Emma Holiday Review Flashcards
Most important factors in Goldman’s index for perioperative risk
CHF status and ejection fraction
(<35 %, no surgery for you! <60% as a aortic regurgitator, also no surgery for you!)
Metformin in periop period
We have patients stop it because there is a risk of lactic acidosis in the perioperative period
The conventional wisdom for warfarin is to discontinue 5 days preop, but what INR do we want to see by the time someone comes in for surgery to consider it safe?
1.5 or less
Insulin prior to surgery
If a patient is on insulin, they should be instructed to take half their morning dose prior to surgery, since they will be NPO
When does a patient on dialysis need to have a dialysis session prior to surgery?
24 hours prior
Four things you need to know about ventilators
- Assist control lets patients determine the rate (down to a certain threshold), but then assists by delivering a tidal volume
- Pressure support does not modulate rate at all, but will ensure a minimum pressure is reached – important weaning setting
- CPAP – patient must have their own respiratory drive
- PEEP… it’s peep.
Which is better to adjust to modulate CO2 blowoff: Tidal volume or rate?
Tidal volume
This minimizes the effects of dead space ventilation, which would be a significant portion of the minute ventilation if you modulated rate instead.
Hyponatremia pathway
- Check Na
- Check Plasma Osm
- Volume status exam
- Urine studies (if necessary)
If a patient has SIADH without a good etiology. . .
. . . get a CXR, particularly if they are a smoker
Small cell lung cancer may present with SIADH
Clear-cut criteria for 3% saline
- Severely symptomatic hyponatremia: Seizures, altered mental status
- Na < 120 mEq/L
Clinical characteristics of central pontine myelinolysis
- Flaccid quadriplegia
- Motor abnormalities
- Respiratory paralysis
- Cranial nerve abnormalities
- AMS change/lethargy/coma
If you correct hyponatremia at a rate greater than ___, you are at risk for ___.
If you correct hypernatremia at a rate greater than ___, you are at risk for ___.
If you correct hyponatremia at a rate greater than 6-8 mEq/L/day, you are at risk for central pontine myelinolysis.
If you correct hypernatremia at a rate greater than 12 mEq/L/day, you are at risk for cerebral edema.
Why do we give topical abx rather than IV or oral abx for burn patients?
It breeds resistance very quickly in this population
So, instead we use: bacitracin, silver nitrate, silver sulfadiazine, sulfamylon
Rule of 9’s (child vs adult)
Quick takeaways on the three main burn emollients
- Silver sulfadiazine: Doesn’t penetrate eschar, don’t use if you suspect active infection, may cause leukopenia
- Silver nitrate:Doesn’t penetrate escharthat well, ok for possibly infected wounds, side effectshyponatremiaandhypokalemia
- Sulfamylon (aka Mafenide acetate): Does penetrate eschar, best for clearly infected wounds, painful, may cause metabolic acidosis due to inhibition of carbonic anhydrase
First best step when someone comes in with electrical burn
EKG
You are worried about rhabdo for sure, but the arrhythmias are what is going to kill this person in the next 24 hours.
Put them on telemetry.
Patient comes in with an electric burn. Their EKG looks good. They start producing red urine. Urine dipstick shows 3+ blood but no red cells on microscopy. What is the first test you want for this patient?
BMP for potassium
Remember, rhabdo puts at risk for renal failure, but the potassium is the most acutely dangerous aspect. It can cause fatal arrhythmias.
In the setting of suspected tracheal injury with subcutaneous emphysema, you need to intubate, but how do you do it?
Carefully with a fiberoptic bronchoscope
Don’t go in blind
Indications to take someone with hemothorax to OR
- > 1.5 L output from chest tube initially
- > 200 cc/hr x 4 hours
Pain control for flail chest
Nerve block
DO NOT give opioids
After needle decompression in tension pneumothorax, . . .
. . . add a chest tube
If you have clinical suspicion for tamponade OR tension peumothorax based on your exam. . .
. . . JUST TREAT
Don’t bother getting an echo or a CXR. These are high morality conditions. Just stick a needle in there.
On a CT, acute blood is . . .
. . . bright
While chronic blood is dark
Target paCO2 for therapeutic hyperventilation in elevated ICP
28-32 mm Hg
Patient is in the ER after epigastric trauma. They are stable but have persistent and significant epigastric pain. CT shows retroperitoneal fluid, but no other obvious signs of injury. What is the likely diagnosis?
Duodenal rupture
Remember, CT is bad at picking up injuries to hollow viscus organs.
Extraperitoneal vs intraperitoneal bladder rupture treatment
Extraperitoneal: actually not a big deal. Conservative therapy, will heal on its own.
Intraperitoneal: big deal. Take to the OR. May cause peritonitis if it hasn’t already.
If a kid is skateboarding, falls, and lands on his outstretched hand, then comes in to the ER with severe pain in the anatomic snuffbox, what is broken?
The scaphoid
Note: X-ray is often negative, so even if X-ray is clear, have a high index of suspicion.
Boxer’s fracture
Fracture that you get by punching something hard
Breaks a metacarpal, usually the 4th or 5th metacarpal
POD#1 necrotizing fasciitis
If someone looks SAS on POD#1, this may be the case
Caused by GAS or C. perfringens that spreads along Scarpa’s fascia
Treat with OR and debridement with IV penicillin
Genetic defect that causes malignant hyperthermia
Ryanodine receptor (RYR1) mutations account for more than 50% of case
This receptor is also the target of dantrolene, which is why it works for MH!
“Salmon colored fluid leaking from painful incision”
Buzz phrase for dehiscence
A wound infection with drainage often requires. . .
. . . wound exploration, debridement, and packing, but NOT NECESSARILY antibiotics
Treatment for deep vein thrombophlebitis (like septic pelvic thrombophlebitis)
Antibiotics, but also heparin
The clot is providing physical shelter to the bacteria and making their environment poorly penetrable to the antibiotic, so you need the heparin to dissolve the clot in order for the antibiotics to act
Where do you draw the line for whether or not to tap a small pleural effusion?
> 1 cm, it has to be tapped.
“Transudative pleural effusion with a low glucose”
Buzz phrase for rheumatic effusion associated with RA
Light’s Criteria
When do we intervene in spontaneous primary pneumothorax?
- Recurrence (same or opposite side)
- Bilateral pneumothoraces
- Presence of blebs
- Lung cannot completely re-expand after treatment
- Occupation where a pneumothorax may result in disaster (pilot, for example)
1st line for lung abscess
- Clindamycin or beta lactam
- NOT drainage – one of the few abscesses where drainage is NOT first-line
“popcorn calcification” in a lung nodule
Likely a hamartoma, which is benign
Lung cancer with “haluronidase-high pleural effusion”
Adenocarcinoma
PTHrP is produced by __ lung cancer
PTHrP is produced by squamous cell lung cancer
What cancer most likes to cause Pancoast syndrome?
Squamous cell lung cancer
Lambert-Eaton mysathenia is associated with. . .
. . . small cell lung cancer
Criteria for a diagnosis of ARDS
- Bilateral infiltrates on CXR
- PaO2/FiO2 < 300
- PCWP < 18 mmHg (rule out cardiac etiology)
“Holosystolic murmur with late rumble”
VSD
“Continuous, washing-machine-like murmur”
Patent ductus arteriosus
“Heart murmur that increases with inspiraton”
Right-sided
Dysphagia worse with hot and cold liquids
Diffuse esophageal spasm / Corkscrew esophagus
Conservative therapy for DES and achalasia
CCBs or nitrates
Krukenberg Tumor
Metastatic disease to the ovaries characterized by mucin-rich signet-ring adenocarcinoma that primarily arises from a gastrointestinal site (specifically the stomach)
Blumer Shelf Tumor
Represents metastatic seeding of a primary gastrointestinal tumor (usually stomach) into the caudal portion of the peritoneal cavity, or the pouch of Douglas.
May be detected on digital rectal exam
Sx: lower abdominal pain, change in bowel habits, tenesmus
Gastric lymphoma is associated with __, MALT lymphoma of the stomach is associated with __.
Gastric lymphoma is associated with AIDS, MALT lymphoma of the stomach is associated with H. pylori.
Menetrier disease
Massive overgrowth of mucous cells in the mucosa of the stomach, resulting in large ruggae. Also results in a protein-losing gastropathy and hypoalbuminemia. Often presents as epigastric abdominal pain.
Gastric vs duodenal ulcer
Gastric ulcers hurt more after eating,
duodenal ulcers hurt less after eating
Best test for H. pylori
Endoscopy + biopsy
___ suppresses gastrin production, except in Zollinger-Ellison syndrome
Secretin suppresses gastrin production, except in Zollinger-Ellison syndrome
Treatment of SMA syndrome
- Restore weight and nutrition (often resolves SMA syndrome without surgery)
- Roux-en-Y gastric bypass (if the above fails)
Three most likely organisms in an intrabdominal abscess
- E. coli
- Bacteroides
- Enterococcus
Two abscesses that are NOT treated with drainage first
- Lung (try antibiotics)
- Non-echinococcal amoebic liver abscess (try metronidazole)
Echonococcal cysts are treated by. . .
. . . surgical removal IN ONE PIECE + albendazole
Two liver abscesses you need to know
Entamoeba histolytica – looks like a regular abscess, but person is extremely sick with fevers, chills, hypotension, eosinophilia. Treat w/ metronidazole.
Echinococcus – hydatid/daughter cysts, eosinophilia, anaphylaxis if ruptured. Treat w/ surgical removal and albendazole.
1 site for GI carcinoid tumor
Appendiceal!!!
People with carcinoid syndrome often become deficient in ____
People with carcinoid syndrome often become deficient in niacin
Serotonin and niacin are both derived from tryptophan. If all of the tryptophan is being funneled into making serotonin. . . there is none left to make niacin!
Niacin deficiency causes pellagra (the 3D’s of B3: diarrhea, dermatitis, dementia)
When to do which surgery for appendiceal carcinoid tumor
< 2 cm, no lymph nodes positive: Appendectomy
> 2 cm and/or lymph nodes positive: R hemicolectomy
Threshold for treating Ogilvie’s syndrome
10 cm dilation of the cecum
Electrolyte disorder that may contribute to ileus
Hypokalemia
