E-Med Flashcards
ORIF
Open Reduction
Internal fixation
CRPPF
Closed Reduction
Percutaneous pin fixation
DRUJ
Distal Radio-ulnar joint
TFCC
Triangular fibro-cartilage complex
AVN
Avascular necrosis
Incomplete FXs
Bowing
Greenstick
Torus
Physeal FX (children)
Salter Harris classif
Type 1 “S”
Separation
right along the physeal line
Type 2 “A”
above the line, into the shaft
Type 3 “L’
Lower, below the line into the epiphysis
Type 4 “T”
Through
through the line
Type 5 “R”
Ruined, rammed
crushed together
high impact, MVA
Comminuated FX
bunch of pieces
Two factors that we can control as providers to prevent Osteomyelitis
Surgical debridement
Proph Abx
Most common open fracture
Tibia (so close to skin)
Most common ABX used for open fractures
IV Cephazolin
What can you add to Cephazolin to treat open fracturess?
+ Aminoglycoside (like Gentamicin)
What do you still have to worry about with open fractures that you may think was not now a problem?
Compartment syndrome
Keep in mind with Scapula fx
Often another injury involved (make sure to evaluate Spine)
Proximal humeral fracture
Neer classification
Humerus Shaft fracture
Radial nerve; “wrist drop”
Humerus AND Forearm fracture result in
“Floating elbow”
X Rays for Humeral Shaft fracture
AP and
AP w external rotation
Most common shoulder dislocation
Anterior
Mechanism: sports, blow to shoulder while abducted
Posterior shoulder dislocation mechanism of injury
Seizures
Electrocution
Sulcus sign
Apprehension and Relocation test
Shoulder dislocation
What do you need to order to rule out Posterior shoulder dislocation?
Axillary view
best to see posterior dislocation
3 injuries associated with Anterior Shoulder dislocation
Bankart lesion
Hills Sachs lesion
Axillary nerve
Bankart lesion
lower part of Labrum becomes detached
Hills Sachs lesion
Fracture, depression of the humeral head
Axillary nerve damage
secondary to Anterior dislocation
Decreased Sensation to lateral aspect of shoulder and Decreased deltoid fx
Elbow fat pad sign
Be cautious of a fracture!!! signifies blood coming out of the bone
Nursemaid’s elbow is an example of
Elbow Sublux
Sublux vs Dislocaiton
Sublux: harder to detect, may spontaneously reduce
Dislocate: clinically deformed, very painful, needs immediate reduction
Main scan for Dislocations
X Ray
If you suspect an Avulsion injury associated with Dislocation, THEN
order CT
If you have concern for Ligament integrity
order MRI
Forearm fracture consideration
Suspect TWO injuries:
two FX
FX + dislocation
What two X Ray views to oder with Forearm fracture?
AP
Lateral
Monteggia fracture
Ulnar shaft + Radial head dislocarion
Colles fracture
“dinner fork”
Dinner fork
Colles fracture
DORSAL displacement
Smiths fracture is
Volar displacement
Dinner fork
Colles fracture mecanism
FOOSh
Snuff box pain, order _____ X Ray
Scaphoid view
Galeazzi fracture
DRUJ
Scaphoid fracture
Snuffbox pain
Complication of Scaphoid fracture
Avascular Necrosis
What part of Scaphoid is at highest risk for Avascular Necrosis?
Proximal aspect
Tx of IP Dislocation
Buddy tape x 2 weeks
Jersey finger
Flexor tendon rupture
Jersey finger
Flexor tendon
Usually also see Avulsion fracture
Jersey finger
ring finger most common
Mallet finger
Rupture of Extensor tendon (DIP)
Tx for Mallet finger (extensor tendon)
STAX extension splint
Boxer’s fracture
Neck of 5th MC
Tx for Boxer’s fracture
Ulnar gutter splint
Bennett’s fracture
base of 1st MC
into joint
Game Keepers thumb fracture
injury to MCP joint, —> ulnar collateral ligament tear
Tx for Game keepers thumb “skiers thumb”
Thumb spica splint
Stop ASA, NSAIDs, Plavix, Warfarin ___ days before surgery
3-5 days before
SCIP
Surgical Care Improvement Project
prevent INFECTION
SCIP was in response to
77% deaths related to infection
SCIP protocol
Proph abx 1 hr before surgery
Stop abx 24 hr after surgery, or end time 48 for Cardiac
Cardiac pts controlled 6am post op glucose measure
Approp hair removal
Colorectal pts appropriate normothermia
ASA classification
Predict operative risk
6 classes:
1: healthy
2: mild systemic dz
3: severe systemic dz
4: dz constant threat to life
5: will not survive w/o surgery
6: organs for donation
Mallampati Score
Class 1-4
Ease of intubation- how well will someone do with protecting airway?
4: toughest time
Pre op EKG needed for
men younger age
Men >45
Women >55
Known hx of Cardiac dz
Diabetes
HTN
Major surgery
Pulm risk assmt
High risk:
- Smoking (stop 2 months before surgery)
- COPD, Asthma
- Thoracic/abd procedure
- Obesity
Pre op assessment for those at high risk - PULMONARY
CXR
Pulmonary Function Tests
ABGs
Pulm consult
Risk of peri-op MI
Prior hx: HTN MI CHF Dysrhythmia Valvular heart dz
Post MI, no surgery until
6 months after MI
Highest risk peri-op MI
dont want a score higher than 10
>age 70 previous MI S3 gallop or JVD Aortic stenosis EKG : PVC Abnormal labs Emergency surgery
Total possible: 53 points
Pre-op Diabetes assessment
Elevations in glucose and A1C increases risk of post op INFECTIONS
Post op care for Diabetics
Follow Blood Sugar every 6 hours
maintain b/w 150-200
Adrenal insufficiency, need to cover pre-op with
Give Hydrocortisone
-otomy
incision into
“thoracotom”
-ectomy
removal of
-ostomy
creation of new opening
-plasty
plastic surgery
repair of something
-pexy
fixation
-rraphy
suturing or oversewing something to make it safe/more durable
Most common used surgical position
supine
Pelvic organs
Central lines
Trendelenburg
Upper abd viscera
reveres Trendelenburg
Sitting position
Cranial surgeries
Lithotomy
Urology
Gynecology
Rectal
Prone
spinal surgery only
Lateral position
Retro-peritoneal approaches
LaparoTOMY
open, large incision
Arthroscopy
used in Ortho
small incision, camera in JOINT SPACE
LaparoSCOPY
minimally invasive
VERY COMMON
use gas (CO2) to inflate peritoneum, use instruments through small incisions, video camera
Referred R shoulder pain
diaphragm stretch
Common procedures done via LaparaSCOPY
Gall bladder removal
Appendectomy
Hernia repair (Inguinal, Ventral)
Nissen fundoplication
What days are we most worried about fever/infection post-op
3-5
Immediate post-op fever
within hours
Meds
Blood products
Malignant hyperthermia
Acute post-op fever
first week
Nosocomial infection
UTI
Aspiration PNA
Subacute post-op fever
1-4 weeks
Central venous catheter
Delayed post op fever
>1 month
Abscess
post op fever >102 F, quick to draw
CBC
UA
Cultures
CXR
on BOTH arms
Post op fever within 48 hours
Atelectasis
Wound infection
Group A strep
Leakage of bowel anastomosis
back to OR
Aspiration PNA
Pulmonary toilet
Get respiratory involved
Clean surgical wounds
Leave in place 48 hours to allow for epithelialization
Contaminated wounds
Packed open
Wet to moist change every 8-12 hours
Infections post op
24-48 hours
Clostridium
Group A Strep
Wound dehiscence
5-8 days post op
salmon colored fluid
GET BACK TO OR
potential risk for Evisceration
Most commonly used Proph abx
1st and 2nd gen Cephalosporin
Most common cause of fever within 48 hours of surgery
Atelectasis
Why is atelectasis so common after surgery?
Surgical manipulation –> Diaphragm dysfx and Diminished surfactant activity
Peritonitis
Look septic
shaking bed test
CXT
CT
US all helpful
Intrabdominal infections
E.coli
Enterobacter
Laparotomy
I and D
Drainage
Broad spectrum Abx
Bacteremia
fever, chills, tachy
check IV lines every 3 days to PREVENT bacteremia
Debridement options
Sharp- remove w blade, often in OR, large amt tissue, infected wounds, fast, painful
Mechanical- wet to dry dressing
Autolytic- use body’s own enzymes
Enzymatic- chemicals, turn necrotic tissue into slough
Biologic- maggot
CONTRA to using VAC drain
Necrotic tissue Untx Osteomyelitis Fistula CA in wound Exposed artery/vein
otherwise, great choice
Mayo Scissors
Multi-purpose “workhorse”
Straight- “suture scissors”, superficial tissue, fascia
VS
Curved- cut tendons, ligaments, muscle, heavy tissue
Metzenbaum Scissors
aka “Metz”
Blunt dissection, or cut delicate tissue
NOT for suture
Mayo Scissors
SUTURE scissors
DeBakey forceps
Grasp fine tissue and blood vessels
Soft tissue dissection
Adson forceps
with teeth
without teeth
grasp delicate tissue
Tissue forceps w/teeth
“Rat tooth Forceps”
grasp HEAVIER tissue for manipulation and retraction
Russian forceps
grasp DENSE tissue
hold during wound debride and closure
MANY types of Locking forceps
Mosquito Hemostat Kelly Tonsil Right angle Ring Babcock Kocher Rochester Peon Allis Towel clips
Mosquito forceps
Fine tip
Use: clamp vessels, grasp bleeding tissue, suture-ligate vessel
Hemostat (crile) forceps
Same as mosquito, just different in size
Clamp vessels, Grasp bleeding tissue, Suture-ligate vessel
Kelly forceps
LARGER hemostat
Clamp large vessels, manipulate heavy tissue, soft tissue dissection
Tonsil forceps
tunneling for Drain placement
Right angle
Hard to reach vessels
“Tie on a passer”
Ring forceps
Sponge forceps, sponge stick
Use: FOLDED SPONGE IN JAWS to retract tissue and ABSORB fluids in surgical field, or tissue removal
Babcock forceps
Tubular organs
Kocher forceps
TRAUMATIC
poky, will do damage to whatever it holds so it will be something you plan to retract anyway
i.e. hemostasis, hold tough cartilage, hold ribs during rib resection
Rochester Peon clamp
Large KELLY
Traumatic
Use: Mesenteric (stomach organ) hemostasis, Chest tube insertion
Allis forceps
Traumatic
Hold tough structures
Grasp tissue that’s going to be removed (i.e. breast tissue, thyroid)
Towel clips
“penetrating type”
Traumatic
Clamp towels together
Clamp tissue for manipulation and removal
Caution- will pierce drapes, gloves, and fingers!!
Towel clips
“Non-penetrating type”
Clamp drapes, towels together
“Self retaining” Retractors
you don’t have to hold them
Weitlaner
Gelpi
Weitlaner (self-retaining) Retractos
sharp or dull ties
Gelpi (self- retaining) Retractors
sharp tips
Retractor holders (manual) may be instructed to
“toe-in” bring the tips closer together, little at a time
Types of manual retractors (MANY)
Army navy Goulet Richardson Malleable/ribbon Dever Rakes
Types of Self-retaining Retractors
only two
Weitlaner
Gelpi
Army Navy and Goulet retractor
Shallow, superficial retraction
Richardson retractor
“Big rich” (large) and “baby rich” (small)
Common in most specialties
retracts various tissues
Malleable/Ribbon retractors
Many widths
Bend to shape
Used often in ABDOMEN and CHEST
Dever retractors
used in DEEP incisions
Consider with Dever retractors
can use blue towel to wrap around edges if you are holding for long time bc sides may be sharp
Rake retractors
Elevating subQ tissue, broad surfaces and edges
Additional equipment
Bovie Irrigation Suction Sponges Needles
“Bovie”
used in Electrosurgery Can do many things: -cut -coagulate -desiccate -destroy tissue
Irrigation
usually saline (diff temps)
Bulb syringe irrigation
irrigate wounds, wet hands for suture tyine
Pitcher pour irrigation
“washout”
Suction types
Yankauer
Poole
Frazier
Yankauer suction
general MULTI PURPOSE suction tip
Poole suction
good for LARGE VOLUME
Frazier suction
very tine suction tip
Suction-Irrigator
just like what it sounds like
can do both things at once
When to stop smoking before surgery
8 weeks is optimal
Post op stress response
“Fight or Flight”
increased SNS
Metabolism, gut motility, absorption affected
Meds to continue throughout surgery
If sig withdrawal sx
Cardiovascular meds
Statins
Tight glycemic control
Med to stop
Anticoags
7-10 days b4 surgery
Assessment of Surgical risk
Age
Urgency of operation
Anesthetic mortality
Risk assessment
If the surgery is emergent, how does that affect the risk for operative mortality?
Doubles it
Coag disorder risk factor
Previous clot
Mobility
Bleeding risk
Prior hx of bleeding is best predictor
Risk for malnutrition
> 15% weight loss over prior 3-4 months
Albumin <3
“Ebb and flow” of post surgery
hours;shock
days; catabolism (break down)
weeks; anabolism (build stuff back up)
“Ebb”
Immediate
Tissue hypoperfusion (LESS blood flow)
Decrease metabolism (slow down)
Ne release
“Flow”
Peaks at 3-5 days
Catabolic and anabolic
Increased CO
Increased metabolism
Hyperglycemia
Anabolic (last part) of the “Flow”
Corticoid withdrawal
Repletion
Most sensitive test of illness and perioperative morbidity
Prealbumin
half life 2-3 days
Serum Transferrin can test for
Protein deficiency
<200
“SQIP” or “SCIP” stands for
Surgical Quality Improvement Project
decreasing surgical infections with standard protocols
Prevent complications in all of these ways:
Normothermia Proph Abx Glucose control Hair removal Skin antiseptic Oxygen Clot prevention
Goal temperature
98.6-100.4
Glucose control
average 150
Skin antiseptic
Chlorhexidine
or maybe Iodine
Oxygenation preferred to remain at
80%
How often to measure I&O after surgery
on day 1: every 4-6 hrs
after that: every 24 hrs
Crystalloids
Most commonly used
Sodium is main osmotically active particle
Colloids
High molecular weight
more likely to stay in vascular compartment
Isotonic Crystalloids
- Normal saline
- Lactated Ringer
Have same salt concentration as normal cells of the body
can bolus
use when someone hasn’t been eating/drinking
When to use Colloids?
high molecular weight, stay in vascular compartment
Burns
Peritonitis
when you NEED to increase volume
Trigger number when we need to TRANSFUSE BLOOD
if Hg <7 : stable pts
may be lower in those with cardiac, pulm, CVA, or transplant
When to transfuse platelets
Active bleeding in Thrombocytopenic (low platelet) pts
when to use FFP
pts with Deficiencies in clotting factors
OR
on Anti-coags
How many hours for epitheliazation
48
How long does it take for gut to become active again
Small int: 24 hrs
R. colon: 48 hrs
L. colon: 72 hrs
POD 1 fever
PNA, atelectasis
POD 3-5 fever
UTI
POD 4-6 fever
Blood clot
POD 5-7 fever
Surgical site infection
OBGYN
POD 7+
drug fever
IV lines or
Rxn to blood products
Gray, dusky discoloration
Crepitence
Need aggressive surgical excision
Necrotizing Fasciitis
Rupture of ALL layers and extrusion of abdominal viscera
Evisceration
5-8 days post op
Meckel’s diverticulum
rule of 2s
Antimesenteric border of ileum (meaning opposite side of ileum)
Mesenteric Ischemia
DEC blood flow
Occlusive (clot) or non-occlusive process (hypotension…etc)
Mesenteric ischemia is most common in
Older pts with dz causing clot formation
Intestinal angina
relating to Mesenteric Ischemia
Stomach pain worse AFTER MEALS
also: pain out of proportion, hematochezia
Tx for Mesenteric Ischemia
Aggressive IVF NG tube Foley catheter Abx Anti-coags Surgery
Enteric fistula
usually happens:
Post-op!!
a connection b/w two epitheliazed surfaces that is not supposed to be there
Problem with Enteric Fistula is:
Loss of GI contents
Malnutrition
losing a much too high amount of GI contents
Tx for Enteric Fistula
Close it Fluids Bowel rest Control drainage/ skin protection Surgery
Bariatric surgery candidates
BMI >40 YO
BMI >35 + comorbidities
Nothing else working
Compliant pt
Roux-En-Y gastric bypass
Most common!!
Restrictive AND Malabsorptive
Make stomach smaller AND bypass duodenum
Gastric banding
Silicone band lines with inflatable balloon
RESTRICTIVE
risk: band can move/slide
Vertical Band Gastroplasty; RARELY done
RESTRICTIVE
staple and band
Sleeve Gastrectomy
Slice off the outside portion of stomach
Staple close
Make stomach smaller; RESTRICTIVE
Perforation is more common if your age is
younger than 10
older than 50
PeritonITIS
follow Perforation
High fever –> SEPSIS risk
can be localized (contained by surrounding viscera or omentum) OR generalized (gross spillage into peritoneal cavity)
Where is Diverticulitis most common?
Sigmoid colon
LLQ
When to consider surgery for Diverticulitis?
Repeated attacks (2 or more)
Complication
Nothing else working
Harmann’s procedure
commonly done for Diverticulitis
Loop colostomy
Helps to:
- decompress Distal end
- allow Proximal end to drain
Ileostomy: loop of ileum (last part of sm. int) brought up to abdominal wall
HIGH OUTPUT
bc you don’t have absorption going on
Proctocolectomy
removal of ENTIRE colon and rectum
Abdominoperineal resection
low rectal CA
Removal of: lower sigmoid, entire rectum and anus
Low Anterior Resection
CA of middle and upper section of rectum
Remove: distal sigmoid, 1/2 of rectum. then perform Proximal sigmoid-distal rectum anastamosis
Common tx for Hemmorhoids
Rubber band ligation
Surgical Hemorrhoidectomy
Mixed internal and external hemorrhoids
Very uncomfortable procedure
Common organisms of Anorectal ABSCESS
E.Coli
Proteus
Common problem after Anorectal Abscess
Fistula
50% chance
What is Seton placement used for?
Tx of Anal Fistula
It’s a loop drainage tube to encourage body to heal from inside out
Borders of Heisselbach’s triangle
Epigastric artery/vein
Rectus abd muscles
Inguinal ligament
INDIRECT hernias go into
inguinal canal
Rate of recurrence with hernias is higher in what type?
DIRECT hernias
