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Surgical Emergencies > Essentials + Miscellaneous > Flashcards

Essentials + Miscellaneous Flashcards

1
Q

What is this finding?
What is this for?

A

It is a Rutherford Morrison Incision. It is a long 20 cm oblique incision that appears to be well healed and no evidence of incisional hernia, pus, erythema, or swelling.

It can be made as a primary incision to provide good access to the right or left colon, retroperitoneum, major vessels (aorta, inferior vena cava and common iliac vessels) and bladder for renal transplantation, colonic resection, caecostomy or sigmoid colostomy.

Note: this is the scar that the skinny female actress has

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2
Q

What is this finding?
What is this for?

A

Posterolateral Thoracotomy scar
Well healed, no evidence of discharge, no incisional hernia or swelling.
For Lobectomy/pneumonectomy/transplant/biopsy

Note: this is the scar that the male actor has

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3
Q

Give 2 Antiemetics:

A

Cyclizine (antihistamine)
Odansetron

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4
Q

Give examples of antiplatelets
What is DAPT? What does it include?
What are the indications for DAPT?

A

Suffix: -grel
Clopidogrel
Ticagrelor

It is Dual antiplatelet therapy which includes Aspirin and a P2Y12 inhibitor

Indications: Acute MI, Stroke, TIA and to prevent Post-op complications of Angioplasty, Stent placement (part of angioplasty), and Coronary artery bypass surgery.

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5
Q

What is the wide bore cannula

A

Remember the lower the G, the thicker the needle

For wide bore it is 18G or less. Typically they’re referring to the orange needle

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6
Q

When implementing NPO as part of ABCDE management, what is an important piece of history to always be asked?

A

Note the last time they ate

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7
Q

Anyone going into surgery needs typing and grouping. Clexane (Enoxaparin) is often given as DVT prophylaxis.
What type of drug is Clexane (Enoxaparin)?
How many hours prior to surgery should it be stopped?

A

It is a LMWH, anticoagulant
It should be stopped 12 hours prior to surgery

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8
Q

How is anticoagulation monitored?

A

Main way of monitoring is via aPTT. Another way is Factor Xa which is used for LMWH like Clexane but is not as readily available nor monitored.

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9
Q

how is Clexane administered?

A

Administered Subcutaneously (deep)

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10
Q

How is Unfractionated heparin administered (with dosages)?

If given too much, how would you reverse it?

A

It can be administered both IV and subcutaneously (very rare). It is administered as a 5,000 IU bolus followed by 1,000 IU infusion afterwards

Reversed with Protamine Sulphate

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11
Q

What are the two types of heparin commonly used?
Discuss the advantages and disadvantages of using each.
What lab finding is associated with both?

A

Unfractionated:
Advantages: Rapid onset (IV administration) and clearance, !anticoag easily monitored via aPTT!, Can be reversed with Protamine Sulphate, okay in patients with renal failure

Disadvantages: Frequent monitoring required (although easy) and risk of Heparin-induced thrombocytopenia

LMWH:
Advantages: Longer duration of action (sub-cutaneous injection) and lab monitoring typically not needed

Disadvantages: Requires less available Factor Xa monitoring to track coagulation, Contraindicated in renal failure, unknown dosing in morbidly obese patients, not well-reversed with protamine, Heparin-induced thrombocytopenia!

Heparin-induced thrombocytopenia

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12
Q

How do beta blockers work?
What are the main indications for Beta blockers?
Differentiate between selective and non-selective beta blockers giving 2 examples of each.
Explain the main side effects of each type
What are some contraindications?

A

They inhibit !beta adrenergic receptors! => blocking release of noradrenaline (remember this acts mostly on alpha adrenergic) and adrenaline (acts on alpha and beta where alpha deals with vasoconstriction and beta deals with heart rate and contractility) => inhibit SNS => reduce HR and BP

Indications: Coronary Heart Disease, Compensated Heart Failure, Cardiac Arrhythmias (Sotalol)

Selective Beta blockers (Atenolol, Bisoprolol, Metoprolol)
These drugs are selective for blocking the B1 receptor which is located in the heart.
Side Effects:
Bradycardia and Syncope (hypotension)
Bradyarrhythmia
At higher doses, affects B2 as well

Non-selective: Propanalol, Timolol, Sotalol Acts on B1 and B2
Beta-2 receptors are found in the bronchial tree, blood vessels, and other organs. This broader action leads to bronchoconstriction and vasoconstriction.

Side Effects:
Vasoconstriction and Bronchoconstriction => Contraindicated in PVD/PAD and asthma/COPD
Bradycardia and Syncope (hypotension)

Contraindications: Recent stroke/TIA, Active bleeding, HIT, Uncontrolled hypertension

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13
Q

When palpating the abdomen, what is the difference between rigidity and guarding?

A

Rigidity is the involuntary tensing of the abdomen that is constantly present
Guarding is the voluntary tensing on palpation due to pain

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14
Q

What is the general initial/immediate management of all surgical emergencies?

A

1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: EXCEPT IN PANCREATITIS Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

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15
Q

What is the triad of ascending cholangitis?

A

Fever + Rigors
Jaundice
Rigors

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16
Q

MOA of ACE inhibitors
Main indications of ACE inhibitors
Give 2 examples of ACE inhibitors
Give the major side effects

A

Inhibits Angiotensin (produced by kidney along with renin) converting enzyme which is responsible for converting Ag1 (produced by liver) into Ag2 which then acts to vasoconstrict (in which the drug will cause vasodilation => reduced BP)

Indications: !HTN, HF, Acute MI!, Nephropathy, Coronary heart disease

Examples: Enalapril, Lisinopril, Ramipril

Side Effects: Hypotension (esp first dose), Dry cough (bradykinin buildup), Hyperkalemia, Renal Dysfunction

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17
Q

What is a common side effect of lumbar puncture or spinal anaesthesia other than bleeding, infection, bruising at site or altered sensation.

A

Post-dural/puncture headache

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18
Q

What are ARBs? give MOA
Give 2 examples

A

Angiotensin receptor blockers. These block the effect of Ag2 on its receptors => vasodilation and reduced BP
Examples: -sartan
Losartan
Valsartan

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19
Q

What is Nebivolol?

A

It is the only beta blocker that cause NO-mediated vasodilation (nitrous-oxide). It does this by stimulating the B3 receptors (Ouuu)

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20
Q

What is Sotalol?
What is it’s main indication

A

Sotalol is a special beta blocker that also blocks K+ channels => Antiarrhythmic effect

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21
Q

What is the drug of choice for a bradyarrhythmia?

A

Atropine

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22
Q

Give some indications for propanolol?

A

Cardiac: CHD, HF, Cardiac arrhythmias (better to go with sotalol for arrhythmias)
Other: Essential tremor, Portal hypertension, Migraine prophylaxis, Thyroid storm.

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23
Q

What is the main non-cardiac indication for Timolol?

A

Glaucoma

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24
Q

Give the indication and procedure of coronary angioplasty (extra) for Angioplasty

A

It is a procedure used in the treatment of Atherosclerosis e.g. Coronary heart disease => Coronary Angioplasty.
This is conducted by interventional radiology whereby It requires vascular access and sheath insertion into the femoral or radial (starting to be done more often) artery. A guide catheter is then placed with X ray guidance followed by microcatheter and microwire insertion. A sausage-shaped, stent-fitted balloon is then passed over the wire and is then inflated for 20-30 seconds (may be multiple times). The stent is then left permanently inside the artery to maintain the structure.

25
Q

What is Heparin-induced Thrombocytopenia? Answer this by explaining the 2 different types of it
How do you treat it?

A

This typically occurs in people starting Heparin anticoagulation therapy where they have reduced platelet count. HIT type 1 is a mild, transient thrombocytopenia occurring within the first 5 days due to Heparin-induced platelet aggregation, not associated with thromboembolic events. Type 2 is a sudden thrombocytopenia typically occurring between 5-10 days after start of therapy and is due to immune-mediated prothrombic state leading to thromboembolic events

Treated by Dabigatran
Others are part of BAD HIT. Bivalirudin, Argatroban

26
Q

Define Sonographic Murphy’s Sign
Honor’s Question:
What would it mean if a patient is presenting with abdominal pain and sonographic findings of cholecystitis in the absence of the sonographic Murphy’s sign?

A

The abrupt cessation of inspiration due to presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder

The sonographic murphy’s sign is prevalent in 99% of cases with extremely high accuracy. The absence of it, based on study, indicates gangrenous cholecystitis as it has passed the stage of vitality.

27
Q

A 65 year old with a history of CKD and CHD is deteriorating quite rapidly. His BP on the other hard is 115/75. Your consultant is concerned. Why would he be concerned?

A

This is a normal BP value and it is an older patient so no compensation. Given the patient’s history of CKD and CHD, they should be hypertensive. They are deteriorating which is why its dropped down to normal values.

28
Q

What is the normal bowel habit range?

A

3 times/day to 3 times/week

29
Q

Acute, sudden onset abdominal pain + Rigors. Give 4 ddx

A

Ascending cholangitis
pyelonephritis
Lobar pneumonia
Malaria

30
Q

Compare Cellulitis and Erysipelas

A

Cellulitis refers to an acute, superficial, DIFFUSE spreading skin infection involving the deeper dermis and adjacent subcutaneous tissue

Erysipelas is a more superficial infection involving the upper dermis and SUPERFICIAL LYMPHATICS => LYMPHADENOPATHY. The borders are WELL DEMARCATED and more intensely red.

31
Q

What plane is this taken in?

A

Ct taken in Axial view = transverse cut

32
Q

What plane is this taken in?

A

CT taken in Coronal view

33
Q

What plane is this taken in?

A

MRI taken in sagittal view

34
Q

What Imaging technique would you use on a fast-growing tumour vs slow-growth

A

Fast-growing tumours produce oedema => can be detected on MRI T2 (H2O) or CT angio or US if superficial enough such as in thyroid!
Slow growing tumours typically do not, or atleast not enough to be detected => MRI T1 w/ Gadolinium contrast which is best because MRIs are best for soft tissue which is tumour + Gadolinium which can help detect abnormal structures/features.

35
Q

An adult presenting with a stridor is an indication of?

A

Airway obstruction => Emergency

36
Q

What is the finding of this image? What condition is it most associated with. Give 2 other differentials

A

Granulomatosis with polyangitis or Wegner’s granulomatosis
Others: Trauma, congenital deformity

37
Q

Oral surgery/tumours/infection poses the greatest risk to which cranial nerves?

A

Cranial nerves V and VII: Trigeminal and facial most affected nerves in these cases

38
Q

What nerve is responsible for muscles of facial expression?

A

Facial nerve

39
Q

What nerve is responsible for muscles of mastication?

A

Trigeminal nerve V

40
Q

Is the larynx a part of the hypopharynx?

A

No, just the same level

41
Q

Patient with hx of an EBV infection is at increased risk of which cancers?

A

3/5 needed for 4/5, 4/5 for 5/5
!Hodgkin’s lymphoma
!Burkitt’s lymphoma
!Nasopharyngeal carcinoma
Gastric Carcinoma
Post-transplant lymphoproliferative disorder

42
Q

Patient with hx of an HPV infection is at increased risk of which cancers?

A

Cervical Cancer, Oropharyngeal cancer, Anal cancer, vaginal, vulvular, penile

43
Q

When caring for a cancer patient, what diet is typically prescribed to them?

A

High protein, high calorie diet
Other reasons: wound healing, dialysis, CKD with major proteinuria

44
Q

List ddx for a patient presenting with chronic malnutrition

A

Cystic fibrosis
IBD
IBS
Cancer (esp if receiving cancer tx)
Liver disease
Pancreatitis (amylase)
Renal Diet - Albuminurea, CKD, Dialysis,
Renal transplant
Celiac

45
Q

Where is albumin produced?
What affects albumin levels?

A

It is affected by sepsis (Reduces albumin), infection, inflammation, fluid shift post-op, protein-losing states (Kidney injury), Hepatic dysfunction => reduced synthesis)

46
Q

Into what vein are central lines typically inserted into?

A

Subclavian vein

47
Q

With regards to refeeding syndrome, what nutrients are most involved?
What should be given to a patient with refeeding?

A

CPM, Calcium, !!Potassium, magnesium + Phosphate
IV pabrinex or 300mg Thamine (B1), Hydration, B vitamins, and multivitamins

48
Q

What is the difference between metabolic bone disease and mineral bone disease

A

Metabolic bone disease refers to any disease causing weaker bones due to either the reduction of vit D activation (mineral bone disease in CKD), reduced calcium (increased PTH), reduced phosphorus (increased PTH), or osteoporosis, pagets etc…

Mineral bone disease is the one commonly seen in CKD and refers to the mineral-specific causes => reduced Vit D activation, reduced calcium and reduced phosphorus or, including all, increased PTH such as in parathyroid adenomas

49
Q

The nurse bleeps you about a patient that you have operated on yesterday saying that while taking the patient’s BP, their hand started to have a tremor and was shaking. What is this called? What caused this?
Once you arrive to the scene, how will you confirm this?

A

Trousseau’s sign - Carpopedal spasm in a hypocalcemic patient induced by secondary ischemia from the sphygmomanometer cuff
This is caused by hypocalcemia
Another sign is Chvostek’s sign - Twitch of facial muscles when gently tapping the facial nerve

50
Q

Define Xerostomia

A

Oral Dryness

51
Q

A patient presents with difficulty swallowing post-op thyroidectomy. She continues to lose considerable weight. You call for Speech and language therapy who tell you that on Bulbar assessment, it was found that the patient experiences pain throughout with restriction on opening the mouth. What is this sign?

A

Muscle spasm in the temporomandibular joint resulting in restricted/reduced opening of the jaw.

52
Q

A post-op patient has tachycardia and pyrexia. Are you concerned?

A

No, these are normal post-op. Patient should still be examined for signs of sepsis or any red flag signs.

53
Q

What cardiac arrhythmia is consistent with hypocalcemia?

A

Toursades de Points, V.Fib

54
Q

What type of cancer is most common in transplant patients?

A

Skin cancers particularly melanoma.

55
Q

How does a PET Scan work?
What is it primarily used for

A

Patient receives an injection of radioactive glucose which will take 30-90 minutes to fully circulate and be absorbed. Cancers, especially those with higher turnover will take in the glucose at a much higher rate. This will highlight that area on a CT scan indicating cancer.

Great for detecting disseminated disease as well as diseases such as lymphoma

56
Q

Someone asks you what analgesia to prescribe what will you say?

A

According to the WHO pain ladder

57
Q

In general, what antibiotics would you prescribe for?
Bowel:
Cellulitis:
Community-acquired pneumonia:
Hospital-acquired pneumonia:
MRSA:

A

Bowel: Co-amox + Metro/Cefuroxime
Cellulitis: Fluclox (staph)/Benzylpenicillin(strep)
Community-acquired pneumonia: Co-amox/clarithromycin
Hospital-acquired pneumonia: Tazocin (Piptaz)
MRSA: Vancomycin + cover for relevant system

58
Q

MOA of ACE inhibitors
Give 2 examples of ACE inhibitors

A

Inhibits Angiotensin converting enzyme which is responsible for converting Ag1 into Ag2 which then acts to vasoconstrict (in which the drug will cause vasodilation => reduced BP)
Enalapril
Lisinopril
Ramipril

59
Q

What are ARBs? give MOA
Give 2 examples

A

Angiotensin receptor blockers. These block the effect of Ag2 on its receptors => vasodilation and reduced BP
Examples: -sartan
Losartan
Valsartan

Surgical Emergencies (13 decks)

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