussesseption month of presentation</p>
<p>Winter months (some link with flu like symptoms pre-disposing)</p>
<p>Age of presentation for intussusception</p>
<p>6-9months old</p>
<p>Intussusception sx</p>
<p>colicky pain</p>
<p>D+V<br></br>
Sausage shaped mass</p>
<p>Red currant jelly stool</p>
<p>Pyloric stenosis age</p>
<p>4-6 wks of life</p>
<p>Pyloric stenosis Sx</p>
<p>projectile non bile stained vomit</p>
<p>Pyloric stenosis Ix</p>
<p>Test feed</p>
USS: thickened pylorus, target sign
<p>Pyloric stenosis mx</p>
<p>Ramstedt pyloromyotomy (open or laparoscopic)</p>
Causes of urinary outlet obstruction
Prostate:
- benign or malignant
- prostatitis
Urethral structure
Constipation
Neurological: MS, DMII
Gleason scoring for prostate
Given as two numbers
Refers to predominant and second most predominant cell type
6 or more tend to do worse
4 or less tend to do better
Gleason scoring for prostate
Given as two numbers
Refers to predominant and second most predominant cell type
6 or more tend to do worse
4 or less tend to do better
Cierny Mader staging system
Osteomyelitis staging 1 and 2 abx, 3 and 4 surgical rx 1. medulla 2. superficial 3. localised 4. diffuse
Mx of cardiac tamponade
Pericardiocentesis
In post op pts: re-do sternotomy and removal of blood in pericardial sac
What are the common sites of post op infection
6 Cs:
Cannula Catheter Calf: dvt Cut (incision) Chest Collection
Boerhaave syndrome
Maklers triad:
- surgical emphysema
- recurrent vomiting
- oesophageal perf
3 types of wound healing
Primary intension: wound closed by sutures
Secondary: closed from base up by granulation formation
Tertiary: delayed closure, first wait for granulation tissue, then close the top
Supracondylar fracture classification
Gartlands classification
1: cast immobilisation 4 wks
2: closed reduction and percutaneous pinning (CRPP)
3 and 4: CRPP or open reduction
Supracondylar fracture classification
Gartlands classification
1: cast immobilisation 4 wks
2: closed reduction and percutaneous pinning (CRPP)
3 and 4: CRPP or open reduction
Different types of haemorrhage
Primary: during operation
Reactive: within 24hrs post-op - clot dislodgement, or rise in BP post op leading to bleeding
Secondary: 7 days post op most likely infection, injury
Volkmanns contracture
Forearm fracture could lead to ischaemia and necrosis of forearm muscles
Leads to fibrosis and shortening, especially the flexor component
