Emma Holliday for Surgery: Part III Flashcards
Review GCS scoring
Best Eye Response. (4) No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously.
Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated
Best Motor Response. (6)
No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localising pain. Obeys Commands
3 causes of increased ICP
Hematoma, edema, tumor
Symptoms of increased ICP
Headache, vomiting, altered mental status
How do we treat increased ICP
Elevate HOB, hyperventillate to pCO2 28-32, give mannitol (watch renal fxn)
Surgical intervention: Ventriculostomy
We can get trauma to the neck in a question stem by a gunshot wound or stab wound. The problem is that we treat differently based on the zone we are in.
What are the neck zones and what do we due with a wound like this
Zone 3 is above the angle of the mandible. Do an aortography and triple endoscopy
Zone 2 is between the angle of the mandible and the cricoid. Do a 2D doppler +/- exploratory surgery
Zone 1 is below the cricoid. Do an aortography
What do we do with a GSW to the abdomen?
Exploratory lap. No matter what.
If we get a stab wound to the abdomen things get more complicated. When do we do an ex lap in this case?
If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration? Do an ex-lap and give tetanus prophylaxis.
If stab wound but pt is stable? Do a FAST exam, DPL if FAST is equivocal. Ex-lap if either is positive.
If someone has a blunt trauma to the abdomen, what do we do?
Hypotensive and tachycardic? Do an Ex-Lap.
Stable? Abdominal CT
On AXR, black underneath the diaphragm =
Go directly to ex-lap, they have fluid, and you don’t know where it is coming from.
Lower rib fracture and bleeding into the abdomen s/p blunt abdominal trauma =
Spleen or liver laceration
If lower rib fracture plus hematuria s/p blunt abdominal trauma =
Kidney lac
If Kehr sign (what is this) and viscera in the thorax on CXR s/p blunt abdominal trauma =
Diaphragm rupture
Kehr’s sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr’s sign in the left shoulder is considered a classic symptom of a ruptured spleen.[1] May result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury or ruptured ectopic pregnancy.
Kehr’s sign is a classic example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is because the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.
If handlebar sign (what is this) s/p blunt abdominal trauma =
Pancreatic rupture
The pancreas may be injured in abdominal trauma, for example by laceration or contusion.[5] Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children and vehicular accidents in adults, usually occur in isolation in children and accompanied by other injuries in adults.[5] Indications that the pancreas is injured include enlargement and the presence of fluid around the pancreas
If patient is stable with epigastric pain s/p blunt abdominal trauma…
Still do an abdominal CT since they are stable. If retroperitoneal fluid is found, consider a duodenal rupture.
If hypotensive and tachycardic after pelvic trauma…
FAST and DPL to r/o bleeding in abdominal cavity.
If blood at the urethral meatus and a high riding prostate after pelvic trauma?
Consider pelvic fracture w/ urethral or bladder injury.
Next best step is Retrograde urethrogram (NOT FOLEY!)
If retrograde urethrogram is normal with blood at the urethral meatus and a high riding prostate after pelvic trauma?
Retrograde cystogram to evaluate bladder
Check for extravasation of dye. Take 2 views to ID trigone injury
If extraperitoneal extravasation, do bed rest and foley.
If intraperitoneal extravasation, do ex-lap and surgical repair.
When do fractures of any kind go to the OR?
–Depressed skull fx
–Severely displaced or angulated fx
–Any open fx (sticking out bone needs cleaning)
–Femoral neck or intertrochanteric fx
Shoulder pain s/p seizure or electrical shock
Post. shoulder dislocation
Arm outwardly rotated, & numbness over deltoid
Ant. shoulder dislocation
old lady FOOSH, distal radius displaced
Colle’s fracture
young person FOOSH, anatomic snuff box tender.
Scaphoid fracture
–“I swear I just punched a wall…”
Metacarpal neck fracture “Boxer’s fracture”. May need K wire
Clavicle most commonly broken where?
Between middle and distal 1/3s. Need figure of 8 device
Fever POD 1
Low fever under 101 with productive cough? What do we do about it?
Atelectasis.
Do a CXR and treat with mobilization and incentive spirometry
Fever POD 1
High fever to 104, very ill
Necrotizing fasciitis that spreads along scarpas fascia in sub Q.
Most commonly GABHS or c. perfringens
Tx with IV PCN, go to OR and debride skin until it bleeds
Fever POD 1
High fever > 104 with muscle rigidity
Malignant hyperthermia from succinyl Choline or halothane anesthesia, usually also secondary to a genetic defect in ryanodine receptor
Treat with Dantrolene Na which blocks the RYR and decreased intracellular calcium
Two options for fever POD 3-5
Pneumonia - Fever, productive cough, diaphoresis. Treat with sputum culture for abx, cover with moxicillin to cover strep pneumo in the meantime.
UTI - Fever, dysuria, frequency, urgency, particularly in a foley patient. Get a UA and culture. Treat with a new foley and wide spec abx until culture returns
Fever after POD 7 with pain at IV site
Central line infection. Do blood cx from the line site, pull it, and give abx to cover staph
Fever after POD 7 with pain at incision site, edema, induration, but no drainage.
Cellulitis. Treat with blood culture and antibiotics.
If there IS drainage then it’s a simple wound infection. Open the wound and repack it, no antibiotics necessary.
POD7 fever with pain and with salmon colored fluid
Wound dehiscence. Surgical emergency, go to OR, IV abx, primary closure of fascia
Fever after 7 days post-op not explained by anything externally with no additional symptoms
Abdominal abscess
Dx with a CT with oral contrast, IV contrast and rectal constrast. Do a diagnostic lap. Drain it percutaneously, IR-guided or surgically
What causes pressure ulcers and what do we do about it
Caused by impaired blood flow leading to ischemia
–Don’t culture, you will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
–Can do tissue biopsy to rule out Marjolin’s ulcer
–Best prevention is turning q2hrs
4 stages of pressure ulcers and what we do about them
–Stage 1 = skin intact but red. Blanches w/ pressure
–Stage 2 = blister or break in the dermis
If stage 1 or 2, get a special mattress and give barrier protection
–Stage 3 = SubQdestruction into the muscle
–Stage 4 = involvement of joint or bone.
If stage 3 or 4, you get flap reconstruction surgery as long as your albumin is more than 3.5 and bacterial load is less than 100,000.
What do we do with a pleural effusion if we see fluid greater than 1 cm on the lateral decubitous position?
Thoracentesis
When we do thoracentesis and we get transudative back, what does it mean?
If transudative, likely CHF, nephrotic, cirrhotic
Look for leukoctes, glucose and blood:
- Glucose in pleura = Rheumatoid Arthritis
- High lymphos - Tuberculosis
- Blood = malignant or pulmonary embolus
When we do thoracentesis and we get exudative back, what does it mean?
Parapneumonic or cancer
When we do thoracentesis and we get gram staining or culture back or the pH is acidic (
Insert chest tube and drain it.
Light’s criteria
Light’s Criteria:
transudative if:
- LDH less than 200
- LDH eff/serum less than 0.6
- Protein eff/serum less than 0.5
Who gets spontaneous pneumo and what do we do about it
–Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
–Dx w/ CXR, Tx w/ chest tube placement
–Indications for surgery = ipsi or contra recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area
Do VATS, pleurodesis (bleo, iodine or talc)
Who do we suspect lung abscess in and what do we do about it
Lung Abscess usually 2/2 aspiration (drunk, elderly, enteral feeds)
–Most often in post upper or sup lower lobes
–Tx initially w/ abx: IV PCN or clinda
–Indications for surgery = abxfail, abscess > 6cm, or if empyema is present.
I see a lung nodule. First step?
Find an old CXR to compare!
Characteristics of a benign nodule (5)
–Popcorn calcification = hamartoma(most common)
–Concentric calcification = old granuloma
–Pt less than 40
- Nodule less than 3 cm
- Well circumscribed nodule
How do we treat a benign solitary lung nodule?
CXR or CT scans q2mo to look for growth
When do we suspect a malignant lung nodule?
If pthas risk factors (smoker, old), If >3cm, if eccentric calcification
How do we treat a malignant lung nodule
Remove the nodule (w/ bronc if central, open lung biopsy if peripheral
How do I know I’m looking at adenocarcinoma patient?
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse
Nonsmoker
Occurs in scars of old pneumonia
What is the effusion of an adenocarcinoma look like and where does the cancer usually reside? Where is it going to go?
Peripheral cancer that is going to met to liver, bone, brain and adrenals.
Effusion is going to be exudative with high hyaluronidase
How do I know I’m looking at squamos lung cancer? (5)
Paraneoplastic syndrome 2/2 secretion of PTH-rP.
- Kidney stones due to high calcium and low phosphate
- constipation for same reasons
- Malaise
- Low PTH because of the related peptide
- Central lung mass
Pt presents with cough, weight loss, dyspnea, bloody cough, history of repeated PNA/lung collapse, so you know it’s cancer. When do you suspect small cell carcinoma?
Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer
Patient with shoulder pain, ptosis, constricted pupil, and facial edema
Lambert Eaton syndrome?
Patient with ptosis better after 1 minute of upward gaze?
Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca channel
Pt presents with cough, weight loss, dyspnea, bloody cough, history of repeated PNA/lung collapse, so you know it’s cancer.
This patient is an old smoker presenting with Na = 125 and moist mucus membranes and no JVD
SIADH from small cell carcinoma.
Produces Euvolemic hyponatremia.
Fluid restrict +/-3% saline in more than 112
Pt presents with cough, weight loss, dyspnea, bloody cough, history of repeated PNA/lung collapse, so you know it’s cancer.
CXR showing peripheral cavitation and CT showing distant mets?
Large Cell carcinoma
What causes ARDS?
Inflammation leading to impaired gas exchange, inflammatory mediator release and hypoxemia
2/2 Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.
How do we diagnose ARDS?
- ) PaO2/FiO2 less than 200 (less than 300 means acute lung injury)
- ) Bilateral alveolar infiltrates on CXR
- ) PCWP is less than 18 (means pulmonary edema is non-cardio
ARDS treatment
Mechanical ventilation w/ PEEP
Murmurs crescendo/decrescendo
Aortic stenosis
Murmurs holosystolic murmur
Mitral regurg
Murmurs louder with squatting
Aortic stenosis
Murmurs radiates to axilla
Mitral regurg
Murmurs parvus et tardus
Aortic stenosis
Murmurs louder with valsalva
Aortic stenosis
Murmurs with LAE
Mitral regurg
Murmurs softer with valsalva
HOCM
Late systolic murmur with click and louder with valsalva, softer with squatting
Mitral valve prolapse
Summary, Aortic stenosis presentation:
- Cresc/Decresc
- Louder with squatting
- Softer with valsalva
- Parvus et tardus
Summary HOCM
- Louder with valsalva
- Softer with squatting or handgrip
Summary Mitral valve prolapse
- Late systolic murmur with a click, louder with valsalva and hand grip, softer with squatting
VSD
Murmur in kids, holosystolic with a late diastolic murmur as the blood rushes across the defect backwards.
PDA
Machine like murmur
ASD
Wide and fixed and split S2
Mitral stenosis
Rumbling distolic murmur with an opening snap, LAE and A-fib
Aortic regurg
Blowing distolic murmur with widened pulse pressure and eponym parade
