Didactics Flashcards
Steps in treatment for bleeding after pelvic fracture
Start w/ binder around pelvis to reduce pelvic volume
If no improvement, angiography to embolize artery that is bleeding
Current indications for laparoscopic hernia repairs
For uncomplicated unilateral hernia repair, open is preferred 2/2 lower recurrence rate
2 indications for lap hernia repair = bilateral and recurrent hernias
Differentiate the two types of ileostomy
End ileostomy = opening in the end of colon to the outside
Loop ileostomy = opening connects back to more colon
Describe abdominal Xray findings of an SBO
Small bowel obstruction:
- distended loops (considered distended for small bowel if over 3cm diameter)
- presence of air fluid levels, sometimes referred to as ‘step ladder’ pattern of differing fluid levels
- possibly string of beads/pearl sign in abdomen representing gas bubbles trapped in a fluid-filled lumen
3 steps to take when pt is hypercalcemia
Hypercalcemia tx
- fluids (tons of fluid!!!)
- saline
- alendronate
Describe dumping syndrome
In gastric bypass pts: feeling of diaphoresis, tachycardia, vasovagal symptoms, faint/nausea/diarrhea after large food intake
2/2 hypovolemia (fluid rushes into intestines after hyperosmolar food load dumped in too quickly) and hypoglycemia (huge insulin secretion 2/2 carbo-load)
E-FAST vs. FAST
FAST = focused assessment w/ sonography in trauma: assess pericardial, pleural, and peritoneal cavities for fluid/air
E-fast is the extended version in which you also look for hemothroax and pneumothroax
Most dangerous complication of gastric bypass surgery
(a) Tx
Leak at the anastomotic site- seen in about 1% of pt
(a) Tx = immediate re-op
Differentiate congenital vs. acquired hernias
Congenital hernias are 2/2 failure of the processus vaginals to close, while acquired hernias are due to gradual weakining fo the abdominal wall tissue over time
Most common etiology of SBO
Post-op
-prior abdominal surgery!
Which nerve runs through the internal ring?
Genital branch of the genitofemoral
Key step before giving meds to delirious trauma pt
(a) What meds could you give?
Need to rule out hypoxia before giving meds to calm down a delirious pt
(a) If QTc is normal- can give Haldol, otherwise can consider Ativan
How long does it take a colonic polyp to develop into cancer?
7 years
Why does someone w/ a fever require increased maintenance fluids?
Bulk of maintenance fluids is used in metabolism, so pts w/ increased metabolic demand (ex: fever/inflammatory state, hyperthyroid) require more fluids
At what GCS do you intubate?
Intubate for GCS under 9, so 8 or below = intubate
“GCS 8, intubate”
Rank from most to least invasive: gastric bypass, lap band, sleeve gastrectomy
Compare/contrast benefits
Most invasive = Gastric bypass
- about 70% excess body wt lost
- Risks: leak in 1%, stricture in 5%, internal hernia, severe dumping syndrome
Middle = Sleeve
- increasing in popularity, cut the stomach but no anastamosis, huge decrease in grehlin (b/c no fundus)
- average 60% EWL
Least invasive = Lap band- foreign object w/ strict f/u for monthly adjustment
What is RSI? Give overview of procedure
RSI = rapid sequence intubation, used when intubating/putting under anesthesia who hasn't had time to be NP (ex: trauma pt) and therefore is at high risk of aspiration RSI = pharmacologically induced sedation and nueormuscular paralysis prior to tracheal intubation
2 steps to RSI
- Induction agents for prompt unconsciousness
- ketamine, propofol - Neuromuscular blockers for paralysis
- sux (succinylcholine)
- roc (rocuronium)
Describe why appendiceal pain starts generalized then migrates to RLQ
At first inflammation in the area causes referred generalized pain to the umbilicus via the T8-T10 dermatome
Then as the appendix becomes inflammed enoughed to hit the peritoneum, there is somatic pain localizable to the RLQ
List the order in which certain features get blocked in an incarcerated hernia
Incarcerated hernias: first lymphatics are blocked, then venous return is blocked, then arterial blood flow is obstructed
Loss of lymphatics –> venous –> arterial
Key clinical features of intermittent claudication
- present on exertion, relieved by rest
- reproducible (same activity level can reproduce same pain, cant just walk it off…)
Most common hernia in
(a) M
(b) F
Most common in both is indirect inguinal
But…overall femoral are more common in F than M
Benefit of using mesh in hernia repair
(a) What is the alternative to using mesh
Benefit of using mesh = reduced recurrence rates 2/2 tension-free
(a) Alternative is Shouldice repair = 4 layer repair in which you directly sew tissue together
- higher recurrence rate
Best lab value to acutely determine tissue perfusion when pt is losing blood
Not reliable to use Hb/hct- can be diluted/concentrated or lag behind
-use lactate as a marker of tissue perfusion
Buzzword pencil thin stools
Buzzword for colorectal polyps or cancer, specifically ‘apple core’ lesions
Distinguish displaced vs nondisplaced fractures
Displaced = no continuity btwn two bone fragments
Nondisplaced = hairline fracture, bones remain continuous
Once you get in laparoscopically, what visual cues could tell you you’re confusing appendicitis for Crohn’s disease
Get in and don’t see inflammed appendix, but see fat wrapping around bowel
POD0 gastric bypass pt w/ tachycardia
Anastamotic leak until proven otherwise
Differentiate incidence vs. prevalence of a disease
Incidence is the number of cases per unit of time (incidence: x annual cases)
Prevalence = number of cases at any one time (very prevalent at this time…)
Differentiate treatment of rectal vs. colon cancer
Colon cancer: tx is always surgery, no adjuvant chemo or radiation
Rcctal cancer: neoadjuvant local radiation and chemo for stage 3/4 disease
-stage 1/2 = resection, but stage 3/4 benefit from neoadjuvant systemic therapy
Is LR or NS used to flush line after blood transfusion?
Can’t use LR b/c the citrate in the transfused blood can precipitate w/ the Ca2+ in LR
-while NS is safe b/c it has no calcium
2 most common etiologies of pseudomyxoma peritonei
- appendiceal cystadenoma
- ovarian carcinoma
Pseudomyxoma peritonei = intraperitoneal mucinous spread (mucus throughout the peritoneum)
Mgmt of appendiceal mucocele
Appendiceal mucocele tx = surgical removal 2/2 risk of malignancy (underlying cystadenocarcinoma possible) and rupture
-rupture could lead to pseudomyxoma peritonei (mucus throughout the peritoneum)
Name the 3 views in FAST
FAST = focused assessment w/ sonography in trauma
P’s: look for free fluid (blood…) or air
- pericardial
- pleural
- peritoneal
Define shock
Shock = dysfunctional cellular metabolism 2/2 tissue underperfusion
Explain how a bariatric surgery pt could have an SBO w/ zero output from NG tube
Risk of gastric bypass = internal hernia, causing SBO
-no NG tube output b/c it is the blind loop (the remnant) that is obstructed
Hepatocystic triangle: define borders
- cystic duct laterally
- common bile duct medially
- inferior edge of the liver is the superior border
Lab values differentiating choledocolithiasis and gallstone pancreatitis
Both can have elevated alk phos, but pancreatitis will also have elevated amylase/lipase
-amylase/lipase may be super super high, then precipitously drop if the stone passes
Parameters for a successful bariatrics surgery
Cut at least 30% of excess weight or achieve BMI under or at 35
Malrotation appearance on Xray
Upper GI series: see bowel concentrated on the right (2/2 narrow mesenteric base)
Post-op consideration for pt after hepatic resection
Add phosphorus to fluids b/c phosphorus needed for liver regeneration
PTH’s effect on
(a) phosphate
(b) magnesium
(b) Hypomagnesemia stimulates PTH secretion
- PTH enhances Mg resorption by kidneys
(a) PTH decreases renal phosphate reabsorption => high PTH would cause decrease in phosphate
When do inguinal hernias get repaired?
(a) When do femoral hernias get repaired?
Repair inguinal hernias when they’re symptomatic
(a) ALWAYS repair femoral hernias b/c of the 30% complication risk (strangulation) even if asymptomatic
- higher baseline risk => repair
If you can’t intubate- give options and how to chose which
If endotracheal intubation can’t be done: options are cric vs. trach
Cric is more superficial and faster
Trach is more permanent
Give some etiologies of brisk upper GI bleed
Brisk upper GI bleed
- esophageal varices
- Mallory-Weiss or Boerrhave’s
- Aortoenteric vistulas = communication btwn aorta and GI tract
- Peptic ulcer disease
Differentiate
(a) cholelithiasis
(b) biliary colic
(c) acute cholecystitis
(a) Cholelithiasis simply is the presence of gallstones
(b/c) Difference is the chronicity of the pain. Biliary colic is intermittent RUQ pain after fatty meal than does not persist 2/2 stone lodging and dislodging out of duct.
While acute cholecystitis is persistent RUQ pain b/c stone is stuck in duct (not lodging in and out)
How many units of the following would you’d give to replace 1L of lost blood
(a) packed RBCs
(b) whole blood
(a) One unit of packed cells is 250 cc => give 4U of packed cells to compensate for 1L blood loss
(b) One unit of whole blood is 500cc
Cutoff measurement for thickened gall bladder wall
Gall bladder wall considered thickened if over 3 cm thick
2 steps for repairing malrotation in 1 mo. old who presents w/ sudden onset bilious emesis
Malrotation repair
- Take down/divide Ladd’s bands
- Widen mesenteric base
Recommendation for pregnancy and bariatric surgery
Recommended for female pts to wait about 2 years after wt loss surgery for wt loss to plateau b/c pregnancy during rapid wt loss can be dangeorus for the developing fetus
Why is surgery indicated in even a well controlled UC pt after 25+ yrs of disease
After 25 yrs UC pts have such a high colon cancer risk that colostomy is suggested even if the pt is controlled on biologic agents
Which two views are taken on mammorgaphy?
- Medio-lateral
- Cranio-caudal
-looking for symmetry and abnormalities
Differentiate where Mallory-Weiss tear vs. Boerrhaves occurs
Boerrhaves = full perforation, occurs about 5cm proximal to the GE jxn
Mallory-Weiss happens at the lesser curvature of the stomach
Using the 4:2:1 rule, calculate the amount of daily maintenance fluids for a 80 kg pt
Per hour: 40cc (4 x first 10kg) + 20 cc (2 x next 10kg) + 60 cc/hr (for total weight -20kg) = 120 cc/hr
120cc/hr x 24 hrs = 2600 cc
Name 6 surgically correctable causes of hypertension (this is hard…)
- Renal artery stenosis
- Pheochromocytoma
- Hyperthyroidism
- Coarctation of the aorta
- Cushing’s syndrome
- Conn’s syndrome = adrenal adenoma
To what degree do the following increase risk of breast cancer
(a) ADH
(b) LCIS
(a) ADH = atypical ductal hyperplasia- increases by 3-5x
(b) LCIS increases risk by 7-11x
Differentiate the effect of adult vs. kid falling on sprained ankle
Ligamentous attachments are stronger than the growth plate
In kids- you’d get a break at the physis (growth plate)
While in adults you’d get a sprain of the ligament
Which has a better prognosis: Wilms tumor or neurobloastoma
Nephroblastoma (Wilms) has better prognosis than neuroblastoma
Explain why a newborn w/ a diaphragmatic hernia may require ECHMO?
Diaphragmatic hernia allows passage of bowel contents into the thorax => compression of the lungs and pulmonary hypoplasia
-pulmonary HTN 2/2 hypertrophy of the pulmonary arteries, pulm HTN may become severe enough to require vents/echmo
In the vogelgram: name late vs. early mutations seen in CRC
Colorectal cancer:
first is APC inactivation (hence why Lynch syndrome is such a shitshow)
-after APC inactivation is K-ras activation
Late is p53 inactivation
In the US why do we remove appendix surgically?
B/c 25% risk of recurrence if managed medically!
-we know this b/c abx is the standard of care used in Europe
Where is the large majority of maintenance fluids used?
Water used in metabolism
Best imaging study if suspecting
(a) cholecystitis
(b) choledocolithialsis
(a) Abdominal ultrasound for cholecystitis
(b) MRCP if suspecting choledocholithiasis
What percent of pts w/ gallstones are symptomatic?
Only 20% of pts w/ gallstones will have symptoms
-so 80% are symptomatic
Give 4 indications for CABG procedure
- Severe tripple vessel CAD
- Symptomatic angina despite maximum medical therapy
- Severe (over 50%) left main coronary artery stenosis
- Multivessel disease w/ decreased EF
Carcinoma vs. sarcoma
Carcinoma = neoplasm from epithelial tissue
Sarcoma = neoplasm from mesenchymeal tissue
Which abdominal wall defect may require ‘paint and wait’
Paint and wait technique sometimes used in omphalocele (covered by sac) b/c defects tend to be much larger and may even include the liver
Explain the purpose of D5 solution
NOT for calories! 2L of D5 will only give you 400 calories…
-used for safety: prevent lysis by having a benign solute present
Why would EMS use NS instead of LR in an emergency situation?
B/c LR has very low K+, so may replete someone’s calcium, avoid LR until you know someone’s K+ level
While NS has high K+ and would even help replenish K+
Give example of meds used in RSI in burn victim
Rapid sequence intubation in burn victim
- Induction w/ fentanyl, propofol
- Neuromuscular blockade w/ rocoronium
- don’t give succinylcholine 2/2 risk of hyperkalemia
UC vs. Crohn’s
(a) Gross pathology inside the colon
(b) Gross pathology outside the colon
UC: surgically curative
-in the colon see psuedopolyps
Crohn’s- avoid surgery as long as possible
(a) Inside colon: non-caseating granulomas, transmural, cobblestoning
(b) Outside colon: fat-wrapping (‘creeping fat’), transmural
Most common etiology of large bowel obstruction
Carcinoma! (colon cancer) 60%
- 20% diverticulitis
- 10% volvulus
Most common location for extra-adrenal pheo
Paraganglioma (extra-adrenal pheo) most commonly found at the bifurcation of the aorta
Why are change in bowel habits seen w/ left vs. right sided colonic lesions
B/c stool is more liquid in the right colon (so more easily passes regardless) and the right colon has a larger diameter
Define dislocation, differentiate from displaced
Dislocation can only happen at a joint
-fracture in the middle
Most common location for diverticulitis
Sigmoid colon
Define carcinoma in situ
Carcinoma in situ means the full thickness of the epithelium is involved, but the basement membrane has not been invaded
Management of asymptomatic gallstones
Surgery NOT indicated, only requires surgery if symptomatic
-80% of pts w/ gallstones are in fact asymptomatic
Calot’s triangle
Calot’s triangle = 3 C’s- anatomic structures important in view during lap choley
- cystic duct laterally
- cystic artery superiorly
- common bile duct medially
Use of oncotyping in breast cancer
Do oncotype in breast cancer pts to stratify risk of recurrence, which in term determines indication for chemotherapy
Oncotyping stratifies into low, int, high risk of recurrence, deterine if adjuvant chemo would be indicated
Name 3 medications that are relevant when taking a history from someone w/ blood in stool
Iron- can turn stool black
ASA/NSAIDs- can cause gastric irritation/PUD
Steps to consider pre-op for removal of pheo
Need alpha blockade
-also need to give TONS of fluids b/c w/o the pheo the pt will vasodilate peripherally
Charcot’s triad
Charcot’s triad of symptoms of acute cholangitis (bile duct inflammation)
- RUQ
- fever
- jaundice
Classic clinical presentation of UC
Bloody, mucosy diarrhea
How many grams of dextrose are in 1L of D5?
D5 means there is 5g of dextrose per 100cc of fluid => 50g of dextrose in 1L
Differentiate management of trauma to r. vs. left renal vein
Injury to left vein- just tie it off, b/c there are collaterals on the left
Injury to the right vein requires nephrectomy b/c it lacks collaterals
Why do we not just use water for maintenance fluids?
B/c water is hypotonic to our cells => would hemolyze us!!!
Name 3 extra-colonic features of UC
- pyoderma gangrenosum
- PSC
- Anterior uveitis
Explain the 4:2:1 rule for maintenance fluids
- 4 cc/hr for the first 10kg
- 2cc/hr for the next 10kg
- 1cc/hr for the rest of the kg
Which 2 groups of women w/ breast cancer get axillary LN dissection
Only indications for LN dissection
- Positive LN found before surgery
- +LN found on mastectomy
Which part of the GCS is the best predictor of outcome in a head injury pt
EVM (eyes, verbal, motor)
Motor is the best predictor of outcome, especially in head injury
Most common cause of lower GI bleed
- Angiodysplasia
2. Diverticulosis
Who gets adjuvant chemo in CRC?
A single positive node w/ CRC indicates adjuvant chemo
Genetics vs. genomics
Genetics = inherited DNA
Genomics = the entire genetic code, including mRNA and proteins made
How to diagnose diverticulitis
CT is diagnostic
-WBC, LLQ pain, palpable mass are supportive- but CT is diagnostic
Composition of gall stones
80% of gall stones are cholesterol stones
20% are pigment stones
Ideal urine output for
(a) normal adult
(b) normal child
(c) Adult w/ burns
Urine output goals
(a) Normal adult: .5 cc/kg/hr
(b) Kids and burn victims: 1 cc/kg/hr
How would a pt present if their lap band was eroding
Erosion of the port site! manifests as port site infection
Rule for upper limit of normal diameter of bowel on abdominal Xray
3-6-9 Rule ULN diameter: -3 cm for small bowel -6 cm for colon -9 cm for cecum
Which stones would we attempt to medically break up?
Kidney stones, NOT gall stones
- if you break up a kidney stone you’re just putting pieces into the bladder/urine (no biggie)
- but if you were to break up gallstones you’d just shoot tiny pieces out into more tiny ducts
Define ascending cholangitis
Ascending cholangitis = infection of the bile duct 2/2 ascending infection from small intestines (usually from duodenum)
-increased risk of bile duct is already partially obstructed by presence of gallstones
Define aneurysm
Focal arterial dilation of at least 50% above expected
ex: upper limit of normal diameter for abdominal aorta in adult male is 2cm => above 3cm is considered an aneurysm
5 P’s of compartment syndrome
5 P’s of compartment syndrome
- pain w/ passive stretch
- pallor
- poikilothermia (warmth)
- pulselessness
- paresthesia
2 ddx for rapidly growing neck mass
Anaplastic thyroid carcinoma vs. lymphoma
