Emma Holiday Review

Question 1

Most important factors in Goldman’s index for perioperative risk

Answer 1

CHF status and ejection fraction

(<35 %, no surgery for you! <60% as a aortic regurgitator, also no surgery for you!)

Question 2

Metformin in periop period

Answer 2

We have patients stop it because there is a risk of lactic acidosis in the perioperative period

Question 3

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?

Answer 3

1.5 or less

Question 4

Insulin prior to surgery

Answer 4

If a patient is on insulin, they should be instructed to take half their morning dose prior to surgery, since they will be NPO

Question 5

When does a patient on dialysis need to have a dialysis session prior to surgery?

Answer 5

24 hours prior

Question 6

Four things you need to know about ventilators

Answer 6

• 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.

Question 7

Which is better to adjust to modulate CO2 blowoff: Tidal volume or rate?

Answer 7

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.

Question 8

Hyponatremia pathway

Answer 8

1. Check Na
2. Check Plasma Osm
3. Volume status exam
4. Urine studies (if necessary)

Question 9

If a patient has SIADH without a good etiology. . .

Answer 9

. . . get a CXR, particularly if they are a smoker

Small cell lung cancer may present with SIADH

Question 10

Clear-cut criteria for 3% saline

Answer 10

1. Severely symptomatic hyponatremia: Seizures, altered mental status
2. Na < 120 mEq/L

Question 11

Clinical characteristics of central pontine myelinolysis

Answer 11

• Flaccid quadriplegia
• Motor abnormalities
• Respiratory paralysis
• Cranial nerve abnormalities
• AMS change/lethargy/coma

Question 12

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 ___.

Answer 12

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.

Question 13

Why do we give topical abx rather than IV or oral abx for burn patients?

Answer 13

It breeds resistance very quickly in this population

So, instead we use: bacitracin, silver nitrate, silver sulfadiazine, sulfamylon

Question 14

Rule of 9’s (child vs adult)

Answer 14

Question 15

Quick takeaways on the three main burn emollients

Answer 15

• 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

Question 16

First best step when someone comes in with electrical burn

Answer 16

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.

Question 17

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?

Answer 17

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.

Question 18

In the setting of suspected tracheal injury with subcutaneous emphysema, you need to intubate, but how do you do it?

Answer 18

Carefully with a fiberoptic bronchoscope

Don’t go in blind

Question 19

Indications to take someone with hemothorax to OR

Answer 19

• > 1.5 L output from chest tube initially
• > 200 cc/hr x 4 hours

Question 20

Pain control for flail chest

Answer 20

Nerve block

DO NOT give opioids

Question 21

After needle decompression in tension pneumothorax, . . .

Answer 21

. . . add a chest tube

Question 22

If you have clinical suspicion for tamponade OR tension peumothorax based on your exam. . .

Answer 22

. . . JUST TREAT

Don’t bother getting an echo or a CXR. These are high morality conditions. Just stick a needle in there.

Question 23

On a CT, acute blood is . . .

Answer 23

. . . bright

While chronic blood is dark

Question 24

Target paCO2 for therapeutic hyperventilation in elevated ICP

Answer 24

28-32 mm Hg

Question 25

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?

Answer 25

Duodenal rupture Remember, CT is bad at picking up injuries to hollow viscus organs.

Question 26

Extraperitoneal vs intraperitoneal bladder rupture treatment

Answer 26

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.

Question 27

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?

Answer 27

The scaphoid Note: X-ray is often negative, so even if X-ray is clear, have a high index of suspicion.

Question 28

Boxer's fracture

Answer 28

Fracture that you get by punching something *hard* Breaks a metacarpal, usually the 4th or 5th metacarpal

Question 29

POD#1 necrotizing fasciitis

Answer 29

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**

Question 30

Genetic defect that causes malignant hyperthermia

Answer 30

**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!

Question 31

"Salmon colored fluid leaking from painful incision"

Answer 31

Buzz phrase for dehiscence

Question 32

A wound infection with drainage often requires. . .

Answer 32

. . . **wound exploration, debridement, and packing, but NOT NECESSARILY antibiotics**

Question 33

Treatment for deep vein thrombophlebitis (like septic pelvic thrombophlebitis)

Answer 33

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**

Question 34

Where do you draw the line for whether or not to tap a small pleural effusion?

Answer 34

\> 1 cm, it has to be tapped.

Question 35

"Transudative pleural effusion with a low glucose"

Answer 35

Buzz phrase for rheumatic effusion associated with RA

Question 36

Light's Criteria

Answer 36

Question 37

When do we intervene in spontaneous primary pneumothorax?

Answer 37

* **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)

Question 38

1st line for lung abscess

Answer 38

* Clindamycin or beta lactam * NOT drainage -- one of the few abscesses where drainage is NOT first-line

Question 39

"popcorn calcification" in a lung nodule

Answer 39

Likely a hamartoma, which is benign

Question 40

Lung cancer with "haluronidase-high pleural effusion"

Answer 40

Adenocarcinoma

Question 41

PTHrP is produced by __ lung cancer

Answer 41

PTHrP is produced by **squamous cell** lung cancer

Question 42

What cancer most likes to cause Pancoast syndrome?

Answer 42

Squamous cell lung cancer

Question 43

Lambert-Eaton mysathenia is associated with. . .

Answer 43

. . . **small cell lung cancer**

Question 44

Criteria for a diagnosis of ARDS

Answer 44

* Bilateral infiltrates on CXR * PaO2/FiO2 \< 300 * PCWP \< 18 mmHg (rule out cardiac etiology)

Question 45

"Holosystolic murmur with late rumble"

Answer 45

VSD

Question 46

"Continuous, washing-machine-like murmur"

Answer 46

Patent ductus arteriosus

Question 47

"Heart murmur that increases with inspiraton"

Answer 47

Right-sided

Question 48

Dysphagia worse with hot and cold liquids

Answer 48

Diffuse esophageal spasm / Corkscrew esophagus

Question 49

Conservative therapy for DES and achalasia

Answer 49

CCBs or nitrates

Question 50

Krukenberg Tumor

Answer 50

**Metastatic disease to the ovaries** characterized by **mucin-rich signet-ring adenocarcinoma** that primarily arises from a gastrointestinal site (specifically the stomach)

Question 51

Blumer Shelf Tumor

Answer 51

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

Question 52

Gastric lymphoma is associated with \_\_, MALT lymphoma of the stomach is associated with \_\_.

Answer 52

Gastric lymphoma is associated with **AIDS**, MALT lymphoma of the stomach is associated with **H. pylori**.

Question 53

Menetrier disease

Answer 53

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.**

Question 54

Gastric vs duodenal ulcer

Answer 54

**Gastric** ulcers hurt **more after eating**, **duodenal** ulcers hurt **less after eating**

Question 55

Best test for H. pylori

Answer 55

Endoscopy + biopsy

Question 56

\_\_\_ suppresses gastrin production, except in Zollinger-Ellison syndrome

Answer 56

**Secretin** suppresses gastrin production, except in Zollinger-Ellison syndrome

Question 57

Treatment of SMA syndrome

Answer 57

1. **Restore weight and nutrition** (often resolves SMA syndrome without surgery) 2. **Roux-en-Y gastric bypass** (if the above fails)

Question 58

Three most likely organisms in an intrabdominal abscess

Answer 58

* E. coli * Bacteroides * Enterococcus

Question 59

Two abscesses that are NOT treated with drainage first

Answer 59

1. Lung (try antibiotics) 2. Non-echinococcal amoebic liver abscess (try metronidazole)

Question 60

Echonococcal cysts are treated by. . .

Answer 60

. . . **surgical removal IN ONE PIECE + albendazole**

Question 61

Two liver abscesses you need to know

Answer 61

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.

Question 62

#1 site for GI carcinoid tumor

Answer 62

Appendiceal!!!

Question 63

People with carcinoid syndrome often become deficient in \_\_\_\_

Answer 63

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**)

Question 64

When to do which surgery for appendiceal carcinoid tumor

Answer 64

\< 2 cm, no lymph nodes positive: Appendectomy \> 2 cm and/or lymph nodes positive: R hemicolectomy

Question 65

Threshold for treating Ogilvie's syndrome

Answer 65

10 cm dilation of the cecum

Question 66

Electrolyte disorder that may contribute to ileus

Answer 66

Hypokalemia