Emergency/Surgery Flashcards
Guillain-Barre syndrome
Acute ascending progressive neuropathy starting in the LE; weakness is symmetric.
-2/3 of cases, a mild upper respiratory infection or gastroenteritis precedes the onset by 1-3 weeks
Wernicke’s encephalopathy
Neuro symptoms due to thiamine (vit b) def
Triad: ophthalmoplegia, ataxia, confusion, but only 10% of cases have all three.
- often from malnourished people from EToH abuse
- give 100 mg IV, immediately on suspicion of this
Reye’s syndrome
Encephalopathy associated with fatty degeneration of the liver.
- Rare but severe cause of delirium progressing to coma
- May be history of viral illness (varicella, influenza)
- Linked to salicylates with virus
- S/sx: protracted vomiting and delirium which progresses to coma within 2 days.
Decerebrate
Arms are extended where as decorticate arms are flexed
Epidural hematoma
Vessel: middle meningeal artery
S/sx: Out, lucid interval, follow by unconsciousness
CT: bioconvex lense hematoma
Dx: Does not cross suture lines,
Bad news if: ipsilateral pupil dialation with contralateral hemiparesis (sx of impending herniation)
Subdural hematoma
Vessel: bridging veins
Sx/s: Gradually increasing HA and confusion
CT: Crescent shaped bleed
Dx: Does cross suture lines
Sub arachnoid hemorrhage
Cause: 80% due to saccular aneurysm
Sx/s: thunderclap HA, photophobia
CT: non-contrast CT, but findings not always present
Tx: craniotomy, clipping the aneurysm
Minimum MAP
90 mmHg
Basilar skull fracture: Sx/s
Hemotympanum Battle sign Raccoon's eyes Cerebrospinal fluid leaking form ear or nose Hearing loss
Coma clinical eye movement
The eyes may conjugately deviate toward the side of the hemorrhage.
If increased innercranial pressure is suspected
Mannitol can decrease intravascular volume
altered mental status
Any change in emotional or intellectual function.
- Includes delirium, dementia, coma
Status epilepticus
single seizure >or= 5 min in length
2 or more seizures without recovery between seizures
Tx: protect airway
- 1st: a lorazepam, Refractory: intubation + phenobarbitol
syncope management
CPR (if cardiac arrest0 EKG (arhythmia) Echo (looking for structural abnorm) Fluids Oxygen
Hypothermia
Rectal temps:
Mild: 90-95F: 34-36C
Moderate: 30-34C
Severe:
Hypothermia treatment
Mild: passive external + heated IV fluids
Mod-Sev: Active external, combined with warm peritoneal dialysis, warm IV, warm GI fluids)
Levels of frostbite
1st: partial skin freezing; erythema and edema, no blistering, stinging, burning
2nd: Full thickness freezing, vessicles that desquamate, black eschar
3rd: Full skin and subQ freezing, violaceous, skin necrosis
4th: Full skin, subQ and mus/tend/bone freeze, little edema, no pain
Chilbains
aka Pernia
Exposure to non freezing temp
Exp: chronic intermittent exp to damp, nonfreezing temp
Heat cramps
Caused by salt depletion
Tx: oral fluid and salt replacement
Heat exhaustion
Caused by primary water loss or sodium loss. (Hypernatremia or hyponatremia)
Sx: non specific, HA, N/V, malasie, cramps, dizziness
Rapidly leads to heat stroke, rehydrate and cool
Head stroke
Can no longer thermoregulate
Classicly associated with alteration in mental status
Body temp > 41C (105.8)
Same as heat exh + CNS dysnfunc: seizures, delirium and coma
Skin is usually dry and hot, anhidrosis not required
Heat stroke: dx and tx?
Dx: Diagnosis of exclusion: rule out infection, toxin, DKA, CNS disorder
Tx: Assess ABCs
IV fluids
Evaporative cooling (antipyretics not indicated)
Pink froth from nose and mouth
Pulmonary edema
Decompression sickness
Type 1: Deep aching pain in large joints (elbow and shoulder most common)
Cutaneous marmorata -> pathognomonic (skin marbling)
Type 2: gen fatigue, spinal para, vertigo, vis/speech disturbance. Multiorgan system disorder.
Tx: give O2 for at least 2 hours
Should wait 12-48 hours to fly
Arterial gas emboli
Sx/s: stroke-like with blindness, confusion.
Sx within 10 minutes of surfacing
Tx: Immediate decompression in HyperB
100% O2, supine on L side
Acute mountain sickness
6-24 hours after arrival at altitude
Sx worse on day 2-3, clear by day 7
Tx: go down, O2, severe may req: dexamethasone
High altitude pulmonary edema
> 8000ft
Cough dyspnea on exertion; pink, frothy sputum
CXR: pathcy infiltrates
Greatest mortality of AMS illnesses
Tx: rapid descent, positive pressure vent, O2, nifedipine, aetazolamide
High altitude cerebral edema
HA, ataxia, papilledema, global encephalopathy
Sx/s: apathy, agitation, focal neuro signs, obtundation, coma
Tx: rapid descent, O2, dexamethasone,
can use acetazolamide (watch cerebral perfusion pressure, so watch for hypoT. Mannitol
Altered Mental Status DDx
Alcohols Endocrine/Environment/Electrolytes/Encephalopathy Infection Oxygen/Opiates Uremia
Trauma/Tumor/Toxin
Insulin,Infarction/Intracranial hemorrhage
Psychogenic/Poisons/Drugs/Porphyria
Stroke/Seizure/Shock/Space occupying
Concussion
Treat early: cognitive rest, physical rest, sleep
Depressed skull fracture
Often found with inspection/palpation, swelling around the injury can mask depression.
Admit and refer to surgery subspecialist
Black widow bite
Severe pain in extremity and stomach/trunk muscle spasms
Systemic systems>local symptoms
N/V, Diaphoresis, HTN
Tx: narcotic analgesics, antivenin
Brown recluse spider bite
Sx/s: venom is cytotoxic (erythematous, blister, fever/V/arthralgia), leads to local progressive tissue destruction/necrosis
Tx: local wound care, tetanus shot, no antidote
Tarantulas
Urticating hairs, minimally toxic to humans
Scorpion stings
Sx/s: intesnsely painful, erythema
Tx: periodic ice, AVOID tourniquet, neuroleptics, antihypertensive, atropine
Tick bites
Sx/s: Wood tick: ascending motor paralysis
Tx: supportive care, remove tick
Abx: doxycycline if infected
Dog and cat bites
Irrigate, debride, leave open or loosely sutured
Abx: augmentin (dogmentin)
Tetanus
Airway obstruction
presenting symptoms:
Stridor, forced ventilatory efforts,
intercostal, suprasternal or supraclavicular retractions or other signs of increased respiratory effort
Airway obstruction managment
Remove foreign body if there is one
If laryngeal edema -> epinephrine subQ or IV
If progressing obstruction -> surgical cricothyrotomy
Tension pneumothorax symptoms
Chest pain, respiratory distress, decreased breath sounds, tympany via percussion
& shift of the mediastinum, destined neck veins, hypotension, shock
Simple pneumothorax symptoms
Chest pain, respiratory distress, decreased breath sounds, tympany via percussion
CXR: air in pleural space, and lung collapse
Tension Pneumothorax management
Supp O2
Tube thoracostomy
Simple pneumothorax management
Unilateral: needle decompression or thoracostomy
Bilateral: Immediate thoracostomy
Pulmonary contusion signs/symptoms
Silent at initial presentation
Hypoxia, dyspnea, hemoptysis, tachycardia, chest injury, decreased breath sounds, crackles.
CXR: apparent within 6 hours, ranging from patchy infiltrates to complete lobar consolidation
Flail chest symptoms
Painful paradoxical motion of the rib cage
Crepitation or subcutaneous emphysema, decreased breath sounds
Status asthmaticus presentation
Severe acute asthma attack
Hypoxemia, tachypnea, tachycardia, accessory muscle use, wheezing
Tx: IV magnesium sulfate, pressure vent, ketamine, epinephrine, mechanical vent
carbon monoxide poisoning/smoke inhalation presentation
Suspect in every fire victim
Cherry-red skin color is frequent but not reliable
Asymptomatic below when O2 decreased 10-15%
50-60% associated with coma and seizures
70% fatal
Findings: MI, arrhythmia, dementia, ataxia, sensory motor findings, loss of consciousness
Anaphylaxis
Within seconds to an hour
Acute progression of organ system involvement that may lead to cardiovascular collapse
Anaphylaxis symptoms
Derm: pruritus, flushing, urticaria, erythema multiforme angioedema
Respiratory: dyspnea, hypoxia, wheezing, cough, stridor
CardiV: dysrhythmias, collapse, arrest
GI: cramping, vomiting, diarrhea
GU: urgency, cramping
Eye: pruritus, tearing, redness
Anaphylaxis management
Resuscitation: ABC, cardiac monitor, pulse ox, IV access
Admin: O2, epi IM in thigh, fluids if hypoT, steroids, antiH, albuterol, glucagon (in patients refractory to other treatments)
Rule of nines
TBSA
Back: 18 Front: 18 Leg each: 18 Arm each: 9 Head: 9 Patient palm surface = 1% of their body surface area
Laparotomy
Surgical opening of the abdomen
Laparoscopy
Abdominal exploration with an endoscope
Enterostomy
Surgically created opening into a portion of the GI tract
anastomosis
Natural connection between two vessels, or surgical connection of two tubular structures.
Z-plasty
the use of Z-shaped incision in plastic surgery to relieve tension in scar tissue
Fundoplication
Surgery for GERD:
Fundus of stomach is wrapped around esophagus.
Strengthens lower esophageal sphincter
Colostomy
Procedure where part of the colon is diverted through the abdominal wall
Colectomy
Removal of a piece of the colon
Hemi-colectomy
Removal of an entire colonic side (ex. ascending or descending or transverse)
Endarterectomy
Surgical removal of the lining (and plaque) of the carotid artery.
Thoracotomy
Surgical incision into the chest wall
Pleurodesis
Obliteration of the pleural space.
Used to treat pleural effusion or recurrent pneumothorax
Sphincterotomy
Cutting of a sphincter muscle to decrease its resting tone.
Used to correct anal fissures and bile duct issues.
Tamponade symptoms
Beck’s triad: hypotension, jugular venous distension, muffled heart sounds
Diminished cardiac output
Narrow pulse pressure
ASA Physical status classification
ASA 1: normal healthy patient
ASA 2: mild systemic disease without limitations
ASA 3: severe systemic disease with functional lim
ASA 4: severe systemic disease with constant threat of life
ASA 5: moribund, not expected to survive without surgery
ASA 6: declared brain dead for organ donor procedure
ASA + E: patient requiring emergency operation
What level predicts an increased risk of cardiac complication in surgery
4 mets or less is of risk
If some one can do 2 sets of stairs: at least 4 mets
Post op bowel movement
24 hour for most operations that don’t involve abd cavity
1st, 2nd, 3rd intention
1st: sutured
2nd: Wound left open
3rd: left open then closed 4-6 days later
Most common bug for furuncle and carbuncle
Staph aureus
Celllulitis
MC due to GABHS and staph
Gas gangrene
C. perfingens most common microb
Incubation :12-24 hours
ABx: empiric combo
Most common type of UTI bug
E.coli 27%
Enterococcus 13%
Candida, P. aeruginosa, Klebsiella
