Gastro PACES Flashcards
Causes of massive splenomegaly?
CML, Myelofibrosis, Malaria, Lymphoma
Causes of palmar erythrema?
Chronic stable liver disease, cirrhosis, hyperthyroidism, pregnancy, RhA, polycythaemia
Signs of chronic stable liver disease?
Palmar erythrema
Dupuytren’s
Clubbing
Corneal arcus
Gynaecomastia (failure of liver to break oestradiol down), axillary hair loss, spider naevi)
Spider naevi (>5 is abnormal, sup. vena cava distribution) – also in those who take COCP and pregnancy
Decompensated liver disease:
o Portal hypertension [SAVE]:
Splenomegaly
Ascites
Varices
Encephalopathy
o Failed clearance of bilirubin (jaundice)
o Failed clearance of ammonia (leads to encephalopathy) flapping tremor (asterixis)
How are sutures chosen?
Sutures chosen based on diameter, tissue strength, duration of closer
Larger no. of zeros = smaller diameter
Absorbable sutures
Vicryl
Monocryl
PDS
Catgut (natural)
Non-absorbable sutures
Nylon (ethilon)
Prolene
Silk
steel
Monofilament sutures pros & cons?
Less trauma and tissue reaction
Lower risk of infection
Braided/polyfilament pros and cons?
Easier to handle + retain knots
Increased risk of infection
When to use monofilament
used for superficial wound closure (less tissue reaction)
When to use non-absorbable sutures?
permanent support + slower healing tissued e.g. vascular anastomoses, tendon, fascia
When to use absorbable sutures?
for deep or rapid healing tissues e.g. bowel/biliary/urinary anastomoses
Complications with Total hip replacements?
Dislocation
Osteolysis
Metal sensitivity
Nerve injury
Chronic pain
CI/ Complications of TED stockings?
patients with arterial disease of the lower limb (need to do ABPI first), severe skin breakdown (ulceration/ infection)
Complications of oropharyngeal airway?
trauma to soft palate
airway hyperreactivity
gagging → vomiting and aspiration
Complications/CI of nasopharyngeal airway?
Complications:
Nasal ulceration, bleeding, laceration of friable lymphoid tissue, rupture of a pharyngeal abscess, laryngospasm
Contraindication:
Patients with basal skull fractures/ severe head/ maxfax = potential passage through the cribriform plate
Complications of ET tube?
Complications: include (but not exhaustive) inappropriate placing (oesophageal), injury to larynx, C spine injury, pneumothorax, atelectasis, sore throat, difficult wean and infection.
Tracheostomy?
This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration.
One of the most common occasions you will see a tracheostomy is on a patient being ventilated on the intensive care unit.
Allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways.
Patients with upper airway obstruction/ severe maxfax trauma or after laryngeal surgery.
Complications of tracheostomy?
Immediate: Bleeding, trauma to oesophagus and RLN, pneumothorax, can’t ventilate
Early: Tracheal erosion, tube displacement/obstruction, surgical emphysema, aspiration pneumonia, pneumomediastinum
Late: Tracheomalacia, tracheoesophageal fistula, tracheal stenosis
iGels and laryngeal mask airways (LMA) what are they?
Supraglottic airway devices that are used as a step prior to intubation i.e. do not prevent aspiration therefore not a definitive airway
When to use LMA?
Elective surgical procedures i.e. day cases/ <2hr ops, cardiac arrests and prehospital airway management (bridge to ET). They have benefits that include reduced trauma to the oropharynx (seen with intubation) and therefore can be used to reduce hospital stays in elective patients
Contraindications/complications of LMA/iGels?
Contraindications: Trismus (lockjaw), limited mouth opening, pharyngo-perilaryngeal abscess, trauma or mass, reduced chest compliance
Complications: Inflation of the device can also cause pressure lesions and nerve palsies. Dislodgement, leak and aspiration as is not definitive airway
Laryngoscope
Indications: A laryngoscope is used to aid ET intubation, visualisation of larynx to aid diagnosis of vocal problems and strictures.
Complications:
Inexperienced users of laryngoscopes can cause severe harm to the patient including mild soft tissue injury, laryngeal and pharyngeal scarring, ulceration and abscess formation. & C spine injury
Nasal Cannulae
It is widely used to carry 1-3L of oxygen per minute (can be upto 4L/min). This delivers between 28-44% of oxygen.
These cannulae differ from high-flow therapy (NIV).
Complications: nasal sores/ ulcerations and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise.
Self-Inflatable Bag-Valve-Mask
Very useful in delivering high levels of oxygen even at low-flow rates.
Can deliver 100% oxygen with flows above 10L/min.
Indications: patients in resp failure, apnoea, patients unable to protect their own airway, patients undergoing anaesthesia in elective procedures
Complications:
Barotrauma from too much lung inflation
Gastric insufflation → vomiting and aspiration
Indication for intubation
Decreased consciousness and loss of airway reflexes (gcs <8) - failure to protect against aspiration
Failure to oxygenate (T1RF) - resp pathology, ARDS, pul oedema
Failure to ventilate (T2RF) - tiring pt eg life threatening asthma
Failure to maintain airway patency - upper airway obstruction, angioedema, facial/ upper airway trauma.
Central Line Insertion Pack
Seldinger central line kits include a 3-5 lumen cannula, guide wire, dilator, scalpel, and introducer needle.
Central venous catheters are placed often into the subclavian or internal jugular veins via ultrasound. They are useful in the delivery of medications/fluids that may be harmful orally or peripherally. Blood tests and central venous pressures can also be obtained.
Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes.
Complications on insertion include: pneumothorax, sepsis, thrombosis and misplacement
Seldinger technique. Order CXR to confirm placement
Hickman vs Tesio
Hickman = 2 ports and 1 tube
Tesio = 2 ports and 2 tubes
Tunnelled central line
Inserted into subclavian through subcut tunnel (decreases incidence of line infection)
Long term use (months to years)
The definitive airway: what is it?
Infraglottic (crosses cords), secure (cuffed), prevents aspiration of gastric contents, condeliver max conc of o2
Indications for tesio/hickman?
IV admin of meds
Abx, chemotherapy
Regular vascular access
RRT
Blood sampling
TESIO indications?
Indication: haemodialysis. Inserted under x-ray guidance
Cuff promotes a tissue reaction with allows for a better seal.
Hickman indications?
Long-term parenteral nutrition, long-term intravenous antibiotic therapy and chemotherapy.
PICC line?
Inserted into basilic or cephalic veins with tip sitting in SVC, CXR used to check placement
Medium term use (weeks to months), tends to have a longer catheter vs central lines
Indications: IV admin of medication - abx, chemo, Poor peripheral access
Complications of PICC lines?
Immediate: haemorrhage, pneumothorax, arterial puncture, arrhythmias, cardiac tamponade, air embolism
Delayed: venous stenosis, thrombosis, erosion of vessel, line fracture, catheter colonisation, line related sepsis
Port-a-Cath?
Long term chemo or Abx.
Centrally placed catheter, SC port made of silicone.
Accessed with Huber point needle. Low infection risk as skin breech very small
Epidural insertion pack
Touhy/Epidural needle – Touhy type needle is provided with clear depth marking for accurate insertion depth reading.
Epidural catheter- It is specially designed for short term and long term anaesthesia and pain relief into extradural space
Epidural catheter adapter – This catheter adapter is for safe and secure attachment to the catheter for convenience of the procedure
Swan ganz catheter
Used to measure the pressures in the heart, the pulmonary artery wedge pressure and can also be used to measure the cardiac output.
These are used in the intensive care setting and are typically inserted into a central vein
Used in ICU/ in cardiogenic or septic shock
Inserted into a central vein
HOWEVER use has not actually shown to improve outcome…
Indications:
Flow directed pulmonary artery catheter
Measure pulmonary capillary wedge pressure
Measure CO
Dever’s retractor
This is a type of retractor which is used in open abdominal surgery to allow the surgeon to operate.
There are different sizes and types of retractors available. You may frequently be asked to use one during you clinical training when you are assisting in theatre.
Can be bent into a suitable shape
Complication: damage to skin and internal structures
Self-retaining retractor
This is a type of retractor used to hold wounds open, e.g. during a hernia repair or an appendicectomy.
Complications: damage to nerves and vessels
Laproscopy port?
Complications
Initial entry carries highest risk of visceral perforation
Extra care taken at extremes of BMI and previous laparotomy
Trucut Needle
This is a trucut biopsy needle which is used to take histological specimens from lesions, e.g. breast lumps or liver.
The procedure can be performed under local anaesthetic.
Complications: bleeding, pain, Ca seeding
Image quality for CXRs?
RIPE
Rotation: clavicle position
Inspiration: 7 anterior/9 posterior
Penetration: visible spine processes behind mediastinum
Exposure: apices to below the diaphragm
CXR - what to look for?
A = airway
Trachea patent and central
B = breathing and bones
Lung fields esp apex
Lung markings
Fractures
C = circulation
Cardiomegaly
Cardio/costophrenic angles
D = diaphragm
Air under the diaphragm
E = everything else
Foreign bodies/artefacts
Subcutaneous emphysema
Heart failure signs on CXR:
Alveolar batwing shadowing
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Pleural Effusion
Ix for pleural effusion
A-E
Pleural aspiration for testing, chest drain for treatment
Bedside – sputum culture
Bloods – FBC CRP UE LFT autoimmune screen
Imaging – fibroscan, ECHO,
Send fluid off for: cytology, culture, biochemistry, culture
Describing pulmonary effusion CXR
Rotation Ok, inspiration good, slight underpenetration
A ok
B – interstitial shadowing pulmonary infiltrates upper lobe diversion
Cardiomegaly
Some blunting and effusions
E no rib fractures, Pacemaker seen
What is the most likely diagnosis?
Pulmonary oedema / acute heart failure
Presenting AXRs?
Assess image type and quality - projection of image (AP) - either supine or erect, exposure of image - ?whole abdomen from diaphragm to pelvis visible
Interpretation - BBC
B = bowels and other organs
Small bowel - more central, valvulae conniventes across whole width, normally <3cm, caecum < 9cm
Large bowel - peripheries, haustra and plicae semilunaris, <6cm
Faeces often mottled appearance and seen in colon
B = bones
C = calcification and artefact
Toxic megacolon?
Toxic megacolon - colonic dilatation without obstruction associated with colitis
IBD mostly, also infective colitis
Also lead pipe - loss of normal haustral markings secondary to chronic colitis (IBD)
Thumb printing in toxic megacolon may also be present +/- pseudopolyps
Faecal loaded bowel/ faecal impaction AXR?
mottled appearance due to gas in to the faecal matter
Treating large bowel obstruction?
A-E
Drip and suck – NBM, IV fluids, analgaesia
Refer to surgeons
What is the single most important investigation to order next?
CT abdomen to find cause, is it volvulus etc
Gout on imaging?
Soft tissue swelling in early disease
Periarticular erosions ‘punched out lesions’ in late disease
Normal joint space
RA hands X-rays
RhA hands - LESS
In MCPs
REMEMBER - to present as a symmetrical polyarthropathy, with your top ddx as rheumatoid arthritis
Loss of joint space
Erosions
Soft tissue swelling
See through bones (osteopenia)
Plus other cardinal signs of RhA e.g. Z thumb, Boutonniere’s deformity, swan-neck deformity etc
RFs for subarachnoid haemorrhage?
PKD, HTN, idiopathic usually, AVM
Psoriatic arthropathies
Psoriatic arthropathy
Pencil in cup
X-ray showing some of changes in seen in psoriatic arthropathy. Note that the DIPs are predominately affected, rather than the MCPs and PIPs as would be seen with rheumatoid. Extensive juxta-articular periostitis is seen in the DIPs but the changes have not yet progressed to the classic ‘pencil-in-cup’ changes that are often seen.
Complications of subarachnoid haemorrhage?
Vasospasm – presents like a stroke
Hyponatraemia – can be SIADH
Rebleed - coil ASAP if possible
Death
Describe CT subarachnoid haemorrhage
hyperdensity in the subarachnoid space, sulcul effacement (so ↑ ICP, bone OK, Vs Ok (no midline shift)
Extradural haematoma findings on CT?
lentiform or convex hyperdense lesion in right hemisphere, causing sulcal effacement and small degree midline shit, no bone fracture, right ventricles effacement, sulci effacement. Extracranial haematoma
Treatment for extradural haemorrhage
How would you manage this patient?
A-E approach
Refer to neurosurgery - burr holes
How would know if this patient was deteriorating?
Monitor GCS, GCS will drop as disease progresses (typically lucid interval then unconscious). If lose consciousness again → emergency as could be herniating
Acute subdural haematoma on CT?
crescent shaped area of hyperdensity, following subdural space in right hemisphere, extending from frontal lone posteriorly, with midline shift, ventricular and sulcal effacement, no bone fractures
RFs for subdural haematoma?
Elderly
Anticoagulant therapy
Alcohol excess
High falls risk
Chronic subdural haematoma: CT findings?
Chronic subdural - cresent shaped hypodense collection that spreads across the hemisphere and is not limited by the suture lines. There is also effacement of the ipsilateral ventricle.
