FIsher Flashcards
DPL criteria
>10cc blood >100,000 pRBC food particles bile bacteria WBC >500
Lefort fractures
I- maxillary
II- lateral to nasal bone, under eyes
III- lateral orbital walls
UE fractures - associated n/a injury ant shoulder dislocation- post shoulder dislocation- proximal humerus fx midshaft humerus fx supracondylar humerus fx elbow dislocation distal radius fx
ant shoulder - axillary n post shoulder- axillary a prox humerus fx- axillary n midshaft humerus fx- radial n supracondylar humerus- brachial a elbow dislocation- brachial a distal radius fx- median n
LE fractures- associated n/a injury ant hip dislocation post hip dislocation supracondylar femur fx posterior knee dislocation fibula neck fx
ant hip dislocation- femoral a post hip dislocation- sciatic n supracondylar femur fx- popliteal a posterior knee dislocation- popliteal a fibular neck fx- common perineal n
RAAS system
renin (from kidney)
convertns angiotensinogen (from liver) –> angiotensin I
ACE (from lung) converts AT I –> AT II
angiotensin II –> aldosterone release from adrenal cortex
acid vs alkalotic burns
acid- coagulation necrosis
alkali- liquefaction necrosis
nutrition needs in burns
25 cal/kg/day + (30cal x %burn)
protein 1g/kg/day + (3g x %burn)
steps in graft take
imbibation 0-3d
neovascularization after 3 d
side effects
silvadene
silver nitrate
sulfamylon (mafenide)
silvadene- neutropenia, thrombocytopenia
silver nitrate- hyponatremia, hypochloremia
sulfamylon- metabolic acidosis
azygous v and thoracic duct course
azygous- right (behind IVC), dumps into SVC
thoracic duct- right side, crosses midline T4/T5, dumps into left subclavian (near IJ)
lung resection PFTs
FEV1 >0.8 postresection (if borderline, consider V/Q scan to see which part of lung is shitty)
DLCO >10 postresection
(or >40% predicted postop value)
or preop pCO2>50, pO2<60
lung cancer stage and management
obtain bx, staging PET/CT, if stage I or II –> surgery; if + spread –> mediastinal eval (mediastinoscopy v EBUS)
Stage I and II - resection (node negative) Stage III (node +) - chemo and resection vs definitive chemo/XRT
(+ nodes –> at least stage III)
T3 (still can be resectable, stage II)- invades chest wall, pericardium, diaphragm, <2cm from carina
T4 (unresectable) - invasion to mediastinum, esophagus, trachea, vertebra, heart, great vessels
mediastinal tumors (by location)
Anterior- thymoma, thyroid CA, t cell lymphoma, teratoma (other germ cell tumors), parathyroid adenomas
Middle (heart trach aorta) - bronchiogenic cysts, pericardial cysts, enteric cysts, lymphoma
Posterior (esophagus, desc aorta)- enteric cysts, neurogenic tumors, lymphoma
risk factor for tracheo-innominate fistula? tx?
trach below 3rd tracheal ring
hold pressure, median sternotomy, ligate innominate
sensory skin nerve cells- pacinian, ruffini, krause, meissner
pacinian- pressure
ruffini- warmth
krause- cold
meissner- tactile
TRAM flap- main vessels
superior epigastrics
periumbilical perforators important determinant of viablity
pressure sore grading
I erythema
II partial skin loss- keep pressure off
III full thickness skin loss- debridement
IV involves bone or muscle- myocutaneous flaps
when to stage melanoma
> 1mm depth (panscan)
head and neck melanoma considerations
superficial parotidectomy if >1mm for anterior H&N melanoma
peripheral palisading nuclei
stromal retraction
(skin)
basal cell carcinoma
most aggressive type of basal cell carcinoma
morpheaform type
margins for basal cell and squamous cell carcinoma
basal cell- 3-4mm
squamous cell 5-10mm
sarcoma management
WLE (1cm), try to get one uninvolved fascial plane
XRT postop, consider preop if really large
risk factors for angiosarcoma
PVC and arsenic
merkel cell carcinoma management
WLE + SLN biopsy
>2cm (stage II) - get adjuvant radiation
bowens disease
squamous cell carcinoma in situ
associated with HPV
imiquimod and ablation
avoid WLE if possible
dermoid cyst management
resect d/t malignancy risk
Frey syndrome
auriculotemporal nerve injury after parotidectomy
gustatotry sweating
thyrocervical trunk
STAT suprascapular transverse cervical ascending cervical inferior thyroid
trap and pec major flaps- artery?
trap- transverse cervical a
pec major- thoracoacromial or IMA
modified radical neck dissection vs radical
MRND- omohyoid, submandibular gland, C2-C5, facial n cervical br, ipsi thyroid
radical- also take CN XI, SCM, IJ
MC oral cancer location
lower lip
oral cavity cancer management
WLE
MRND + radiation if >4cm, clinical nodes, or bony invasion
pharyngeal cancer management
- XRT only if <4cm
- combine sx, xrt for >4cm or bony/nodal invasion
- angiofibroma, embolize b/f resection
- nasopharyngeal XRT only
salivary cancer management
resection
MRND
postop XRT
CSF rhinorrhea indicator
tau protein
peritonsillar vs retropharyngeal vs parapharyngeal abscess
peritonsillar- >10yo
retropharyngeal- <10yo ; airway emergency
parapharyngeal (dental infection)- mediastinal spread concern, lateral neck drainage
cleft lip vs palate timing of repair
lip- 10wks, 10lbs, hgb 10
palate- 12mo
medical management for pituitary tumors
dopamine agonists (bromocriptine or cabergoline) consider before transphenoidal resection
nelsons syndrome
hypertrophy of pituitary after bilateral adrenalectomy
amenorrhea, visual problems, hyperpigmentation (MSH)
Tx steroids
adrenal vasculature
superior adrenal a (inferior phrenic)
middle adrenal a (aorta)
inferior adrenal a (renal a)
incidentaloma workup
urine metanephrines/VMA/catecholamines
urine hydroxycorticosteroids
K, renin, aldosterone
management of incidentaloma
resect if >4cm, >10HF units, slow washout <50%
biopsy if hx of cancer (lung MC, breast, melanoma)
primary hyperaldosteronism (conn syndrome)- dx and management
salt load suppression test (wont suppress)
Renin:aldosterone >20
adrenalectomy
if hyperplasia, consider med management (spironolactone, CCB, potassium replacement); if bilateral adrenalectomy will need lifelong steroid replacement
adrenal insufficiency test
cosynotropin test (in acute setting give dex before doing this test)
adrenocortical carcinoma management
open adrenelectomy, debulking
mitotane
pheochromocytoma rule of 10%
malignant bilateral children familial extraadrenal (organ of zuckerkandle, RP)
diagnosis of pheochromocytoma
VMA, urine metanephrines
MIBG scan
clonidine suppression test (does not suppress)
management of pheo
alpha before beta
adrenalectomy (ligate vein first)
metyrosine (inhibits tyrosine hydroxylase)
ima artery
occurs in 1%
from innominate or aorta –> thyroid
nerves in thyroidectomy
superior laryngeal nerve - circothyroid only, runs superior and lateral to thyroid; loss of projection, easy fatigue
recurrent laryngeal nerve- all other layrngeal mm, in tracheoesophageal groove, hoarseness, airway obstruction if bilateral injury
tubercle of zuckerkandl
lateral portion of thyroid
recurrent laryngeal n will be behind this
tubercle is left if subtotal thyroidectomy (ti keep RLN safe)
wolff chaikoff effect
thyroid suppression with iodine loading
useful thyroid storm
PTU and methimazole side effects
PTU - aplastic anemia, agranulocytosis
MMA- cretinism in preggo, same as PTU
also dont give radioactive iodine to preggo
thyroid cancers
PTC- MC, psammoma body, orphan annie nuclei
Follicular- hematogenous spread (usu to bone)
MTC- parafollicular c cells (calcitonin), amyloid deposition
ATC-
MRND for nodal dz or local dz
XRT for unresectable dz
indications for surgery in primary hyperparathyroidism
symptomatic
Ca>13, decreased creatinine clearance, kidney stones, low bone mass
tertiary hyperparathyroidism
persistent hyperPTH after renal transplant
MEN syndrome genetics
Auto dom
MEN I - MENIN gene
MEN IIa, IIb - ret proto oncogene
MEN I
parathyroid hyperplasia (usu first sign) pancreatic (usu gastrinoma) pituitary adenoma (usu prolactinoma)
MEN IIa
parathyroid hyperplasia
medullary CA- most will have, diarrhea, ppx thyroidectomy at 6yo
pheo
MEN IIb
pheo
medullary Ca- most will have, diarrhea, ppx thyroidectomy at 2yo
mucosal neuromas
marfans
LCIS management options
observation
tamoxifen ppx
bilateral ppx mastectomy
BRCA I vs II
I 60% breast, 40% ovarian
II 60% breast, 10% ovarian, 10% male breast, 10% pancreatic
inflammatory breast cancer management
neoadjuvant chemo –> MRM –> adjuvant chemoXRT
contraindications for breast conserving therapy
2+ tumors
pregnancy
prior radiation to breast
pagets disease of breast management
mastectomy or BCT + radiation
SLN biopsy
stewart treves syndrome
upper inner arm
lymphangiosarcoma from chronic lymphedema (after axillary dissection)
usu 5-10 yrs after surgery
type I vs II pneumocytes
I gas exchange
II surfactant production
MC lung cancer met?
to brain
horners syndrome
pancoast tumor
ptosis, miosis, anhidrosis
mediastinal GCT management
teratoma- resection
seminoma (beta HCG some, no AFP)- XRT
nonseminoma (most will have beta HCG and AFP)- chemo
management of pericardial vs bronchiogenic cysts
resect bronchiogenic
leave pericardial cysts
lung abscess management
abx usu will resolve
drain only if unsuccessful
left vs right chylothorax
injury above T5/6 = left
injury below T5/6 = right
chest wall tumors MC (benign and malignant)
benign- osteochondroma
malignant- chondrosarcoma
ductus arteriosus and ductus venosum
areriosus- desc aorta to left PA (shunts away from lungs)
venosum- portal vein to IVC (shunts away from liver)
Tetralogy of fallot
VSD, pulmonic stenosis, overriding aorta, RVH
indications for CABG
left main >50%
>70% in other vessels
indications for Aortic valve repair
peak gradient >50
valve area <1cm2
or symptomatic
endocarditis valves involved, bugs involved
aortic valve- prosthetic mitral- native tricuspid- drug abusers staph MC, pseudomonas in drug abusers (abx first, surgery if fails)
MC cardiac tumors- benign, malignant, met
myxoma
angiosarcoma
lugn CA
SVC syndrome management
usu lung CA mets
emergent XRT
CEA nerve injuries
vagus n (MC from vascular clamp)- hoarseness
hypoglossal
glossopharyngeal (rare, if high dissection)
ansa cervicalis (no deficits)
facial n mandibular br
aortic dissection into which layer?
medial layer
AAA d/t degen of which layer?
medial layer
where does AAA rupture most commonly?
left posterolateral wall, 2-4cm below renals
Complications after AAA repair
impotence
MI (MC acute death reason)
kidney failure (MC chronic death reason)
AAA endovascular repair criteria
neck length >15mm neck diameter 2-3cm neck angle <60 common iliac length >1cm common iliac diameter 8-18mm
endoleak types
I at attachment sites II collaterals III overlap sites IV porosity V aneurysm expansion without leak
common infections in aortic aneurysms
graft infection- staph #1, e coli #2
mycotic aneurysm - salmonella #1, staph #2 (bacteria invades plaque)
(management same, bypass and resect)
aortoenteric fistula- presentation and location
hematemesis herald bleed, blood per rectum
erosion to 3/4 duodenum at proximal suture line
compartment syndrome mediated by which cell type; also which compartment usually?
PMNs
anterior compartment
popliteal entrapment syndrome
claudication with plantar flexion (loses pulses)
resect gastroc muscle
most common site of embolic disease
common femoral a
arterial emboli vs thrombosis management
emboli- embolectomy
thrombi- heparin and thrombectomy if limb threatened, otherwise angio and thrombolytics
subclavian steal syndrome
subclavian artery stenosis –> reversed flow through vertebral artery
angio w stent; common carotid to subclav artery bypass if stent fails
median arcuate ligament syndrome
median arcuate compresses celiac artery
transect liagment
aneurysm complciations
rupture (above inguinal ligament)
thrombosis/emboli (below inguinal ligament)
when to repair splanchnic artery aneurysms, how
> 2cm
except splenic (MC)- symptomatic or childbearing age or >3-4cm
covered stent
renal artery, iliac artery, femoral artery, popliteal- when to treat
renal 1.5cm iliac 3 femora 2.5 popliteal (MC) 2cm (all repair with covered stent, except popliteal (bypass!)
pseudoaneurysms- management
if from percutaneous interventions- compression w thrombin injection, if fails, surgical repair
if at suture line after surgery –> surgical repair
if later complication after surgery, probably graft infection
dialysis graft failure MC reason
venous obstruction 2/2 intimal hyperplasia
migratory thrombophlebitis sign?
pancreatic cancer
which side more common DVT
left more common
MC lymphedema bug
strep
lymphocele management
first try perc drainage
resection if fails
isosulfan blue dye to foot to ID channels
gastrin, somatostatin, CCK, secretin
gastrin (g cells, antrum) –> increase HCl
somatostatin (D cells, antrum) –> inhibits
CCK (I cells, duo) –> GB contract, panc enzyme secretion
Secretin (S cells, duo)–> panc bicarb secretion
pancreatic polypeptide action
islet cells of pancreas
decrease panc and GB secretions
peptide YY
term ileum inhibs gastric acid secretion GB contraction gastric contraction panc secretions
bowel turnover - stomach, SB, colon
stomach 48hrs
SB 24 hours
colon 3-5days
esophagus vascular supply
mostly directly off aorta
cervical- inferior thyroid a
abdominal- left gastric
venous- azygous and hemiazygous
MC location of esophageal perf
at cricopharyngeus
distance from incisors- UES and LES
15cm 40cm
surg approach to esophagus
cervical left
upper 2/3 right (to avoid aorta)
lower 1/3 left
traction diverticulum etiology and management
true diverticulum
usu lateral, mid esophagus
inflammation, granulomatous dz, cancer
excision and closure if symptomatic
manometry- achalasia, DES, nutcracker
achalasia- increased LES pressure, incomplete LES relaxation, no peristalsis
DES- strong, nonperistaltic contractions, normal LES
Nutcracker- high amplitude peristalsis, normal LES
achalasia, DES, nutcracker management
achalasia- balloon dilation first + CCB/nitrates; consider heller (lower esophagus only)
DES and nutcracker- CCB/nitrates, consider heller (lower and mid esophagus)
achalasia causes
usu neuronal degeneration
T cruzi can cause similar syndrome
esophageal cancer staging and management
TNM + grade, similar to colon cancer TNM stage I (T1 or low grade T2) - esophagectomy only stage II (high grade T2 or above) - neoadju chemorads endomucosal resection for stage IA (low grade T1)
esophageal adeno vs squmous cell mets MC
adeno- liver
squmous cell- lung
blood supply to stomach after esophageectomy
right gastroepiploic
leiomyoma esophageal- where from and management
muscularis propria
no biopsy
excision if >5cm or symptomatic
caustic esophageal injury management
no NGT, NPO, no vomiting
endoscopy to assess lesion (only do if there is no perf on CT)
primary burn (hyperemia)- conservative management
secondary (ulcers, sloughing)- attempt conservative management
tertiary (deep ulcers, charring) usu will need esopahgectomy
esophageal perforation management
contained perfs- conservative
<24hrs - consider pirmary repair, consider muscle flaps
>48hrs - if in neck (just place drains), if chest resect or divert…delayed gastric replacement
boerhaaves most common perf location
usu left lateral wall, 3-5cm above GE junction
higher mortality than other perfs (like iatrogenic)
parietal cells
release H and IF (binds B12 in term ileum)
stim by Ach (vagus), gastrin (G cells), histamine (mast cells)
gastric volvulus management
associated with type II hernias
reduction and nissen
vagotomy postop problems
increased liquid emptying
decreased solid emptying for truncal vagotomy (always do pylorplasty or antrectomy with truncal vagotomY)
diarrhea (due to uncontrolled MMC )
anterior vs posterior duodenal ulcer
anterior- perforate
posterior- bleed
(anterior MC)
management of bleeding duodenal ulcer
EGD first
surgery- duodenotomy and GDA ligation
gastric ulcer types
(types go from MC to least) I lesser curve at antrum II duo and gastric ulcer III prepyloric IV lesser curve higher up V NSAID associated
gastric ulcer complication management
truncul vagotomy and antrectomy; resect ulcer
intestinal vs diffuse gastric cancer management
intestinal- subtotal gastrectomy 10cm margins
diffuse - total gastrectomy
no resection if metastatic dz
GIST- histo and management
ckit postive
malignant if >5cm, >5 mitosis/50HPF
resect w 1cm margins
imatinib
RNYGB risks
marginal ulcers
B12 definiciency (IF cant bind B12 if not acidic)
IDA (duo bypassed)
gallstones
intestinal vs diffuse gastric cancer management
intestinal- subtotal gastrectomy 10cm margins
diffuse - total gastrectomy
no resection if metastatic dz
hepatic veins drain what
left- II, III, IV (sup)
middle- V, IV (inf)
right- VI, VII, VIII
(middle hepatic usu off left hepatic vein)
RNYGB risks
marginal ulcers
B12 definiciency (IF cant bind B12 if not acidic)
IDA (duo bypassed)
gallstones
MC hepatic artery variants?
right hepatic - SMA (behind CBD)
left hepatic - left gastric a (in gastrohepatic ligament)
hepatic veins drain what
left- II, III, IV (sup)
middle- V, IV (inf)
right- VI, VII, VIII
coag factors not made in liver
vWF and factor VIII (from endothelium
crigler najar, dubin johnson
gilberts and rotors
crigler najar and gilbert- indirect
dbin johnson and rotors- direct
best lab for liver function
PT
best diuretic for ascites
aldactone
aldosterone usu high, d/t poor hepatic cleranace
Spont bacterial peritonitis features
PMN >250
usu e coli (mono organism MC)
esophageal varices med management
vasopressin (constricts)
octreotide
propranolol (prevents rebleed)
childs pugh score and mortality risk
A 2%
B 10%
C 50%
liver abscesses
amebic- entamoeba, tx w flagyl
echinococcus- ectocyst (calcification), endocyst (double walled), dont’ aspirate!, albendazole and resect
pyogenic
kasabach merritt syndrome
coagulopathy and CHF 2/2 liver hemangioma
HCC margins
1cm
Meds to contract, relax sphincter of oddi
morphine contrascts
glucagon relaxes
hormone from duo and stomach
gastrin (g cells, antrum) –> increase HCl
somatostatin (D cells, antrum) –> inhibits
CCK (I cells, duo) –> GB contract, panc enzyme secretion
Secretin (S cells, duo)–> panc bicarb secretion
CCK HIDA indications for cholecystectomy
no gallbladder filling
EF <40%
>60min to empty (chronic cholecystitis)
bile duct stricture causess
lap chole (ischemia)
chronic pancreatitis
cancer (until proven otherwise if non above)
hemobilia-
fistula bile duct and hepatic artery UGI bleed, jaundice, RUQ pain usu d/t trauma and iatrogenic angiogram dx angioembo tx
gallbladder cancer resection
gallbladder only if not into muscle
wedge resection if to muscle of 4b and 5
formal resection if past
bile duct cancer risk factors
c sinesis, UC, choledochal cysts, PSC, CBD infections
choledochal cyst types
I- fusiform II- diverticulum III intraduodneal IV- intra and extrahepatic V caroli
endocrine pancreatic cells
alpha- glucagon beta- insulin delta- somatostatin F- pancreatic polypeptide Islet- VIP
Pancreatic divisum ERCP findings
minor papilla (santorini) will be big major papilla with be short (wirsung)
pancreas “chain of lakes”
chronic pancreaatitis
chronic pancreatitis surgical management
puestow- pancreaticojejunostomy (if large duct)
beger- head resection
frey- core out pancreas, pancreaticoJ
pancreatic endocrine tumors- malignant vs benign
nonfunctional- usu malignant insulinoma- usu benign gastrinoma 1/2 1/2 glucagonoma- usu malignant somatostatinoma- usu malig VIPoma- usu malig
management of NEC panc tumors
<2cm enucleat
>2cm formal resection
5FU and streptozocin
gastrinoma triangle
CBD, pancreas neck, D3
imaging for gastrinoma
octreotide scan
ITP vs TTP treatment
ITP - steroids and IVIG; try to avoid splenectomy before 10yo
TTP- plasmapheresis (usu wont require spelenctomy)
feltys syndrome
RA, hepatomegaly, splenomegatly
dentate line- differentiates
2cm from anal verge divids upper 2/3 from lower third columnar vs stratified squamous superior rectal vs mid/inf rectal v internal vs ext hemorrhoids
Crohns features
spares rectum transmural involvement skip lesions cobblestoning creeping fat fistulas
small intestine carcinoid
5HT, bradykinin
octreotide scan to localize
chromagranin A
enterochromaffin cells
dentate line- differentiates
2cm from anal verge internal iliac v superior inguinal LN columnar vs stratified squamous superior rectal vs mid/inf rectal v internal vs ext hemorrhoids
rectum arteries and veins
superior rectal –> IMA
middle rectal –> interal iliac
inferior rectal –> interal pudendal (int iliac)
sup/mid rectal
colon main nutrient
Short chain FA
