from UT review Flashcards
what is an absolute contraindication for surgery? why?
DKA/diabetic coma/skyhigh glucose– bc risk of ifxn is too high
what are three indicators of poor nutritional status that would make you want to delay surgery?
albumin 20%, transferrin
what are three indicators of poor nutritional status that would make you want to delay?
albumin 20%, transferrin
what are indicators of liver failure that would make someone want to delay surgery
bilirubin >2, PT > 16 (coags = imp before surgery!), ammonia > 150, clinical signs of encephalopathy
what are indicators of liver failure that would make someone want to delay surgery
bilirubin >2, PT (coags = imp before surgery!), ammonia > 150, encephalopathy
when should you recommend smokers stop smoking prior to surgery?
8 wks
what does Goldman’s Index do?
tells you who is at greatest risk from surgery
what is the most important factor in Goldman’s index (tells you who’s at greatest risk from surgery)
CHF– greatest factor for periop death
what is the most important factor in Goldman’s index (tells you greates risk for surgery)
CHF– greatest factor for periop death
How do you check if someone has CHF before surg?
ejection fraction. if
What are first 6 criteria for Goldman’s index (tells you who’s at greatest risk for surgery)
- CHF
- MI w/in 6 mo (surrogate for CV status)
- arrhythmia
- Old (>70 yo)
- Surgery is emergent
- AS (Aortic stenosis), poor medical condition, surgery in chest/abd
what are you checking on pt >50 or Pt w/recent MI (w/in 6 mo)
EKG - if abnormal —> stress test, if abnormal —> cardiac cath —> reperfusion with stenting or revasc w/CABG
what else should be checked before surg related to AS (aortic stenosis)
- Listen for murmur– late systolic- systolic ejection murmur, crescendo-decrescendo murmur that radiates to carotids. Increase w/squatting, decrease with decr preload
MEDS to STOP before surgery
7-10 days ahead, preferably 2 wks: Aspirin, NSAIDS, Vitamin E (affects coags)
5 days: warfarin
metformin- lactic acidosis
what should your INR be before operating?
how should insulin dependent pts take their insulin before surg?
1/2 nl dose in morning because NPO after midnight the night before
pts w/CKD on dialysis need to be dialized when?
24 hrs before
why do we check BUN and Cr before surgery i people with CKD
bc increased risk of bleeding due to uremic toxins –> uremic platelet dysfunc, especially if BUN > 100
what would you see in the labs if someone was bleeding due to uremic platelet dysfunc?
pt with CKD, BUN > 100, nl platelets but increased bleeding time
what is pressure support vent?
pt rules rate but a boost of pressure is given (8-20) to help give Tidal Volume
what is pressure support vent?
pt rules rate but a boost of pressure is given (8-20)
what is CPAP?
cont. positive airway pressure– pt must breathe on own (must have sufficient resp drive) but + pressure given all the time to keep alvioli open
what is CPAP?
cont. positive airway pressure– pt must breathe on own but + pressure given all the time
What is PEEP?
Positive end expiratory pressure– given at end of cycle to keep alveoli open (5-20)
what is the best test to evaluate management of pt on vent?
ABG– check pa02 and paCO2
what is the best test to evaluate management of pt on vent?
ABG
If person is on a vent and ABG shows Pa02 is high, you should…
lower Fi02– bc free radicals can form–> increase damage
If person is on a vent and ABG shows Pa02 is high, you should…
lower Fi02
If person is on a vent and ABG shows PaC02 is high (pH is low), you should…
increase rate or TV
which is a more eficient change? rate or TV?
TV is a more efficient change– bc increased rate = increased deadspace (Minute ventilation equation)
steps to checking type of acidosis
- check pH–> respiratory acidosis
– if HC03 is low and PaCO2 is low —> metabolic acidosis –> metabolic acidosis - Check AG (Na- [Cl+HCO3])
– nl = 8-12
Gap: MUDPILES
steps to checking type of alkalosis
- check pH –> if > 7.4 = alkalotic
- check bicarb and paC02
- - if HCO3 = low, and paC02 = low —> respiratory alkalosis
- - if HCO3 = high and paCO2 = high –> metabolic alkalosis - Check urine Cl
- - if [Cl] = less than 20 –> vomiting/NG, antacids, diuretics
- - if [Cl] > 20 –> Conn’s, Bartter’s Gittleman’s
steps to checking type of alkalosis
- check pH –> if > 7.4 = alkalotic
- check bicarb and paC02
- - if HCO3 = low, and paC02 = low —> respiratory alkalosis
- - if HCO3 = high and paCO2 = high –> metabolic alkalosis - Check urine Cl
- - if [Cl] = less than 20 –> vomiting/NG, antacids, diuretics
- - if [Cl] > 20 –> Conn’s, Bartter’s Gittleman’s
what are three indicators of poor nutritional status that would make you want to delay?
albumin 20%, transferrin
how would you maximize someone’s nutrition?
enteral feedings (NOT TPN!)
what are indicators of liver failure that would make someone want to delay surgery
bilirubin >2, PT (coags = imp before surgery!), ammonia > 150, encephalopathy
what are common causes hyperchloremic (>20) metabolic alkalosis?
Conn’s (hyper aldo) & Bartter’s, Gittleman’s
If smoker, what should you watch post-op as waking up from anesthesia?
O2 sat– don’t go to 100 bc used to retaining C02, need signal to breathe (possible BS per schwarzstein)
what are common causes of metabolic acidosis?
MUDPILES Methanol uremia DKA Propylene glycol isoniazide lactic acidosis (MOST COMMON) ethylene glycol salicylates
Causes of Non gap metabolic acidosis
diarrhea (pooping out bicarb –> metabolic acidosis), diuretics, renal tubular acidoses (RTAs) (I
How do you check if someone has CHF before surg?
ejection fraction. if
What are first 6 criteria for Goldman’s index (tells you who’s at greatest risk for surgery)
- CHF
- MI w/in 6 mo (surrogate for CV status)
- arrhythmia
- Old (>70 yo)
- Surgery is emergent
- AS (Aortic stenosis), poor medical condition, surgery in chest/abd
what are you checking on pt >50 or Pt w/recent MI (w/in 6 mo)
EKG - if abnormal —> stress test, if abnormal —> cardiac cath —> reperfusion with stenting or revasc w/CABG
what else should be checked before surg related to AS (aortic stenosis)
- Listen for murmur– late systolic- systolic ejection murmur, crescendo-decrescendo murmur that radiates to carotids. Increase w/squatting, decrease with decr preload
MEDS to STOP before surgery
7-10 days ahead, preferably 2 wks: Aspirin, NSAIDS, Vitamin E (affects coags)
5 days: warfarin
metformin- lactic acidosis
what should your INR be before operating?
how should insulin dependent pts take their insulin before surg?
1/2 nl dose in morning because NPO after midnight the night before
pts w/CKD on dialysis need to be dialized when?
24 hrs before
why do we check BUN and Cr before surgery i people with CKD
bc increased risk of bleeding due to uremic toxins –> uremic platelet dysfunc, especially if BUN > 100
what would you see in the labs if someone was bleeding due to uremic platelet dysfunc?
pt with CKD, BUN > 100, nl platelets but increased bleeding time
what is an assist control vent?
set TV & rate, but if pt takes a breath, vent gives the volume
what is pressure support vent?
pt rules rate but a boost of pressure is given (8-20)
when is pressure support vent particularly important?
imp for weaning
what is CPAP?
cont. positive airway pressure– pt must breathe on own but + pressure given all the time
What is PEEP?
Positive end expiratory pressure– given at end of cycle to keep alveoli open (5-20)
when is PEEP used most often?
ARDS and CHF
what is the best test to evaluate management of pt on vent?
ABG
how do you treat hypokalemia (Paralysis, ST depression, U waves happens)?
Give K (but don’t forget to moniter renal func!!! can become hyperkalemic quickly), max 40 mEq/hr
Peaked T waves, prolonged PR and QRS, sine waves = assoc w/which electrolyte derangement?
increased K
Txt for hyperkalemia (Peaked T waves, prolonged PR and QRS, sine waves)
Give Ca-gluconate then insulin + glucose, kayexalate, albuterol (B-agonist) and Na-bicarb. Last resort: dialysis!
In pt when ca is too high or too low, what is next best step?
EKG– look at QT interval, assess risk for torsades
which is a more eficient change? rate or TV?
TV isa more efficient change– bc increased rate = increased deadspace (Minute ventilation equation)
steps to checking type of acidosis
- check pH–> respiratory acidosis
– if HC03 is low and PaCO2 is low —> metabolic acidosis –> metabolic acidosis - Check AG (Na- [Cl+HCO3])
– nl = 8-12
Gap: MUDPILES
steps to checking type of alkalosis
- check pH –> if > 7.4 = alkalotic
- check bicarb and paC02
- - if HCO3 = low, and paC02 = low —> respiratory alkalosis
- - if HCO3 = high and paCO2 = high –> metabolic alkalosis - Check urine Cl
- - if [Cl] = less than 20 –> vomiting/NG, antacids, diuretics
- - if [Cl] > 20 –> Conn’s, Bartter’s Gittleman’s
If pH
-> respiratory acidosis (with metabolic comp)
what are risks of TPN?
acalculus cholecystitis, hyperglycemia, liver dysfxn, zinc deficiency, other ‘lyte probs
if pH > 7.4 = & if HCO3 = high and paCO2 = high what is the acid/base status?
–> metabolic alkalosis
If pH
metabolic acidosis w/resp comp
what are common causes hyperchloremic (>20) metabolic alkalosis?
Conn’s & Bartter’s Gittleman’s
what are common causes of hypochloremic (
vomiting, NG tube, antacids, diuretics
what are common causes of metabolic acidosis?
MUDPILES Methanol uremia DKA Propylene glycol isoniazide lactic acidosis ethylene glycol salicylates
Non gap metabolic acidosis
diarrhea, diuretics, renal tubular acidoses (RTAs) (I
Pt comes in w/confusion, HA, cherry red skin– what are you concerned with? what test should you run? what is the txt?
CO poisoning, test carboxyhemoglobin (pulse ox is worthless because left ward shift- 02 doesn’t dissoc from Hgb). Txt w/100% O2 (hyperbaric if CO-Hb is really elevated!)
what do you do w/hyponatremia…
- check plasma osms– make sure it’s real (not high glucose)
- check volume status
If you see clotting in a person w/edema, HTN & foamy pee think…
nephrotic syndrome (losing prots in urine– some of the first to go are things like antithrombin III and other anti-clotting prots)
suspected diagnoses for hypovolemia (tachy, dry mucus memb, tenting) w/ hyponatremia?
diuretics, vomiting + free water consumption
what’s special about ATIII deficiency as surgery students?
Heparin won’t work– can’t give it to them!
If you see clotting in a young woman w/multiple spontaneous Abortions, think…
Lupus anticoagulant
If you see clotting in someone who’s post-op & decreased plts and heparin was started w/in 5-14 days, think…
HIT (heparin induced thrombocytopenia)– sometimes they won’t say they gave them heparin, they’ll just say they’re “post-op”- code for given heparin! But if it’s low platelets + clotting + post-op THINK HIT!
what do you treat HIT (heparin induced thrombocytopenia) with? (Ab to heparin bound to PF4)
Leparudin or agatroban (synthetic heparin)–
if a pt is BLEEDING with an isolated decrease in platelets, think…
ITP (idiopathic thrombocytopenic purpura)
if a pt is BLEEDING w/normal platelets but increased bleeding time and PTT think…
vWD (Von Willebrand’s Disease)– problem with platelet function, not number
if pt is bleeding with low platelets, increased PT, PTT bleeding time, low fibrinogen and high Ddimer and schistocytes, think…
DIC- caused by gram - sepsis (LPS), disseminated carcinomatosis, OB stuff
how do you treat hypernatremia?
Replace w/D5W or hypotonic fluid
what do you worry about when correcting hypernatremia?
cerebral edema
how quickly can you correct hyper/hyponatremia?
btwn .5 and 1 meq/hr or between 12 & 24 meq/day
numbness, chvostek or troussaeu, prolonged QT interval happens with what electrolyte derangement?
decreased Ca
stones, bones, groans, psychotic overtones and shortened QT interval happens with what electrolyte derangement?
increased Ca
Burn pts are very susceptible to ifxn. how should you give someone abx after a burn?
topically! No PO or IV abx because breeds resistance!!
how do you treat hypokalemia (Paralysis, ST depression, U waves happens)?
Give K (Kidneys!), max 40 mEq/hr
Peaked T waves, prolonged PR and QRS, sine waves = assoc w/which electrolyte derangement?
increased K
Txt for hyperkalemia (Peaked T waves, prolonged PR and QRS, sine waves)
Give Ca-gluconate then insulin + glucose, kayexalate, albuterol and Na-bicarb. Last resort: dialysis!
what should someone do with a chemical burn (esp in eyeballs)?
irrigate > 30 min prior to ER
what is best first step for someone who had an electrical burn?
EKG– arrhythmia is most likely to kill person
if someone w/an electrical burn had LOC or an abnormal EKG, what should you do?
48 hr telemetry
If after a burn a urine dipstick is positive for blood but microscopic exam is negative for RBCs what is going on?
think rhabdo causing myoglobinuria, causing renal failure– (think ATN)
If after a burn a urine dipstick is positive for blood but microscopic exam is negative for RBCs what is going on? and what else should you check?
rhabdo –> myoglobinuria – think ATN. Check K+ – might be too high from cells breaking open
what are risks of TPN?
acalculus cholecystitis, hyperglycemia, liver dysfxn, zinc deficiency, other ‘lyte probs
erythematous, painful but not peeling burn = what degree?
1st degree– effects epidermis
dark or pale burn w/no sensation is what degree burn?
3rd degree, through epidermis and dermis to the nerves
what is the concern w/circumferential burns?
compartment syndrome
loss of integrity of epidermis, very painful burn is what type?
2nd degree
how could you treat a circumferential burn to avoid compartment syndrome?
consider escharotomy
if pt comes in with singed nose hairs, wheezing, soot in mouth/nose, what should you be concerned about
laryngeal edema! Low threshhold for intubation!
if guy is stabbed in the neck and there are crackly sounds w/palmating the anterior neck tissue, what should we do?
fiberoptic broncoscope!! (might have airway.laryngail injury with sub q emphysema)
If guy has huge facial trauma, blood obscures the oral and nasal airway and GCS = 7, what should you do?
cricothyroidotomy (when you can’t asses airway)
If you see clotting in a person w/edema, HTN & foamy pee think…
nephrotic syndrome
if you have intubated a pt and find decreased breath sounds on the left, what happened?
you intubated the rt mainstem broncus– pull out!!
what’s special about ATIII deficiency?
Heparin won’t work
If you see clotting in a young woman w/multiple spontaneous Abortions, think…
Lupus anticoagulant
A pt dies suddenly after a 3rd yr medical student removes a central line. Dx? when else to suspect it?
Dx: air embolism.
Suspect it also when: lung trauma, vent use overzealous w/tidal volume, during heart vessel surgery
what do you treat HIT (heparin induced thrombocytopenia) with?
Leparudin or agatroban
if a pt is bleeding with an isolated decrease in platelets, think…
ITP (idiopathic thrombocytopenic purpura)
what’s next best step if pt is in hemorrhagic/hypovolemic shock (tachy, hypotensive, flat neck veins, nl CVP)
2 large bore periph IV- 2L NS or LR over 20 min followed by blood if we don’t see approp rise in VS
if pt is bleeding with low platelets, increased PT, PTT bleeding time, low fibrinogen and high Ddimer and schistocytes, think…
DIC- caused by gram - sepsis, carcinomatosis, OB stuff
how do you confirm pericardial tamponade?
FAST scan or just treat if strong clinical suspicion
what is the rule of 9s for a child?
head: 19 thorax/abdo: 18 back: 18 each arm front and back: 9 each leg front and back: 14 genitalia: 1
what is the parkland formula for hydration s/p burn in an adult?
Kg x %BSA x 3-4
what is next best step for tension pneumo?
needle decompression, followed by chest tube. Don’t do CXR.
after a burn, what fluid should you use to replenish pts with?
Ringers lactate or NS
what do you see on a Swan-Ganz catheter in hypovolemic shock in terms of RAP/PCWP, SVR and CO?
RAP/PCWP decreases
SVR increases
CO decreases
what topical medication for s/p burns doesn’t penetrate an eschar and can cause leukopenia?
silver sulfadiazine
what topical med for s/p burns penetrates eschar but hurts like hell?
mafenide
what topical burn med doesn’t penetrate eschar and causes hypokalemia and hyponatremia?
silver nitrate
what do you see on Swan-Ganz cath in vasogenic shock in terms of RAP/PCWP, SVR and CO?
RAP/PCWP decreased
SVR decreased
CO increased (EF decreases)
what is best first step for someone who had an electrical burn?
EKG
if someone w/an electrical burn had LOC or an abnormal EKG, what should you do?
48 hr telemetry
If after a burn a urine dipstick is positive for blood but microscopic exam is negative for RBCs what is going on?
myoglobinuria– think ATN
what do you see on Swan-Ganz cath for neurogenic shock in terms of RAP/PCWP, SVR and CO?
RAP/PCWP decreased
SVR decreased
CO increased (EF decreases)
how do you txt neurogenic shock?
in adrenal insuff: txt w/dexamethasone and taper over several weeks
what are the criteria for compartment syndrome?
- 5 P’s: Pain, parasthesia, pallor, paralysis and poikilothermia (inability to regulate temp) and/or pulselessness
- Or compartment Pressure > 30 mmHg
what is the treatment for compartment syndrome s/p burn?
fasciotomy (or escharotomy)– at bedside!
if trauma pt comes in unconscious, what should you do?
intubate!!
if a trauma pt comes in w/a GCS
intubate!!
if a guy is stung by a bee and develops stridor and tripod posturing, what should you do?
intubate!!
if guy is stabbed in the neck, GCS = 15, but there’s an expanding mass in the lateral neck, what should you do?
intubate!!
if guy is stabbed in the neck and there are crackly sounds w/palmating the anterior neck tissue, what should we do?
fiberoptic broncoscope!!
txt for cardiogenic shock?
diuretics, tx the HR to 60-100, then address the rhythm. Next give vasopressor support if necessary
once you’ve intubated the pt, what’s the best next step?
check bilat breath sounds! then check pulse ox, keep it > 90%
if you have intubated a pt and find decreased breath sounds on the left, what happened?
you intubated the rt mainstem broncus– pull out!!
a pt has has inward mvmt of the rt ribcage upon inspiration. Dx? txt?
Dx: flail chest (> 3 consec rib fractures)
Txt: O2 and Pain control
a pt has confusion petechial rash in chest, axilla and neck and acute SOB. Dx? when to suspect it?
Dx: fat embolism
Suspect it: after long bone fracture (esp femur)
A pt dies suddenly after a 3rd yr medical student removes a central line. Dx? when else to suspect it?
Dx: air embolism.
Suspect it also when: lung trauma, vent use, during heart vessel surgery
if pt is hypotensive and tachycardic, worry about…
shock!
If pt is hypotensive, tachy w/flat neck veins and nl CVp what should you wory about?
shock! hypovolemic vs hemorrhagic
what’s next best step if pt is in hemorrhagic/hypovolemic shock (tachy, hypotensive, flat neck veins, nl CVP)
2 large bore periph IV- 2L NS or LR over 20 min followed by blood
if heart sounds are muffled, there’s JVD and electrical alternans and pulsus paradoxus– what are you worried about?
pericardial tamponade
how do you confirm pericardial tamponade?
FAST scan
what is the txt for pericardial tamponade?
Needle decompression, pericardial window or median sternotomy
if there are decreased breath sounds on one side and tracheal deviation AWAY from the collapsed lung what are you worried about?
tension pneumothorax
what is next best step for tension pneumo?
needle decompression, followed by chest tube. Don’t do CXR.
what would you expect on PE with hypovolemic shock?
hypotensive, TACHY, DIAPHORETIC, COOL, CLAMMY extrem
what do you see on a Swan-Ganz catheter in hypovolemic shock?
RAP/PCWP decreases
SVR increases
CO decreases
how do you txt hypovolemic shock?
crystalloid resuscitation
what causes vasogenic shock?
decreased resistance w/in capitance vessels, seen in sepsis (LPS) and anaphylaxis (histamine)
what is PE on person with vasogenic shock?
AMS, hypotension, WARM, DRY extrem (early), late looks like hypovolemic
what do you see on Swan-Ganz cath in vasogenic shock?
RAP/PCWP decreased
SVR decreased
CO increased (EF decreases)
how do you treat vasogenic shock?
fluid resuscitation (may cause edema) and tx offending organism
what is neurogenic shock?
form of vasogenic shock caused by spinal cord injury, spinal anesthesia, or adrenal insufficiency (suspect in pts on steroids encountering a stressor!!) causes an acute loss of sympathetic tone.
what do you see on PE in neurogenic shock?
hypotensive, BRADYCARDIC, WARM, DRY etrem, absent reflexes and flaccid tone. Adrenal insuff will have hypoNa and HyperK
what is the workup for penetrating wound in zone 1 of the neck (from the cricoid down)
aortography
how do you txt neurogenic shock?
in adrenal insuff: txt w/dexamethasone and taper over several weeks
what is cardiocompressive shock?
cardiactamponade or other processes exerting pressure on the heart so it can’t fulfill its role as a pump
what do you see on PE in cardio-compressive shock?
hypotensive, tachy, JVD, decreased heart sounds, nl breath sounds, pulsus paradoxus
if pt has a stab wound to the abdomen, but pt is stable- what do you do?
FAST exam. DPL (diagnostic peritoneal lavage) if FAST is equivocal. Exlap if either FAST or DPL are positive
if blunt abdo trauma pt w/hypotension/tachy, what should you do?
ex-lap
what is cardiogenic shock?
failure of heart as a pump– arrhythmias or acute heart failure
what would you expect to see on PE in person w/cardiogenic shock?
SOB, clammy extremities, rales bilat, S3, pleural effusion, decreased breath sounds, ascites, peripheral edema
what would you expect to see on swan-ganz cath in termsof RAP/PCWP, SVR and CO in cardiogenic shock?
RAP/PCWP increased
SVR increased
CO decreased
txt for cardiogenic shock?
diuretics, tx the HR to 60-100, then address the rhythm. Next give vasopressor support if necessary
what would we hear/see on PE for person with a pneumothorax?
absent/decreased breath sounds on one side, hyperressonance to percussion, distended neck veins and tracheal deviation if tension pneumo
what would we hear on PE for person with hemothorax?
absent/decreased breath sounds on one side, dull to percussion
when do we take someone to the OR for hemothorax?
high output > 1.5 L immediately or greater than 200 cc/hr over first 4 hours
how do we txt hemothorax?
chest tube
“white out lung” after car accident? possible rib fractures?
pulmonary contusion
do people with pulm contusion go to the OR?
no- -just make sure they’re coughing/clearing the airway
what do we do for pain control with flail chest?
nerve block
do we give opiates for flail chest?
no, decrease respiratory drive
what are the 3 categories in GCS and the highest you can get for it
eyes (4), motor (6) voice (5)
head trauma + LOC, what should you do?
CT!!!
biconcave disk on head CT after head trauma =
epidural hematoma
how can you tell acute from chronic subdural hematoma on a CT?
acute blood is bright, chronic is dark
what can cause increased ICP?
hematoma, edema and tumor
symptoms of increased ICP?
HA, vomiting, AMS
what common ortho injury is assoc w/shoulder pain s/p seizure or electrical shock?
posterior shoulder disloc
what common ortho injury is assoc w/arm outwardly rotated & numbness over deltoid…
ant shoulder disloc (numb bc of axillary nerve damage)
what common fracture is assoc w/old lady FOOSH, distal radius displaced
Colle’s fracture– dinner fork deformity
what are the anatomical borders of zone 3 of the neck?
upward from the angle of the mandible (includes trachea, esophagus)
what common fracture is assoc w/”I swear I just punched a wall”
Metacarpal neck fracture “Boxer’s fracture” (usually 4-5th metacarpal) - May need K wire
the clavicle is most commonly broken where?
btwn middle and distal 1/3s. Need figure of 8 device
what is work up for penetrating wound to zone 2 of the neck? (angle of mandible down to the cricoid)
2d doppler +/- exploratory surgery (to check patency of vessels)
what are the anatomical borders of zone 1 of the neck?
from the cricoid down
what is the workup for penetrating wound in zone 1 of the neck (from the cricoid down)
aortography
If there’s a GSW to the abdomen, what do you do?
ex lap + tetanus PPX
If there’s a GSW and you don’t know where it went, but CXR shows free air under the diaphragm, what do you do?
ex-lap!! (+ tetanus PPX)
if stab wound and pt is unstable, with rebound tenderness & rigidity, or w/evisceration what should you do?
ex-lap + tetanus PPX
if pt has a stab wound to the abdomen, but pt is stable- what do you do?
FAST exam. DPL if FAST is equivocal. Exlap if either FAST or DPL are positive
if blunt abdo trauma pt w/hypotension/tachy, what should you do?
ex-lap
blunt abdo trauma + unstable… what do you do?
ex-lap
blunt abdo trauma + stable… what do you do?
get a CT
if there’s a lower rib fx + bleeding into the abdome, be concerned about…
a spleen or liver lac (depending on side of fracture)
if lower rib fx plus hematuria be concerned about…
kidney lac
if kehr sign & viscera in thorax on CXR, be concerned about…
diaphragm rupture
if handlebar sign, be concerned about…
pancreatic rupture
if stable w/epigastric pain, best test is…
abdo CT
if stable w/epigastric pain and retroperitoneal fluid is found on CT, consider…
duodenal rupture
what is the kehr sign?
referred pain to shoulder from phrenic nerve of diaphragm
if pt has pelvic trauma and is hypotensive and tachy (unstable!) you should…
do FAST and DPL to r/o bleeding in abdo cavity
how do you stop a bleed into the pelvis?
stop bleed by fixing fx –> internal if stable, external if not
if blood at the urethral meatus and high riding prostate consider…
pelvic fracture w/urethral or bladder injury
what is next best test if blood at the urethral meatus and high riding prostate?
retrograde urethrogram– not a foley!! check urethral integrity!
txt for simple wound ifxn (Fever POD >7 w/ pain at incision site, induation w/drainage)?
open wound and repack, no abx necessary
what are you looking for on retrograde urethrogram in pt w/ blood at the urethral meatus and high riding prostate?
extravasation of dye– take 2 views to ID trigone injury
if retrograde cystogram shows extraperitoneal extravasation in pt w/ blood at the urethral meatus and high riding prostate, what should you do?
bed rest + foley
if retrograde cystogram shows intraperitoneal extravasation in pt w/ blood at the urethral meatus and high riding prostate, what should you do?
ex-lap and surgical repair
what type of fractures always go to the OR? (4)
- depressed skull fx
- severely displaced/angulated fx
- any open fx (sticking out bone needs cleaning)
- femoral neck or intertrochanteric fx
what common fracture is assoc w/shoulder pain s/p seizure or electrical shock?
posterior shoulder disloc
what common fracture is assoc w/arm outwardly rotated & numbness over deltoid…
ant shoulder disloc
what common fracture is assoc w/old lady FOOSH, distal radius displaced
Colle’s fracture
what common fracture is assoc w/young person FOOSH, anatomic snuff box tenderness?
scaphoid fracture
what common fracture is assoc w/”I swear I just punched a wall”
Metacarpal neck fracture “Boxer’s fracture”- May need K wire
the clavicle is most commonly broken where?
btwn middle and distal 1/3s. Need figure of 8 device
with scaphoid fracture, what do you usually see on xray?
nothing, esp immediately
Fever on POD#1 most commonly caused by? how would you describe sx? how would you dx it? txt it?
- caused by atelectasis2
2. sx: low fever (
POD 1 high fever (to 104) w/very ill appearing pt, most likely caused by…
Nec Fasc
what is the pattern of spread of nec Fasc?
in sub q along scarpa’s fascia
what are the common bugs of nec fasc?
GABHS or clostridium perfringens
what is the txt for nec fasc?
IV PCN, Go to OR and debride skin until it bleeds
most common cause of VERY HIGH FEVER (> 104) on POD1 + muscle rigidity!!
malignant hyperthermia
malignant hyperthermia (VERY HIGH FEVER (> 104) on POD1 + muscle rigidity) is caused by…
succinylcholine or halothane
what is the genetic defect that causes malignant hyperthermia?
Ryanodine receptor gene defect that caues increased intracellular calcium
what is the txt for malignant hyperthermia?
dantrolene Na (blocks Ryanodine receptor an decreases intracellular calcium)
Most common cause of Fever on POD 3-5 w/productive cough, diaphoresis…
PNA
how to txt fever on POD 3-5 w/ productive cough, diaphoresis (PNA)
check sputum sample for culture, cover w/moxi etc to cover strep pneumo in the meantime
Most common cause of Fever on POD 3-5 w/dysuria, frequency, urgency, particularly in pt w/a foley…
UTI
next best test for person w/ fever on POD 3-5 w/dysuria, frequency, urgency, particularly in pt w/a foley…
UA (nitrite and LE) and culture
how to txt fever on POD 3-5 w/dysuria, frequency, urgency, particularly in pt w/a foley…
change foley and txt w/wide spec abx until culture returns
Fever POD 3-5 most likely caused by what or what?
UTI or PNA
Fever > POD 7 w/ tenderness at central IV site?
central line ifxn
what to do if you suspect central line ifxn?
blood cx from the line, pull it, abx to cover staph
Fever POD > 7 w/ pain at incision site, edema, induation but no drainage
cellulitis
txt for cellulitis (assoc w/Fever POD 7 w/ pain at incision site, edema, induation but no drainage)?
blood cx, start abx
Fever POD >7 w/ pain at incision site, induation w/drainage?
simple wound ifxn
txt for simple wound ifxn (Fever POD >7 w/ pain at incision site, induation w/drainage)?
open wound and repack, no abx necessary
Fever POD > 7 w/pain w/ salmon colored fluid from incision?
dehiscence– surgical emergency!
how do you txt dehiscence (Fever POD > 7 w/pain w/ salmon colored fluid from incision)?
surgical emergency! go to OR, iv abx, primary closure of fascia
unexplained Fever pod > 7
abdominal abcess
how do you dx abdominal abcess?
CT w/oral, IV and rectal contrast to find it. Diagnostic lap
Tx of abdominal abcess
Drain it! Percutaneously, IR guided or sugically!
what are random causes of fever > POD 7? (5)
thyrotoxicosis thrombophlebitis adrenal insufficiency lymphangitis sepsis
pressure ulcers are caused by…
impaired blood flow –> ischemia
should you culture pressure ulcers?
no– will just get skin flora
rather than culturing pressure ulcers (which will just be contaminated by skin flora) you should…
check CBC and Blood Cx which can point toward bacteremia or osteomyelitis. Can also do a tissue bx to r/o marjolin’s ulcer
best prevention of pressure ulcers?
turning q2h
describe stage 1 pressure ulcer
skin intact but red. Blanches w/pressure
describe stage 2 pressure ulcer
blister or break in the dermis
describe stage 3 pressure ulcer
SubQ destruction into the muscle
describe stage 4 pressure ulcer
involvement of joint or bone
stage 1-2 pressure ulcer txt:
get special mattress, barrier protection
stage 3-4 pressure ulcer txt
get flap reconstruction surgery
CXR showing peripheral cavitation and CT showing distant mets is most likely…
large cell carcinoma
pleural effusions where you see fluid > 1cm on lat decubitus CXR should be txt w/…
thoracentesis
transudative pleural effusions are most likely caused by…
CHF, nephrotic or nephrotic syndromw
transudative pleural effusions with low pleural glucose is most likely caused by…
RA
transudative pleural effusions with high lymphocytes is most likely caused by…
TB
transudative pleural effusions with blood, most likely caused by…
malignancy or pulmonary embolus
exudative pleural effusions are most likely…
papapneumonic, cancer, etc
if a pleural effusion is complicated (+ gram stain or culture, pH
insert chest tube for drainage
by light’s criteria an effusion is transudative if…
LDH
in tall, thin young men w/sudden dyspnea (or person w/asthma or COPD/emphysema) suspect…
spontaneous pneumothorax – subpleural bleb ruptures –> lung collapse
dx of spontaneous pneumothorax?
CXR
txt of spontaneous pneumothorax?
CXR, txt w/chest tube placement
indications for surgery for spontaneous pneumothorax?
ipsi or contra recurrence, bilateral pneumo, incomplete lung expansion, pilot, scuba diver or lives in a remote area
if surgery is recommended for person w/spontaneous pneumo (ipsi or contra recurrence, bilateral pneumo, incomplete lung expansion, pilot, scuba diver or lives in a remote area), what surgery is recommended?
VATS, pleurodesis (bleo, iodine, or talc)
lung abcesses are usually 2/2…
aspiration (drunk, elderly, enteral feeds)
lung abcesses are most often found in what areas of the lung?
posterior upper or superior lower lobes
Blowing diastolic murmur w/wodened pulse pressure and eponym parade?
aortic regurg
what are indications for surgery for lung abcess?
abx fail, abcess > 6 cm, empyema present
in the work up for a lung nodule, what is the first step?
find an old CXR to compare!
characteristics of benign nodules?
1, popcorn calcification = hamartoma (most common)
- concentric calcification = old granuloma
- Pt
txt of benign looking lung nodule?
CXR or CT scans q2mo to look for growth
characteristics of malignant nodules
- pt has RF (smoker, old)
- > 3cm
- calcification
tx of malignant looking nodule in the lung
remove nodule (w/bronc if central, open lung bx if peripheral)
pt presents w/wt loss, cough, dyspnea, hemoptysis, repeated PNA or lung collapse, suspect
lung cancer!
Most common lung cancer in non-smokers and women (also very commonly seen in smokers!)?
adenocarcinoma, occurs in scars of old PNA
where is adenocarcinoma most commonly located in the lungs, and where does it metastasize to?
peripheral cancer.
mets to liver, bone, brain and adrenals
common characteristic of neoplastic effusions?
exudative w/high hyaluronidase
pt w/Kidney stones, constipation and malaise low PTH and central lung mass most likely has…
squamous cell carcinoma w/paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
Pt w/shoulder pain, ptosis, constricted pupil and facial edema most likely has…
superior sulcus syndrome from small cell carcinoma (a central cancer)
indications for surgery w/GERD?
bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/still sxs, or no want meds
if hematemesis occurs after vomiting w/subq emphysema, and high amylase content in pleural effusion think…
Boerhaave’s (esophageal rupture)
how do you txt SIADH from small cell carcinoma?
fluid restric +/- 3% saline in
CXR showing peripheral cavitation and CT showing distant mets is most likely…
large cell carcinoma
Pathophys of ARDS?
inflammation –> impaired gas xchange, inflam mediator release, hypoxema
causes of ARDS?
sepsis, gastric aspiration, trauma, low perfusion, pancreatitis
Diagnosis of ARDS is dependent on (3 things)
- Pa02/Fi02
txt of ARDS?
mechanical vent w/PEEP
Systolic ejection murmur w/crescendo/decrescendo, louder w/squatting, softer w/valsalva + parvus et tardus = what murmur?
Aortic stenosis
what makes aortic stenosis w/crescendo/decrescendo systolic ejection murmur louder? softer?
louder w/squatting, softer w/valsalva
Systolic ejection murmur louder w/vasalva, softer w/squatting or handgrip = what murmur?
HOCM
what makes HOCM systolic ejection murmur louder? softer?
louder w/vasalva, softer w/squatting or handgrip
what murmur = late systolic w/click, louder w/vasalva and handgrip, softer w/squatting?
MVP
MVP late systolic murmur w/click is louder with __? softer?
louder w/vasalva and handgrip, softer w/squatting
holosystolic murmur radiates to axilla w/left atrial enlargement (LAE) = what murmur?
mitral regurg
Holosystolic murmur w/late diastolic rumble in kids is ?
VSD
continuous machine like murmur =?
PDA
wide fixed and split S2 =?
ASD
rumbling diastolic murmur w/an opening snap, left atrial enlargement (LAE) and A-fib?
mitral stenosis
Blowing diastolic murmur w/wodened pulse pressure and eponym parade?
aortic regurg
when should you do surgery for gastric ulcer?
if lesion persists after 12 wks of txt
how do you txt zenker’s diverticulum?
surgery
is zenker’s diverticulum a tru or false diverticulum?
false! only contains the mucosa!
dysphagia to liquids and solids, think…
achalasia
txt achalasia (dysphagia to liquids and solids) w/… (4)
- Calcium channel blockers (CCB)- like nifedipine
- nitrates ( isosorbide dinitrate and nitroglycerin)
- botox
- heller myotomy
achalasia (dysphagia to liq + solids) = assoc w what 2 dz?
chagas dz and esophageal cancer
dysphagia worse w/hot & cold liquids + chest pain that feels like mI w/NO regurg =?
diffuse esophageal spasm
how do you txt diffuse esophageal spasm (dysphagia worse w/hot & cold liquids + chest pain that feels like mI w/NO regurg)?
calcium chan blockers (CCB) like nifedipine or nitrates (isosorbide dinitrate and nitroglycerin)
epigastric pain worse after eating or when laying down, assoc w/ cough, wheeze and hoarse =
GERD
most sensitive test for GERD?
- 24 hr pH monitoring.
- do endoscopy if “danger signs” present. Tx w/behav mod 1st, then antacids, H2 blocker
what is dieulafoy’s
massive hematemsis bc the mucosal artery erodes into the stomach
how do you txt GERD?
Tx w/behav mod 1st, then antacids, H2 blocker, PPI
indications for surgery w/GERD?
bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/still sxs, or no want meds
if hematemesis occurs after vomiting w/subq emphysema, think
Boerhaave’s
if gross hematemesis unprovoked in a cirrhotic w/pHTN, think…
Gastric varices
If progressive dysphagia w/wgt loss think…
esophageal carcinoma
next best test if you suspect boerhaave syndrome?
CXR, gastrograffin esophagrom. NO endoscopy!!
what test is contraindicated in boerhaave syndrome?
endoscopy!!!
if pt is in hypovolemic shock s/p esophageal varices you should…
do ABC
NG lavage
medical txt w/octreotide or SS balloon
tamponade only if you need to stabilize for transport
txt of boerhaave syndrome?
surgical repair if full thickness
txt of choice for esophageal varices?
endoscopic sclerotherapy or banding
Should you prophylactically band asymptomatic varices?
no! Give BB
what is txt of SMA syndrome?
restore weight/nutrition. Can do Roux-en-Y
most common esophageal cancer/location in people w/long standing GERD?
adenocarcinoma in the distal 1/3
Best 1st test for suspected esophageal cancer?
barium swallow, then endoscopy w/Bx, then staging CT
acid reflux pain after eating, when laying down = assoc w/?
hiatal hernia
type 1 hiatal hernia?
sliding GE jxn herniates into thorax. Worse for GERD. Tx sxs
Type 2 hiatal hernia
paraesophageal. Abd pain, obstruction, strangulation –> needs surgery!
does type 1 or type 2 hernia need surgery?
T2. T1 can be txt w/meds for GERD
middle epigastric pain worse w/eating?
gastric ulcers
gastric ulcers = assoc w/what 3 RF?
H. pylori, NSAIDS, steroids
work up for gastric ulcers?
double contrast barium swalow- punched out lesion w/regular margins. EGD w/bx can tell H-pylori, malignant or benign
tx adenocarcinoma of the panc w’wipple IF… (3)
- no mets outside abdomen,
- no extension into SMA or portal vein
- no liver or peritoneal mets
what kind of gastric cancer is most common, especially in Japan?
adenocarcinoma
what is a Krukenberg tumor?
Gastric CA that has met to the ovaries
where is virchow’s node?
in the L supraclavicular fossa
Lymphoma is often assoc w/…
HIV (check this fact from slide 41 of PDF)
what is Blummer’s shelf?
mets in the pelvic cul de sac felt on digital rectal exam (DRE) (assoc with gastric cancer?)
Where is the Sister Mary Joseph node?
umbilical node (important for gastric ca?)
MALT-lymphoma is associated w/…
H pylori
what is mentriers? What finding on endoscopy is characteristic?
a protein losing erteropathy– look for enlarged ruggae
Gastric varices are indicative of…
splenic vein thrombosis
tx for VIPoma?
octreotide can help sx
middle epigastric pain that gets better w/eating is assoc w/what?
duodenal ulcers
biggest RF for duod ulcers?
H pylori – 95%
txt of healthy pts
trial of H2 block or PPI
Dx of duodenal ulcers?
blood, stool or breath test for h pylori but endoscopy w/bx = best b/c it can exclude cancer
Tx of duodenal ulcers w/H-pylori and how do you make sure h-pylori is gone afterwards?
PPI, clarithromycin & amoxicillin x2wks. Breath or stool test can be test of cure.
what should we suspect if middle epigastric pain/ulcers don’t resolve w/txt?
zollinger-ellinson syndrome
best test for zollinger-ellison syndrome?
secretin stim test (find innap high gastrin)
txt for zollinger ellison syndrome?
surgical resection of pancreatic/duodenal tumor
if someone is dx with zollinger ellison syndrome, what else should you look for?
Pituitary and parathyroid probs– think MEN 1
a pt has bilious vomiting and post-prandial pain. He recently lost 200 lbs on “biggest loser” Be concerned about…
SMA syndrome (acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation)
pathophys of SMA syndrome
acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation
what is txt of SMA syndrome?
restore weight/nutrition. Can do Roux-en-Y
Middle epigastric pain straight through to the back– most likely…
pancreatitis
most common etiologies of pancreatitis?
ETOH and gallstones
txt cholangiocarcinoma w…
surgery + rad
Txt of pancreatitis?
NG suction, NPO, IV rehydration and observation
Bad prognostic factors for pt w/pancreatitis? (13)
- old
- WBC > 16k
- Glc > 200
- LDH > 350
- AST > 250
- drop in Hct
- decreased Ca
- acidosis
- hypoxemia
- pseudocyst (no cells)
- hemorrhage
- abcess
- ARDS
chronic pancreatitis is assoc w/? (3)
chronic MEG pain, DM, malabsorption (steatorrhea)
chronic pancreatitis can cause splenic cein thrombosis what can lead to,,,
gastric varices
If in the head of the panc, adenocarcinoma of the pancreas can cause courvoisier’s sign which is…
large non-tender GB, itching and jaundice
what is trousseau’s sign?
migratory thrombophlebitis– assoc w/ adenocarcinoma of the panc
tx adenocarcinoma of the panc w’wipple IF… (3)
- no mets outside abdomen,
- no extension into SMA or portal vein
- no liver or peritoneal mets
what is whipple’s triad (assoc w/ insulinoma)
Sxs (sweat, tremors, hunger, seizures) + BGL
what are sxs of insulinoma?
same as low glucose!– sweat, tremors, hunger, seizures
labs c/w insulinoma?
insulin increased
c-peptide inc
pro-insulin inc
sxs of glucagonoma?
hyperglycemia, diarrhea, wt loss
rash characteristic of glucagonoma?
necrolytic migratory erythema
somatistainoma are assoc w/?
malabsorption (seatorrhea) etc from exocrine panc malfxn
are somatistainoma usually malig or benign?
malig
VIPoma sxs?
watery diarrhea, hypokalemia, dehydration, flushing
VIPoma looks similar to what syndrome?
carcinoid
tx for VIPoma?
octreotide can help sx
most likely dx w/ RUQ pain into the back, n/v, Fever, worse s/p fatty foods?
acute cholecystitis
best 1st test?
US
txt?
cholecystectomy? perc cholecystostomy if unstable (CHECK THIS– now it mt be abx!)
RUQ pain, high bili and high alk phos =?
choledocolithiasis
dx of choledocolythiasis?
US will show CBD stone (or lg dilitation of CBD?)
txt for choledocolithiasis?
chole +/- ERCP to remove stone
rupture of enchinococcus liver cyst (pt from mexico presents w/RUQ pain and lg liver cysts found on US) will cause…
anaphylaxis
what is Charcot’s triad? Assoc w/?
RUQ pain, F, jaundice– ascending cholangitis
what is Reynold’s pentad? assoc w/?
RUQ pain, fever, jaundice, ↓BP, AMS– ascending cholangitis
txt ascending cholangitis w/?
fluids & broad spectrum abx, ERCP and stone removal
describe T1 choledochal cysts…
fusiform dilation of CBD
how do you txt T1 choledochal cysts (fusiform dilation of CBD)?
excision
T5 choledochal cysts = assoc w/what dz? what is txt?
Caroli’s Dz. Cysts in intrahepatic ducts– needs liver transplant!
cholangiocarcinoma is rare. RF for it are (3)
Primary sclerosing Cholangitis (UC)
Liver flukes
thorothrast exposure
txt cholangiocarcinoma w…
surgery + rad
Hepatitis where AST = 2x ALT =?
Alcoholic hep (reversible)
hepatitis where AST > ALT high (1000s) = ?
Viral hep
AST & ALT high s/p hemorrhage, surg or sepsis is most likely…
shock liver
cirrhosis and portal htn txt with…
SS and VP vasoconstrict to decrease portal pressure
Bblockers also decrease portal pressure
do you need to treat esophageal varices prophylactically?
no, but band/burn them once they bleed once
TIPS relieves portal HTN BUT worsens…
hepatic encephalopathy
txt hepatic encephalopathy w/…
lactulose (helps rid body of ammonia)
RF for hepatocellular carcinoma?
chronic HepB carrier > Hep C
cirrhosis for any reasons
aflatoxin or carbon tetrachloride exposure?
Dx hepatocellular ca w/?
high AFP (in 70%), CT/MRI
txt of hepatocellular ca?
surgically remove solitary mass, use rads or cryoablation for pallation of multiple
women on OCP w/palpable abd mass or spontaneous rupture of abdo mass w/hemorrhagic shock =?
hepatic adenoma
how do you dx hepatic adenoma (women on OCP w/palpable abd mass or spontaneous rupture of abdo mass w/hemorrhagic shock)?
US or MRI
Txt of hepatic adenoma (women on OCP w/palpable abd mass or spontaneous rupture of abdo mass w/hemorrhagic shock)?
D/c OCPs, resect if lg or pregnancy is desired
2nd Most common benign liver tumor. It’s more common in W > M, but less likely to rupture than hepatic adenomas?
focal nodular hyperplasia
most common bugs causing bacterial abcess on the liver?
E. Coli, bacteriodes, enterococcus
tx of bact abcess on the liver?
surgical drainage and IV abx
RUQ pain, profuse sweating and rigors, palpable liver =?
liver abcess 2/2 entamoeba histolytica
txt for liver cyst 2/2 entamoeba histolytica?
metronidazole. Don’t drain it!
pt from mexico presents w/RUQ pain and lg liver cysts found on US =?
echinococcus
mode of eccinococcus transmission?
hydatid cyst paracyte from dog feces
lab findings common w/ eccinococcus ifxn (pt from mexico presents w/RUQ pain and lg liver cysts found on US)
eosinophilia and + casoni skin test
what is the casoni skin test?
immediate hypersensitivity skin test used in the diagnosis of hydatid disease of enchinococcus (pt from mexico presents w/RUQ pain and lg liver cysts found on US)
how do you txt enchinococcus (pt from mexico presents w/RUQ pain and lg liver cysts found on US)?
albendazole and surgery to remove entire cyst. RUPTURE CAUSES ANAPHYLAXIS!!
rupture of enchinococcus liver cyst (pt from mexico presents w/RUQ pain and lg liver cysts found on US) will cause…
anaphylaxis
s/p splenectomy, what should you do for post-ob thrombocytosis > 1mil?
give aspirin
what ppx should you give s/p splenectomy?
prophylactic PCN + S. pneumo, H. flu and N meningitidis vaccines
ITP should be considered in cases of…
- isolated thrombocytopenia (with bleeding gums, petechiae, nosebleeds)
- decreased plt count/inc megakaryocytes in marrow
- NO SPLENOMEGALY
how should ITP be txt?
steroids 1st. If relapse, splenectomy
what should be considered in pt w/isolated thrombocytopenia (with bleeding gums, petechiae, nosebleeds), decreased plt count/inc megakaryocytes in marrow, & NO SPLENOMEGALY
ITP!
what should you consider in pt w/ sxs of hemolytic anemia (jaundice, inc indirect bili, LDH, decreased hapto, elevated ritic count) + spherocytes on smear and + osmotic fragility test?
hereditary spherocytosis
pts w/hereditary spherocytosis are prone to…
gallstones
how should you txt pt w/hereditary spherocytosis?
splenectomy (accessory spleen too)
what dx should be considered w/L lower rib fx, intra abdo hemorrhage, +/- kehr’s sign (irritates L diaphragm –> pain in L shoulder via phrenic nerve)?
splenic fracture
Kehr’s sign in the left shoulder is considered a classical symptom of…
splenic rupture
