Dr. P's notes Flashcards
Which is taken care of first, the airway, or a cervical spine issue?
Airway
If there is SQ emphysema in the neck, then what type of device is used to place an airway? Why?
Endoscope
Is a sign of major trauma to the tracheobronchial tree
What happens to CVP with tension pneumothorax and pericardial tamponade respectively?
Both elevated
What is the type of fluid used in the trauma patient
2 L of LR, followed by packed RBCs
Is it appropriate to wait to obtain a CXR for a tension pneumothorax?
No
What is the treatment for cardiogenic shock?
Do not administer fluids or blood–circulatory support
What happens to CVP with cardiogenic shock?
Increased
What is the general indication for surgical treatment of a skull fracture?
Left alone if they are closed–open, comminuted, or depressed fractures require surgical intervention
What other part of the body must be assessed/imaged if there is a basilar skull fracture?
C-spine
What type of intubation must be avoided in patients with a basilar skull fracture?
Nasotracheal
What are the three components that can cause neurological damage in the head trauma patient?
- Initial blow
- Hematoma that develops afterward
- Increased ICP
What is the classic sequence of events for an epidural hematoma?
Trauma, unconsciousness, lucid interval, coma
Lens-shaped hematoma = ?
Epidural
Semilunar, crescent shaped infarct = ?
Subdural hematoma
True or false: mannitol is contraindicated in an acute subdural hematoma
False–indicated.
What is the treatment for diffuse axonal injury?
Decrease ICP
What is the cause of a subdural hematoma?
Rupture of bridging veins
True or false: hypovolemic shock cannot happen from intracrainial bleeding
True–not enough space for the bleed
What is the general workup for penetrating neck trauma to the upper zone?
Arteriographic study
What is the general workup for penetrating neck trauma to the base of the neck?
arteriography
Esophagogram
Esophagoscopy
True or false: Stab wounds to the upper and middle zones in asymptomatic patients can be safely observed.
True
What are the s/sx of Brown-Sequard syndrome?
Loss of pain contralateral
Loss of proprioception ipsilateral
What are the s/sx of anterior cord syndrome?
Loss of motor function and loss of pain/ temp sensation on both side distal to the injury
-Preserved proprioception and vibratory sense
What is the cause, and s/sx of central cord syndrome?
Forced hyperextension of the neck
-Paralysis and burning pain in the UE, but normal LE
What is the treatment for a rib fracture?
Local nerve block and an epidural catheter
What is a common complication of a rib fracture in an elderly patient?
Atelectasis 2/2 pain, leading to pneumonia
What is the treatment for a sucking chest wound?
Three sided flap to let air out, but not in
What happens to the chest with flail chest?
Goes out during expiration, and in during inspiration (paradoxical breathing pattern)
What is the problem with a flail chest? What is the appropriate management?
Consution of the lung
Fluid restriction and the use of diuretics
What is the treatment for a pulmonary contusion?
Deteriorating ABGs, white out on CXR
What type of injury usually produces a traumatic rupture of the aorta? S/sx?
- Sudden deceleration
- Asymptomatic until adventitia that is holding in the blood ruptures and kills the patient
What are the s/sx of a traumatic rupture of the trachea?
Emphysema in the upper chest or lower neck
Emphysema in the upper chest is suspicious for what disorders?
Esophageal rupture
Tracheal rupture
Tension penumo
What is the treatment for an air embolism?
Left side down
cardiac massage
What is the treatment for a fat embolism?
Respiratory support
What are the two major indications for avoiding laparoscopic exploration of a stab wound?
- No bulging viscera or peritoneal signs
- VSS
When does blunt trauma to the abdomen require laparoscopic exploration?
If there are signs of peritoneal irritation or shock
What are the three locations in the body that can hide blood in trauma?
Thighs
Abdomen
Pelvis
What is the old alternative to a FAST exam?
Peritoneal lavage
What is the treatment for intraoperative development of coagulopathy?
Ffp
What are the exams that should be done on a patient with a pelvic fracture?
Retrograde urethrogram pelvic exam, and DRE
What is the Hallmark symptom of Urologic injury?
Hematuria
What prostate finding is associated with urethral injuries in men?
High riding
What should be done in a suspected case of a urethral injury?
Retrograde urethrogram
When are scrotal hematomas concerning?
If the testicle is ruptured
What is the order of repair in terms of the following: nerves vasculature bone?
Bone
Vasculature
Nerves
Why give copious amounts of IVFs with electrical burns?
Myoglobinemia may lead to renal failure
What is the best diagnostic criteria to determine if someone with smoke inhalation injury needs oxygen?
ABGs
What is the concern with circumferential burns of the extremities?
Cut off blood supply as edema accumulated underneath the eschar
What are escharotomies, and what are their indications?
Breakdown of an eschar
Done in the case of circumferential burns
What causes the hypovolemic shock in burn patients?
Movement of fluids into burn areas
What is the goal urine output and CVP in burn patients?
- 2 mL/kg/hr
- Avoid CVP over 15 mmHg
What is the protocol for burn patients with over 20% burn surface area?
1 L / h of LR
What is the standard topical agent for burn patients?
Silver sulfadiazine
When is a skin graft indicated for a burn patient?
If not healed after 2-3 weeks of supportive measures
what are the signs of envenomation of a snake bite?
severe local pain, swelling, and discoloration developing within 30 minutes of the bite.
True or false: Antivenin dosage relates to size of the envenomation, not size of the patient
True
What is the only valid first aid technique for a snake bite?
Splint the extremity (no icing, tourniquet, or cutting)
What are the coral snakes colors, and why are these concerning?
Red on yellow, kill a fellow
Deadly neurotoxin
What is the characteristic feature of black widow spiders, and what is the antidote to their venom?
Red hourglass on stomach
IV calcium gluconate
What is the treatment for brown recluse spider bites?
Surgical excision PRN
What is the treatment for developmental dysplasia of the hip?
Treatment is abduction splinting with Pavlik harness for about 6 months.
What is Legg-Calvé-Perthes disease? S/sx?
Avascular necrosis of the femoral epiphysis
insidious development of limping, decreased hip motion, and hip (or knee) pain.
What is slipped capital femoral epiphysis? S/sx?
When they sit with the legs dangling, the sole of the foot on the affected side points toward the other foot. On physical exam there is limited hip motion, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally.
What is the general position that patients place their hip in with a septic hip?
Flexed, slight abduction, and external rotation
Genu varum is normal up to what age?
3 years
Genu valgum is normal between what ages?
4-8
What is osgood-Schlatter disease? S/sx?
(osteochondrosis of the tibial tubercle) is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps.
What is clubfoot (talipes equinovarus)?
Both feet are turned inward, and there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia.
What is the treatment for club foot?
Serial plaster casts
How do supracondylar fractures of the humerus usually happen? What is the major complication that can arise from this?
FOOSH
Vascular or nerve injuries can easily occur, and they could lead to Volkmann contracture.
When is open reduction and fixation required when a growth plate is involved?
If the plate itself it broken, not just displaced
What is the age range that bone tumors usually affect?
10-25
What part of the bone does Ewing’s sarcoma usually affect?
Diaphysis of long bones
What are some of the common presenting symptoms of bone cancers?
Fractures or bone pain
Where do most metastatic bone cancers come from in women and men?
Women = breast Men = prostate
What is the drug that can be used it multiple myeloma if chemotherapy is ineffective?
Thalidomide
What is the usual position of the arm when the shoulder is anteriorly dislocated? Posteriorly?
Anterior = Close to body, but like about to shake your hand
Posterior = close in and internally rotated
What is a colles fracture? treatment?
fracture and posterior displacement of the distal radius
Treat with close reduction and long arm cast
What is a monteggia fracture?
Night stick fracture
What is a galeazzi fracture?
one: the distal third of the radius gets the direct blow and has the fracture, and there is dorsal dislocation of the distal radioulnar joint.
What is the treatment for a scaphoid fracture?
thumb spica
What is the treatment for a metacarpal neck fracture(s)?
Closed reduction and ulnar gutter splint
What is the classic presentation of a hip dislocation?
Affected leg is shortened and externally rotated
How are intertrochanteric fractures treated?
Open reduction and internal fixation
How are femoral shaft fractures treated?
intramedullary rod placement, but orthopedic emergency if open
What is the best and fastest way to determine if a knee injury is serious or not?
if there is swelling
What is the classic symptom of meniscal tears?
Clicking or locking
What is the treatment for tibial stress fracture?
Cast /crutches and repeat x-ray in two weeks
What are the most common areas of the body to develop compartment syndrome?
distal leg
Forearm
What is the treatment for an achilles tendon rupture?
Casting in equinus position
When are fractures of the ankle fixed with open reduction?
If fragments are displaced.
What is the treatment for gas gangrene?
IV PCN, emergency surgical debridement, and hyperbaric oxygen
How does the leg appear with a posterior hip dislocation?
leg shortened, adducted, and internally rotated.
What is the classic motor deficit associated with radial nerve injury?
Inability to extend the wrist
True or false: even if the patient regains function in the distribution of the radial nerve after splinting, they need surgical exploration
False
How is the popliteal artery usually injured?
Posterior dislocation of the knee
What does it mean to follow the direction of force with injuries?
follow lines of force to assess other bones that may be impacted
Facial fractures always necessitate the need to evaluate what other part of the body?
Neck
What is the treatment for radial nerve compression?
Splints and antiinflammatories
Electromyography + surgery if that doesn’t work
What is the first line therapy for trigger finger?
Steroids, then refer to surgery
Where is the pain with De Quervain tenosynovitis?
radial side of the wrist and the first dorsal compartment
What is a felon? Treatment?
An abscess in the pulp of a fingertip, caused by a neglected penetrating injury
Drain it
What is jersey finger, and what is the treatment?
injury to the flexor tendon when the flexed finger is forcefully extended
splint
What is mallet finger? Treatment?
Extended finger is forcefully flexed, and the extensor tendon is ruptured
What is the progression of symptoms with a disc herniation?
vague, discogenic pain from anterior ligament compression, then neurogenic pain
What is the treatment for a ruptured disc?
Spinal block, and rest
Surgery if neurological symptoms are progressing
What are the s/sx of cauda equina syndrome?
Distended bladder
Flaccid rectal sphincter
Perineal saddle anesthesia
What is the general appearance of arterial insufficiency ulcers?
White base withOUT granulation tissue
What two systemic diseases should be evaluated for with chronic foot ulcers?
Diabetes
Atherosclerotic disease
How do venous stasis ulcers usually appear?
Painless, with a granulating bed
What are Marjolin ulcers?
a squamous cell carcinoma of the skin developing in a chronic leg ulcer.
What is the treatment of plantar fasciitis?
Supportive, and removal of bone spur if bad
What is morton’s neuroma? Treatment?
Inflammation of the common digital nerve at the third interspace between the third and fourth toes
Analgesic and shoes
What are the two drugs that are used for an acute attack of gout?
Indomethacin
Colchicine
What are the two drugs that are used for chronic control for gout?
Allopurinol
Probenecid
What is a normal ejection fraction? under what amount poses a prohibitive cardiac risk for noncardiac operations?
55% is normal
Below 35% is risky
What are the components of Goldman’s index of cardiac risk?
- JVD
- Recent MI
- PVCs or any arrhythmia
- age over 70
- Emergency surgery
- aortic valvular stenosis
- poor medical condition
- Surgery within the chest or abdomen
What is the issue with smoking and surgery? What is not?
Compromised ventilation (high pCO2, low FEV1)
NOT compromised oxygenation
Two clinical findings and three laboratory values are used to predict operative mortality in patients with liver disease. Name them
- Encephalopathy
- Ascites
- serum albumin
- prothrombin time (INR)
- Bilirubin
What are the indicators of severe malnutrition that is a contraindication to surgery?
- Loss of 20% body fat over a few month period
- Serum albumin below 3
- Serum transferrin below 200
What are the two drugs that classically precipitate malignant hyperthermia?
Halothane
Succinylcholine
Severe wound pain and very high fever within hours of surgery = ?
gas gangrene
What is the sequence of things that cause post op feveR?
atelectasis pneumonia UTIs DVTs wound infection Deep abscesses
What is the ultimate therapy for atelectasis?
bronchoscopy
Fever 2/2 a wound infection usually occurs after how many days post surgery?
7 days
What is the most common cause of MI in the perioperative setting?
Hypotension
What cannot be used to treat MIs in the post op setting? What should be?
Cannot use thrombolytics
Emergency angioplasty
Coronary stent placement
When do PEs usually occur in post op patients?
day 7
What will an ABG analysis show with a PE?
hypoxemia and hypocapnia
What is the treatment for PEs?
Heparin
What are the indications for an IVC filter?
Recurrent PEs in a patient that cannot take anticoagulants, or for whom they are ineffective
What are the signs of a developing tension pneumothorax?
Increased effort to bag
Decreased stats
BP declines
CVP rises
What is the first etiology that should be suspected in a post op patient that is disoriented and confused?
Hypoxia
What is the electrolyte abnormality associated with SIADH?
hyponatremia
What is the treatment for hypernatremia?
D5, 0.5NS
When is a straight and foley cath indicated for post op patients with urinary retention?
- Straight after 6 hours of no voiding.
- Foley needed if need additional catheterizations
What happens to the fraction of excrete sodium in renal failure?
Decreases
Paralytic ileus is prolonged if there is what electrolyte abnormality?
Hypokalemia
paralytic ileus that does not resolve by 7 ish days should be suspicious for what etiology?
Mechanical bowel obstruction
What is ogilvie syndrome?
Common idiopathic ileus of the colon, usually found in alzheimer’s patients.
Presents with abdominal distention, but no TTP
What is the drug that classically stimulates bowel motility? MOA?
Why should this not be used?
Neostigmine
Acetylcholinesterase inhibitor
Should not be used since if bowel obstruction, then lethal
what is the treatment for ogilvie’s syndrome?
Colonoscopy
salmon colored fluid from an abdominal incision is suspicious for what?
Peritoneal fluid from wound dehiscence
What is the treatment for a wound dehiscence?
The wound has to be taped securely, the abdomen bound, and mobilization and coughing done with great care, while arrangements are made for prompt reoperation to prevent evisceration now or ventral hernia later on.
What is evisceration?
Where the skin itself opens up, and the abdominal contents rush out
what are the complications of fistulas in the GI tract?
Electrolyte disturbances
Every (__) mEq of Na above 140, correlates with 1 L of fluid loss.
3 mEq
What is the treatment for hypernatremia? Why this?
- D5 0.5 NS
- prevent too rapid a correction, which can lead to pontine demyelination
What is the treatment for rapid onset hyponatremia?
hypertonic saline
Which is used for alkalotic patients, and which for acidotic patients: LR or NS?
NS if there is alkalosis
LR if acidotic
What is the “speed limit” of potassium replacement?
10 mEq/ h
What is the ultimate therapy for hyperkalemia?
dialysis and 50% dextrose + insulin
What is a normal anion gap?
10 or 15
When is bicarb therapy indicated for acidosis? Why not all the time?
If the acidosis is 2/2 bicarb loss
Otherwise risks a rebound alkalosis when the underlying problem is corrected
One must be prepared to replace K as part of the therapy of acidosis. Why?
therapy. In long-standing acidosis, renal loss of K leads to a deficit that does not become obvious until the acidosis is corrected.
What is the treatment for metabolic alkalosis?
KCl
What is a Nissen fundoplication?
In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.
What are the two diagnostic techniques for motility problems of the GI tract?
Manometry
Ba swallow
Dysphagia that is worse for liquids = ?
Achalasia
What is the classic sign of esophageal perforation in the EGD setting?
Emphysematous neck
What is the initial treatment for a SBO?
NPO
NG suction
IVFs
Surgery if does not resolve within 24 hours
What is the difference in presentation of a bowel obstruction vs a strangulated obstruction?
Strangled will have peritoneal signs, as well as leukocytosis
What is the treatment for a strangulated obstruction?
Surgery
What is the treatment for a mechanical obstruction 2/2 an incarcerated hernia?
Manually reduce. If not able, then surgery
What is the usual presentation of cancer of the right colon?
Asymptomatic anemia
What is the usual presentation of cancer of the left colon?
BRBPR
Constipation and/or stool of narrow caliber
Are colonic polyps 2/2 peutz jeghers syndrome premalignant?
No
When is surgery indicated for crohn’s disease?
Only if there are complications such as bleeding, stricture, or fistulaization.
UC can be treated surgically, but usually is not. Why not?
because it always requires removal of the rectal mucosa, raising the need for a stoma or an ileoanal anastomosis.
What is the best method of diagnosing c.diff?
Toxin screens
Should antidiarrheals be used to treat c.diff?
No
What is the DOC for c.diff?
Metronidazole
What are the indications for emergency colectomy from c.diff?
Severe leukocytosis (50,000+)
Serum lactate above 5
No response to treatment
What is the treatment for internal and external hemorrhoids?
Internal = band ligation External = excision
What are the s/sx of anal fissures?
Exquisite pain with defecation, as well as bloody stools
What is the cause of anal fissures? Treatment?
Tight anal sphincter
Local botox,
topical NTG,
CCBs
Failure of an anal fistula is suspicious for what disease?
Crohn’s disease
What is a possible complication of a perianal abscess, particularly in diabetic patients?
Necrotizing fasciitis
What is the usual presentation of SCC of the anus?
Fungating mass growing outside the anus, and inguinal lymph node involvement
What is the treatment for SCC of the anus? Prognosis?
Resection, Chemo, and radiation
90% success rate
Which is more common: upper or lower GI bleeds?
upper, by far
What is the first step in diagnosing GI bleeding?
Pass and NG tube for suction and look for blood. If there is, then it is an upper source
- If not, and no bile, then f/u with EGD (since duodenum not sampled)
- If not, but with bile, then do lower
If there is active bleeding from the lower GI tract, what should be done?
- If more than 2 ml/min, then go angiogram
- If less than 0.5 m;L/min, then wait until stops, then colonoscopy
BRBPR in a child is almost always 2/2 what?
Meckel’s diverticulum
What is the best therapeutic option for stress ulcers?
Angiographic embolization
What is the treatment for a perforated colon?
Emergent surgery
What is the presentation and treatment for primary peritonitis?
Mild generalized abdominal pain
Abx
The treatment for a generalized acute abdomen is what?
Exploratory laparotomy
What are the x-ray findings of a volvulus?
air-fluid levels in the small bowel, very distended colon, and a huge air-filled loop in the right upper quadrant that tapers down toward the left lower quadrant with the shape of a “parrot’s beak.”
What is the treatment for a volvulus?
Proctosigmoidoscopic exam with the old rigid instrument resolves the acute problem. Rectal tube is left in. Recurrent cases need elective sigmoid resection.
ACute pain and GI bleeding (that is not hemorrhoids) = ?
ischemic colitis
What are the s/sx of a primary hepatoma?
vague RUQ pain, weight loss
What is the blood marker for a primary hepatoma?
alpha fetoprotein
What is the treatment for a pyogenic liver abscess?
Percutaneous drainage
What is the treatment for amebic abscesses of the liver?
Metronidazole
What is the relative level of bili in a patient with jaundice 2/2 hemolytic anemia?
5-8, (not 35-40)
What happens to direct and indirect bili with hepatocellular jaundice?
Both increase
True or false: obstructing gallstones are commonly seen on imaging
False
What is an ERCP?
An endoscopic retrograde cholangiopancreatogram (ERCP) is an invasive procedure that allows visualization and instrumentation of the biliary and pancreatic ducts. An endoscope descends into the duodenum, the ampulla is cannulated, and x-ray dye is injected.
