gen surg Flashcards
1
Q
treat malignant hyperthermia
A
o2
dantrolene
cold ivf
2
Q
dantroline
moa
and use in surgical context
A
uncouples excitation contraction by decreasing intracellular calcium by blocking ca release from sarcoplasmic reticulum
tx malignant hyperthermia
3
Q
which anesthetics cause malignant hyperthermia
A
volatile ones
inhaled halothane, fluranes
succinylcholine
4
Q
mechanism of malignant hyperthermia
A
variant dihydropyridine or ryanodine ca receptors cause unregulated release of ca when certain volatile anesthetics bind (halothane, fluranes, succinylcholine) – sustained muscle contraction and hypercatabolic state, rhabdo when atp depleted, hyperthermia when heat generation outweighs dissipation
5
Q
pyridostigmine moa
and use in tx of postop complication
A
blocks AchE
tx Olgilvie Syndrome – ileus of colon, commonly post-op in elderly
(more Ach, more ANS, more GI motility)
6
Q
does hepatitis cause direct or indirect hyperbilirubinemia
A
mixed, intrahepatic
7
Q
is genetic hyperbilirubinemia typically direct or indirect?
A
mixed, intrahepatic
8
Q
signs and symptoms of choledocolithiasis vs biliary stricture/cancer
A
choledocolithiasis:
-fever, leukocytosis, +murphy, pain
stricture/cancer -afebrile, normal WBC, -murphy, wight loss clay colored stool painless jaundice distended non-painful gallbladder
9
Q
how to diagnose choledocolithiasis vs biliary stricture/cancer
A
RUQ US
MRCP
for both
10
Q
treat choledocholithiasis
A
ECRP (preferred)
cholecystectomy
11
Q
treat biliary stricture/cancer
A
depending on specific disease:
EUS + bx (pancreatic cancer) – whipple
ERCP + bx (cholangiocarcinoma) – resection
stenting (stricture not PSC (don’t stent PSC because need transplant…)
resection (ampulla of vater)
12
Q
s&s of obstructive jaundice not choledocholithiasis
A
wight loss
clay colored stool
painless jaundice
distended non-painful gallbladder
13
Q
signs of ampulla of vater as cause of painless obstructive jaundice
dx
tx
A
+FOBT
-colonoscopy
ERCP + bx
resection
14
Q
sings of pancreatic cancer as cause of painless obstructive jaundice
A
migratory thrombophlebitis
EUS + bx
whipple
15
Q
signs of cholangeocarcinoma as cause of painless obstructive jaundice
dx
tx
A
PSC (beads on string)
ERCP + bx
resection
16
Q
how to treat biliary stricture
A
stent
unless PSC.. will need… transplant..?
17
Q
simple definition of thrombophlebitis
A
venous clots associated w inflammation and pain
18
Q
painless obstructive jaundice and migrating thrombophlebitis suggests
A
pancreatic cancer
dx EUS + bx
tx whipple
19
Q
painless obstructive jaundice
+FOBT
-colonoscopy
suggests…
A
ampulla of vater issue..
20
Q
painless obstructive jaundice and PSC suggests…
A
cholangeocarcinoma
dx ERCP + bx
tx resection
21
Q
2 biggest cardiovascular CIs to surgery
A
HFrEF v35% = moratility risk 75%
MI v 6 mos (40% mort at 3, 6% mort at 6)
22
Q
goldman index
what is it
A
measure of cardiovascular CIs to surgery
most important factors are
HFrEFv35%
MIv6mos
23
Q
CV preop screen
A
ECG (CI if MIv6mos)
echo (CI if HFrEFv35% - 75% mort)
stress test / left heart cath (CI if MIv6mos)
24
Q
surgical mortality risk if MI within
3 mos
6 mos
A
40% at 3
6% at 6
25
treat MI
stent (preferred)
| CABG
26
treat CHF
BB
ACEI
diuretics
27
pulm CIs to surgery
smoker
COPD/asthma
ILD
28
preop pulm screen
PFTs
ABG
(for COPD, asthma, ILD... ^CO2, vO2)
29
preop liver screen
mortality risk
management
```
MELD
Childs-Pugh
important factors include:
albumin v
pt/ptt ^
TBili ^
ascites
encephalopathy
--any 1 = 40% mort, all = 100% mort
--liver transplant
```
30
why is nutrition screened preop?
affects healing ability
31
preop nutrition screen
workup
management
20% weight loss in 3 mos
albumin v 3
skin anergy (not enough proteins for Igs for allergy)
prealbumin & CRP -- other proteins body makes, to diff malnutrition from liver failure
PO nutrition preferred to parenteral IV
for 10 days preferred to 5 days
32
tf
| prealbumin is made by the liver and turns into albumin
f
it comes before albumin when run on gel electrophoresis
it is another protein made by the body, screened eg to diff malnutrition from liver failure
33
preop metabolic screen
| management
blood glucose
for DKA (glucose ^^ in DKA)
IVF and IV insulin
34
preop screen consists of these tests for these diseases of 5 organs/systems
ECG, echo, stress test/LHC -- HFrEF, MI
PFTs, ABG -- COPD, asthma, ILD
alb, pt/ptt, tbili, ascites, encephalopathy - liver failure
20% weight loss 3 mos, alb, skin anergy, prealbumin, crp -- malnutrition
blood glucose -- dka
35
another name for prealbumin
transthyretin
called prealbumin because runs just ahead of albumin on gel electrophoresis, not a synthetic precursor to albumin, not synthesized by liver
36
overview of post-op fever and causes days 0-14
```
0 intraop wonder drugs malignant hyperthermia
postop day of surg bacteremia
1 wind atelectasis
2 wind PNA
3 water UTI
5 water DVT/PE
7 wound cellulitis
10-14 wound abscess
```
37
intraop fever
dx
tx
ppx
clinical dx
malignant hyperthermia
O2; dantrolene, cool IVF
get family history
38
postop fever day of surgery
dx
tx
ppx
blood cx
bacteremia
broad abx eg vanc piptazo
sterile precautions
39
postop fever day 1
dx
tx
ppx
CXR
atelectasis
tx & ppx incentive spirometry, get out of bed
40
postop fever day 2
dx
tx
ppx
CXR
PNA
broad abx (HAP... vanc piptazo)
incentive spirometry, out of bed
41
postop fever day 3
dx
tx
ppx
UA Ucx
UTI
abx
remove foley ASAP
42
postop fever day 5
dx
tx
ppx
US bilateral LE
DVT/PE
heparin - warfarin
LMWH (can start postop), out of bed
43
postop fever day 7
dx
tx
ppx
clinical, may be erythematous, not closed well
US negative for abscess, CT positive for cellulitis
Abx
sterile precautions and hygiene
44
postop fever day 10-14
dx
tx
ppx
US or CT shows abscess
abscess
abx; I&D
sterile precautions and hygiene
45
7 broad classes of postop complications to look out for
```
fever
AMS
chest pain
abdominal distension
renal failure (v output)
wound non-closure
fistula
```
46
ddx postop AMS and how to treat
```
# DTs - 24-48hr hypot, tachyc, sweats; 48-72 hr tremors -- benzos
# hypoxemia: PE-anticoag; HAP-abx; ARDS-PEEP
# sundowning (elderly) - anipsychotics
# elytes - replete Na, Ca etc
```
47
brief definition of sundowning
| tx
dementia-related agitation, confusion, hyperactivity building in late afternoon and evening
-antipsychotics
48
ddx postop chest pain
workup
tx
```
# MI - ECG trops - PCI heparin NOT tPA POSTOP
# PE - US CT sprial - heparin--warfarin
```
49
ddx postop dec urinary output
workup
tx
urge - bladder scan - obstruction - unkink foley, irrigate, in&out cath
no urge = renal failure - 500cc fluid bolus
inc output after bolus - prerenal - IVF
still no output after bolus - intrarenal - int med
50
ddx postop abdominal distension
workup
tx
```
no stool no flatus
# day 1,2 - ileus / ogilvie - KUB - IVF, K+, out of bed for ileus -- rectal tube, stigmine, colonoscopy for ogilvie (colon ileus in elderly)
# day 5 - obstruction - KUB - SBO vs LBO - NG tube npo ivf for sbo... surg, lbo is surg
```
51
SBO vs LBO appearance on KUB
SBO dilated proximal sb compressed distally
| LBO dilated proximal lb compressed distally but normal sb because ileocecal valve prevents further backup
52
wound dehiscence is a failure of what layer of a wound
the fascia
53
wound dehiscence
s&s
dx
tx
```
serosanguinous/salmon colored drainage
herniation
clinical dx
binders
avoid straining
elective reoperation
```
54
difference betwen dehiscence and evisceration
dehiscence - failure of fascia
| evisceration - failure of whole wound
55
wound evisceration
dx
tx
clinical dx - intestines are spilling out
apply warm saline dressing
emergent surgery
NEVER PUT SPILLAGE BACK IN w/o surgical setting
56
postop fistula
ddx
tx
FETID
foreign body, epithelialization, tumor, inflammation/irradiation, distal obstruction
resect fistula
divert into ostomy while treating cause if necessary
57
most common complication of thyroidectomy
and assoc sx
hypoParathyroidism/hypocalcemia
from asymptomatic incidental lab finding
to non-specific fatigue anxiety depression
to severe tetany seizures qt prolongation (qtc v460 normal)
58
normal QTc
v460
59
what electrolyte abnormality is seen with persistent hypothyroidism post-thyroidectomy
hyponatremia
60
tf
| qt prolongation a result of hypothyroidism post thyroidectomy
f
not a result of hypothyroidism/hyponatremia
a result of hypoParathyroidism hypoCalcemia
61
how does vitamin D toxicity affect ekg
qt shortening from hypercalcemia
62
electrolyte disturbance in hypoparathyroidism
hypocalcemia
hyperphosphatemia
if renal function intact
63
tf
| rapid deceleration blunt chest trauama is high risk for airta injury
t
64
s and s
workup
mgmt
for potential aorta injury after rapid deceleration blunt chest trauma
hypotension, evidence of external trauma, ams... if contained... if not contained usually death
stabilize abc's airway breathing circulation
upright cxr (wide mediastinum, large left hemothorax, right mediastinum deviation, abnormal aorta contour)
confirm w chest ct
immediate operative repair...
65
cxr findings consistent with aorta injury
wide mediastinum
large left hemothorax
right mediastinum deviation
abnormal aorta contour
66
tf
| esophageal rupture after blunt trauma like car accident is common
f
| rare
67
s and s
dx
esophageal rupture
pneumomediastinum
pleural effusion
water-soluble contrast esophagography
68
tf
| circulatory collapse with esophageal rupture
f
69
immediate result of most myocardial ruptures
death
occasionally cardiac tamponade if contained by pericardium
70
physical exam findings cardiac tamponade
hypotension
distended neck veins
muffled heart sounds
71
ekg changes with myocardial contusion
tachycardia
new bbb's
arrhythmia
72
tf
| sternal fx a common associated finding with myocardial contusiom
t
73
s and s
xr findings
diaphragmatic rupture
abdominal pain
shoulder pain (referred)
sob
vomiting
abdominal cotents above diaphragm
loss of diaphragmatic contour
74
```
pneumothorax that does not resolve w chest tube
pneumomediastinum
subcutaneous emphysema
after blunt chest trauma
think...
```
bronchial rupture
| rare after blunt chest trauma
75
how does prerenal aki cause cr rise?
dec perfusion
dec cr filtration
inc serum creatinine
76
bun/cr ^20:1 suggests...
prerenal aki
77
quantitatively define oliguria
v500ml/24hrs
78
urine sediment in prerenal aki
unremarkable
bland
no casts cells or protein
79
tf
| heart failure can cause prerenal aki in the setting of hypervolemia
t
dec Eabv
decreased Effective arterial blood volume
80
treat prerenal aki
ivf isotonic fluid (normal saline)
to restore renal perfusion
as long as no signs of fluid overload (elevated jvp, lung crackles)
81
differentiate prerenal from intrarenal aki in postop gi surg pt on piptazo
piptazo (beta lactams) can cause AIN acute interstitial nephritis... expect leukocytes in ua, skin rash
prerenal aki bland urine sediment no casts cells or protein
82
how dose low dose dopamine affect renal blood flow
primarily d1 agonist
dilates afferent arteriole,
increasing rbf
83
tf
| give furosemide and mannitol to achieve urine output in pt w prerenal aki
F
loop diuretics and osmotic diuretics will further deplete eabf effective arterial blood volume, reduce renal blood flow, worsen prerenal aki, and potentially lead to atn acute tubular necrosis from low rbf
84
for what is intravenous urography useful
eval for ureteral injury
85
most pts w acute appendicitis will seek medical care within how long of start of sx?
within 24-48 hours
if delayed presentation w longer sx (^5days) think apendiceal rupture w contained abscess
86
s and s
tx
acute apoendicitis
vague periumbilical to rlq pain
fever nv anorexia
parietal peritoneal irritation signs (rebound tenderness, involuntary guarding, ab rigidity) if rupture impending or completed with diffuse peritonitis
-urgent appendectomy
87
what to suspect in delayed presentation of appendicitis (^5days sx)
and how to work up and manage
appendiceal rupture w contained abscess
fev leuk
unhelpful anterior ab exam
psoas sign (ext), obturator sign int rot), rectal exam more informative
ct confirms
ivabx npo, maybe percutaneous drainage, elective interval appendectomy at 6-8 wks (avoid immediate surgery as compx rate high w large surrounding inflammation friable debris and adhesions)
88
psoas sign
what is it
ddx for + sign
pain on hip ext
abscess near psoas or retrocecal appendix
89
obturator sign
what is it
ddx for + sign
rlq pain w internal rot of hip
pelvic appendix or abscess
90
physical exam findings in appendicitis
```
peritoneal signs (rebound tenderness, involuntary guarding, abdominal rigity) - rupture or impending
rovsing sign (rlq pain on llq palp), psoas sign (ext), obturator sign (int rot), rectal exam tenderness
```
91
presentation of colon cancer
anemia
constipation
weight loss
92
tf
| psoas sign positive w pyelonephritis
f
93
tf
| atelectasis is common after abdominal surgery
t
94
pathogenesis of postop atelectasis
pain and changed in lung compliance
cause shallow breathing and reduced cough reflex
limiting recruitment of alveoli at bases
and allowing small airway mucous plugging
resultant hypoxia stimulates respirstory rate and hypocapnea
95
when is postop atelectasis most likely to manifest
day 2-3...-5
| after postop night 2 (the start of day 2) to postop night 5, usually postop day 2-3
96
decrease the incidence of postop atelectasis
```
adequate pain control
deep-breathing exercises
incentive spirometry
directed coughing
out of bed (early mobilization)
```
97
decreased breath sounds in the bases 2-3-5 days postop think...
atelectasis
98
sudden onset
dyspnea cough fever ronchi/crackles
within hours postop before leaving perioperative unit
think...
aspiration
(of gastric contents)
due to impaired laryngeal defenses after postop anesthesia
99
consequences of unilateral vs bilateral diaphragmatic paralysis
usually asymptomatic
vs
hypoxemia, rapid shallow breathing, orthopnea, sometimes respiratory failure
100
pathogenesis of VAP ventilator-associated pneumonia
impaired lung defenses
after ^48 hours on ventilator
causing fever, hypoxia
suspect pseudomonas
101
s and s
| necrotizing surgical site infection
- pain edema erythema beyond surgical site
- fev tachyc hypot (systemic signs)
- anesthesia paresthesia at edges of wound
- "dishwater drainage" purulent cloudy gray
- subq crepitus
102
big risk factor for surgical site infection
diabetes
103
bug in most surgical site infections
polymicrobial
104
when is a surgical site infection considered an emergency
when it invades the fascial plain and becomes nec fasc
105
manage necrotizing surgical site infection
EARLY SURGICAL EXPLORATION to eval extent and debride necrotic tissue
-broad abx, hydration, glycemic control are secondary
106
tf
| next step in mgmt of infected surgical wound is vac dressing broad abx and glucemic control
Fish tish
SURGICAL EXPLORATION to assess extent and debride necrotic tissue... if only cellulitis, abx dressing and glucose control appropriate
-appropriate dressing (don't vac infected/necrotic wound immediately, reserved for healthy granulation tissue to accelerate healing), broad spectrum abx, glycemic control all important but not sufficient without surgical exploration for necrotizing infection
107
differentiate necrotizing infection demanding surgical exploration from celullitis amenable to abx dressings and glycemic control
think when getting down to bottom 3 you have to suspect necrosis... also intensity of pain...
- pain edema erythema beyond surgical site
- fev tachyc hypot (systemic signs)
- anesthesia paresthesia at edges of wound
- "dishwater drainage" purulent cloudy gray
- subq crepitus
108
describe use of topical antimicrobial agents for surgical site infections
no clear use
may inhibit healing
and parenteral abx treat infection better
109
person amputated a digit or limb, please advise
wrap in gauze
moisten with saline
put in plastic bag, on ice
send pt w limb to ed
(cool limb without freezing, will keep viable for reimplantation for up to 24 hours)
110
best candidates for reimplantation of amputated limb
young
sharp cut not crush or avulsion
wrap in saline-moistened gauze and put on ice in plastic bag (don't freeze) to preserve for up to 24 hours
111
```
tf
good ideas for amputated digit include
immerse in water
immerse in antiseptic solution or alcohol
put directly on ice
```
f
water immersion makes vessel repair more difficult
chemical injury may result from immersion in chemicals -- the digit will be prepped appropriately with irrigation and abx for surgery in the hospital
frostbite injury can occure from direct placement on ice
112
tf
| varicocele transilluminates
f
hydrocele transilluminates
(peritoneal fluid collection between visceral and parietal tunica vaginalis)
varicocele does not transilluminate (dilation of pampiniform plexus)
113
difference between hydrocele and varicocele
hydrocele transilluminates
(peritoneal fluid collection between visceral and parietal tunica vaginalis)
varicocele does not transilluminate (dilation of pampiniform plexus)
114
presentation of varicocele
soft bag of worms in scrotum, size inc standing valsalva, dec supine
subfertility
testicular atrophy
115
us findings in varicocele
dilation of pampiniform plexus
retrograde venous flow
tortuous anechoic tubules adjacent to testis
116
treat varicocele
young men and boys with scrotal atrophy who desire fertility -- scrotal vein ligation
old guys no more kids -- scrotal support and nsaids...
117
pres
dx
tx
varicocele
painful bag of worms in scrotum, inc w standing valsalva, subfertility testicular atrophy
us - dilated pampiniform plexus, retrograde venous flow
fertility desired - scrotal vein ligation.. if not, scrotal support and nsaids
118
varicocele is more common on what side?
left
| left gonadal vein drains into left renal vein, can get nutcracked between sma and aorta
119
when can right varicocele present
mass effect eg from renal cell carcinoma or thrombus causing back up in gonadal vein into pampiniform plexus
120
where do the left and right gonadal veins drain, respectively
left renal vein
| ivc
121
does the right renal artery cross ant or post to ivc
post
| (remember left renal vein crossed ant to aorts for nutcrack under sma, so ivc shifted just ant to aorts at that level
122
spermatocele
definition
presentation
does it change size with position or valsalva
fluid filled cist of head of epididymis
painless palpable mass at superior pole of testis
does not change size w standing valsalva etc
123
tf
| hydrocele changes w position
tish
| Can change with position if communicating w peritoneum via patent processus vaginalis
124
tf
| a femoral hernia can protrude into scrotum
f
| indirect inguinal hernia does this
125
demo
pres
femoral hernia
older women
| discomfort upper thigh, groin, pelvis
126
where is the femoral ring relative to the inguinal ligament
below it
127
borders of anatomkc snuffbox
(in anatomic position - vetruvian man)
medially extensor pollicus longus
laterally abductor pollicus longus
128
what to do if scalhoid fx suspected but initial xr normal
get ct or mri or repeat xr after 7-10 days spica cast
129
how to treat displaced scaphoid fx
vs
nondisplaced
surg
vs
thumb/wrist spica w fu xr
130
etiology of bacterial tenosynovitis
penetrating injury eg cat bite to hand
hematogenous spread of distant inf (eg n. gonorrhoeae)
131
etiology of fat embolism
long bone fracture
extensive soft tissue injury eg burn
132
synovial cyst aka
ganglion cyst
133
demo
etiology
synovial (ganglion) cyst
15-40yo
| repetitive stress or inflammation
134
tf
| nerve injury is common w scaphoid fx
f
| but lunate disloc next to it can cause median nerve compression in carpal tunnel
135
etiologies of anal fissures
constipation, prolongued diarrhea, anal sex (trauma)
ibd
malignancy
136
tf
| skin tags associated w anal fissure
t
| chronic fissure may have skin tag at distal end
137
most common position of anal fissure
posterior midline...
138
anal fissures relative to dentate line
distal to dentate line
139
mechanism of chronic anal fissure
pain causes sphincter spasm which tears again/larger
140
how does comstipation cause anal fissure
hard stools high pressures tears
141
external skin tag at distal end of chronic anal fissure aka
sentinal pile
142
what is a sitz bath
warm water dip for the perineum and/or anus
-sometimes with iodine, salt, baking soda, vinegar
warm water for blood flow, faster healing, itch irritation pain relief
143
treat anal fissure
fiber diet, adequate hydration
stool softener
sitz baths
topical anesthetic (lidocaine) and vasodilator (nifedipine, nitroglycerin)
144
why are topical vasodilators like nifedipine and nitroglycerin used to tx anal fissure
relieve sphincter pressure (dilate sphincter?)
| increase blood flow for healing...
145
tf
| topical vasoconstrictors used to stem bleed of anal fissure
f
topical lidocaine used for anesthesia, topical nifedipine or nitroglycerin used for vasoDILATION to relieve sphincter pressure and inc blood flow for healing...
146
when to consider fissure excision or lateral sphincterotomy for anal fissure
why
complications
when refractory to medical management (fiber, hydration, stool softener, sitz bath, lidocaine, nifedipine nitroglycerin)
to relieve pressure and/or interrupt spasm
but compx include incontinence and recurrent fissures
147
```
nausea
post prandial pain
vomiting of partially digested food
early satiety
weight loss
think...
```
gastric outlet obstruction
148
etiologies of gastric outlet obstruction
```
gastric malgnancy
pud peptic ulcer disease
crohn's
stricture with pyloric stenosis from caustic substance ingestion
gastric bezoar
```
149
caustic means
able to burn or corrode organic tissue by chemical rxn
| literally or figuratively eg sarcasm
150
define abdominal succussion splash
splashing sounds heard with stethescope over upper abdomen while rocking hips
retained gastric material ^3hrs, liquid gas
151
how long after acid ingestion to fibrosis eg pyloric stricture
6-12 wks
| 1.5-3 mos
152
dx and tx pyloric stricture
upper endoscopy
| surg
153
tf
| pancreatitis causes gastric outlet obstruction
f
| may cause inflammation amd fibrosis and rarely obstruction of duod jeju transv colon, not usually stomach
154
typical duration of diabetes before gastroparesis
a decade or longer
