gen surg Flashcards
treat malignant hyperthermia
o2
dantrolene
cold ivf
dantroline
moa
and use in surgical context
uncouples excitation contraction by decreasing intracellular calcium by blocking ca release from sarcoplasmic reticulum
tx malignant hyperthermia
which anesthetics cause malignant hyperthermia
volatile ones
inhaled halothane, fluranes
succinylcholine
mechanism of malignant hyperthermia
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
pyridostigmine moa
and use in tx of postop complication
blocks AchE
tx Olgilvie Syndrome – ileus of colon, commonly post-op in elderly
(more Ach, more ANS, more GI motility)
does hepatitis cause direct or indirect hyperbilirubinemia
mixed, intrahepatic
is genetic hyperbilirubinemia typically direct or indirect?
mixed, intrahepatic
signs and symptoms of choledocolithiasis vs biliary stricture/cancer
choledocolithiasis:
-fever, leukocytosis, +murphy, pain
stricture/cancer -afebrile, normal WBC, -murphy, wight loss clay colored stool painless jaundice distended non-painful gallbladder
how to diagnose choledocolithiasis vs biliary stricture/cancer
RUQ US
MRCP
for both
treat choledocholithiasis
ECRP (preferred)
cholecystectomy
treat biliary stricture/cancer
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)
s&s of obstructive jaundice not choledocholithiasis
wight loss
clay colored stool
painless jaundice
distended non-painful gallbladder
signs of ampulla of vater as cause of painless obstructive jaundice
dx
tx
+FOBT
-colonoscopy
ERCP + bx
resection
sings of pancreatic cancer as cause of painless obstructive jaundice
migratory thrombophlebitis
EUS + bx
whipple
signs of cholangeocarcinoma as cause of painless obstructive jaundice
dx
tx
PSC (beads on string)
ERCP + bx
resection
how to treat biliary stricture
stent
unless PSC.. will need… transplant..?
simple definition of thrombophlebitis
venous clots associated w inflammation and pain
painless obstructive jaundice and migrating thrombophlebitis suggests
pancreatic cancer
dx EUS + bx
tx whipple
painless obstructive jaundice
+FOBT
-colonoscopy
suggests…
ampulla of vater issue..
painless obstructive jaundice and PSC suggests…
cholangeocarcinoma
dx ERCP + bx
tx resection
2 biggest cardiovascular CIs to surgery
HFrEF v35% = moratility risk 75%
MI v 6 mos (40% mort at 3, 6% mort at 6)
goldman index
what is it
measure of cardiovascular CIs to surgery
most important factors are
HFrEFv35%
MIv6mos
CV preop screen
ECG (CI if MIv6mos)
echo (CI if HFrEFv35% - 75% mort)
stress test / left heart cath (CI if MIv6mos)
surgical mortality risk if MI within
3 mos
6 mos
40% at 3
6% at 6
treat MI
stent (preferred)
CABG
treat CHF
BB
ACEI
diuretics
pulm CIs to surgery
smoker
COPD/asthma
ILD
preop pulm screen
PFTs
ABG
(for COPD, asthma, ILD… ^CO2, vO2)
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
why is nutrition screened preop?
affects healing ability
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
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
preop metabolic screen
management
blood glucose
for DKA (glucose ^^ in DKA)
IVF and IV insulin
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
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
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
intraop fever
dx
tx
ppx
clinical dx
malignant hyperthermia
O2; dantrolene, cool IVF
get family history
postop fever day of surgery
dx
tx
ppx
blood cx
bacteremia
broad abx eg vanc piptazo
sterile precautions
postop fever day 1
dx
tx
ppx
CXR
atelectasis
tx & ppx incentive spirometry, get out of bed
postop fever day 2
dx
tx
ppx
CXR
PNA
broad abx (HAP… vanc piptazo)
incentive spirometry, out of bed
postop fever day 3
dx
tx
ppx
UA Ucx
UTI
abx
remove foley ASAP
postop fever day 5
dx
tx
ppx
US bilateral LE
DVT/PE
heparin - warfarin
LMWH (can start postop), out of bed
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
postop fever day 10-14
dx
tx
ppx
US or CT shows abscess
abscess
abx; I&D
sterile precautions and hygiene
7 broad classes of postop complications to look out for
fever AMS chest pain abdominal distension renal failure (v output) wound non-closure fistula
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
brief definition of sundowning
tx
dementia-related agitation, confusion, hyperactivity building in late afternoon and evening
-antipsychotics
ddx postop chest pain
workup
tx
# MI - ECG trops - PCI heparin NOT tPA POSTOP # PE - US CT sprial - heparin--warfarin
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
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
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
wound dehiscence is a failure of what layer of a wound
the fascia
wound dehiscence
s&s
dx
tx
serosanguinous/salmon colored drainage herniation clinical dx binders avoid straining elective reoperation
difference betwen dehiscence and evisceration
dehiscence - failure of fascia
evisceration - failure of whole wound
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
postop fistula
ddx
tx
FETID
foreign body, epithelialization, tumor, inflammation/irradiation, distal obstruction
resect fistula
divert into ostomy while treating cause if necessary
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)
normal QTc
v460
what electrolyte abnormality is seen with persistent hypothyroidism post-thyroidectomy
hyponatremia
tf
qt prolongation a result of hypothyroidism post thyroidectomy
f
not a result of hypothyroidism/hyponatremia
a result of hypoParathyroidism hypoCalcemia
how does vitamin D toxicity affect ekg
qt shortening from hypercalcemia
electrolyte disturbance in hypoparathyroidism
hypocalcemia
hyperphosphatemia
if renal function intact
tf
rapid deceleration blunt chest trauama is high risk for airta injury
t
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…
cxr findings consistent with aorta injury
wide mediastinum
large left hemothorax
right mediastinum deviation
abnormal aorta contour
tf
esophageal rupture after blunt trauma like car accident is common
f
rare
s and s
dx
esophageal rupture
pneumomediastinum
pleural effusion
water-soluble contrast esophagography
tf
circulatory collapse with esophageal rupture
f
immediate result of most myocardial ruptures
death
occasionally cardiac tamponade if contained by pericardium
physical exam findings cardiac tamponade
hypotension
distended neck veins
muffled heart sounds
ekg changes with myocardial contusion
tachycardia
new bbb’s
arrhythmia
tf
sternal fx a common associated finding with myocardial contusiom
t
s and s
xr findings
diaphragmatic rupture
abdominal pain
shoulder pain (referred)
sob
vomiting
abdominal cotents above diaphragm
loss of diaphragmatic contour
pneumothorax that does not resolve w chest tube pneumomediastinum subcutaneous emphysema after blunt chest trauma think...
bronchial rupture
rare after blunt chest trauma
how does prerenal aki cause cr rise?
dec perfusion
dec cr filtration
inc serum creatinine
bun/cr ^20:1 suggests…
prerenal aki
quantitatively define oliguria
v500ml/24hrs
urine sediment in prerenal aki
unremarkable
bland
no casts cells or protein
tf
heart failure can cause prerenal aki in the setting of hypervolemia
t
dec Eabv
decreased Effective arterial blood volume
treat prerenal aki
ivf isotonic fluid (normal saline)
to restore renal perfusion
as long as no signs of fluid overload (elevated jvp, lung crackles)
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
how dose low dose dopamine affect renal blood flow
primarily d1 agonist
dilates afferent arteriole,
increasing rbf
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
for what is intravenous urography useful
eval for ureteral injury
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
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
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)
psoas sign
what is it
ddx for + sign
pain on hip ext
abscess near psoas or retrocecal appendix
obturator sign
what is it
ddx for + sign
rlq pain w internal rot of hip
pelvic appendix or abscess
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
presentation of colon cancer
anemia
constipation
weight loss
tf
psoas sign positive w pyelonephritis
f
tf
atelectasis is common after abdominal surgery
t
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
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
decrease the incidence of postop atelectasis
adequate pain control deep-breathing exercises incentive spirometry directed coughing out of bed (early mobilization)
decreased breath sounds in the bases 2-3-5 days postop think…
atelectasis
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
consequences of unilateral vs bilateral diaphragmatic paralysis
usually asymptomatic
vs
hypoxemia, rapid shallow breathing, orthopnea, sometimes respiratory failure
pathogenesis of VAP ventilator-associated pneumonia
impaired lung defenses
after ^48 hours on ventilator
causing fever, hypoxia
suspect pseudomonas
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
big risk factor for surgical site infection
diabetes
bug in most surgical site infections
polymicrobial
when is a surgical site infection considered an emergency
when it invades the fascial plain and becomes nec fasc
manage necrotizing surgical site infection
EARLY SURGICAL EXPLORATION to eval extent and debride necrotic tissue
-broad abx, hydration, glycemic control are secondary
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
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
describe use of topical antimicrobial agents for surgical site infections
no clear use
may inhibit healing
and parenteral abx treat infection better
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)
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
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
tf
varicocele transilluminates
f
hydrocele transilluminates
(peritoneal fluid collection between visceral and parietal tunica vaginalis)
varicocele does not transilluminate (dilation of pampiniform plexus)
difference between hydrocele and varicocele
hydrocele transilluminates
(peritoneal fluid collection between visceral and parietal tunica vaginalis)
varicocele does not transilluminate (dilation of pampiniform plexus)
presentation of varicocele
soft bag of worms in scrotum, size inc standing valsalva, dec supine
subfertility
testicular atrophy
us findings in varicocele
dilation of pampiniform plexus
retrograde venous flow
tortuous anechoic tubules adjacent to testis
treat varicocele
young men and boys with scrotal atrophy who desire fertility – scrotal vein ligation
old guys no more kids – scrotal support and nsaids…
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
varicocele is more common on what side?
left
left gonadal vein drains into left renal vein, can get nutcracked between sma and aorta
when can right varicocele present
mass effect eg from renal cell carcinoma or thrombus causing back up in gonadal vein into pampiniform plexus
where do the left and right gonadal veins drain, respectively
left renal vein
ivc
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
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
tf
hydrocele changes w position
tish
Can change with position if communicating w peritoneum via patent processus vaginalis
tf
a femoral hernia can protrude into scrotum
f
indirect inguinal hernia does this
demo
pres
femoral hernia
older women
discomfort upper thigh, groin, pelvis
where is the femoral ring relative to the inguinal ligament
below it
borders of anatomkc snuffbox
(in anatomic position - vetruvian man)
medially extensor pollicus longus
laterally abductor pollicus longus
what to do if scalhoid fx suspected but initial xr normal
get ct or mri or repeat xr after 7-10 days spica cast
how to treat displaced scaphoid fx
vs
nondisplaced
surg
vs
thumb/wrist spica w fu xr
etiology of bacterial tenosynovitis
penetrating injury eg cat bite to hand
hematogenous spread of distant inf (eg n. gonorrhoeae)
etiology of fat embolism
long bone fracture
extensive soft tissue injury eg burn
synovial cyst aka
ganglion cyst
demo
etiology
synovial (ganglion) cyst
15-40yo
repetitive stress or inflammation
tf
nerve injury is common w scaphoid fx
f
but lunate disloc next to it can cause median nerve compression in carpal tunnel
etiologies of anal fissures
constipation, prolongued diarrhea, anal sex (trauma)
ibd
malignancy
tf
skin tags associated w anal fissure
t
chronic fissure may have skin tag at distal end
most common position of anal fissure
posterior midline…
anal fissures relative to dentate line
distal to dentate line
mechanism of chronic anal fissure
pain causes sphincter spasm which tears again/larger
how does comstipation cause anal fissure
hard stools high pressures tears
external skin tag at distal end of chronic anal fissure aka
sentinal pile
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
treat anal fissure
fiber diet, adequate hydration
stool softener
sitz baths
topical anesthetic (lidocaine) and vasodilator (nifedipine, nitroglycerin)
why are topical vasodilators like nifedipine and nitroglycerin used to tx anal fissure
relieve sphincter pressure (dilate sphincter?)
increase blood flow for healing…
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…
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
nausea post prandial pain vomiting of partially digested food early satiety weight loss think...
gastric outlet obstruction
etiologies of gastric outlet obstruction
gastric malgnancy pud peptic ulcer disease crohn's stricture with pyloric stenosis from caustic substance ingestion gastric bezoar
caustic means
able to burn or corrode organic tissue by chemical rxn
literally or figuratively eg sarcasm
define abdominal succussion splash
splashing sounds heard with stethescope over upper abdomen while rocking hips
retained gastric material ^3hrs, liquid gas
how long after acid ingestion to fibrosis eg pyloric stricture
6-12 wks
1.5-3 mos
dx and tx pyloric stricture
upper endoscopy
surg
tf
pancreatitis causes gastric outlet obstruction
f
may cause inflammation amd fibrosis and rarely obstruction of duod jeju transv colon, not usually stomach
typical duration of diabetes before gastroparesis
a decade or longer
