General surgery 2 Flashcards

Question

What is the effect of shock to the kidneys

Answer 1

Autoregulation over 70-170 but below this - oliguria | impaired renal function

Answer 2

Decreased gut motility and nutrient absorption, and decreased ability to sustain normal flora, leading to infection susceptibility

Answer 3

Blood supply is centralised, giving cool/clammy/mottled peripheral skin

Answer 4

>3 urgent medical review | >5 critical care team

Answer 5

``` 2+ of: temperature >38.8 or <36 RR >20 or PCO2 <4.3 HR >90 WCC: <4 or >12x109 ```

Answer 6

SIRS + suspected site of infection

Answer 7

Sepsis + hypotension or evidence of end organ dysfunction (oliguria, confusion, lactate >3, SpO2 <94%

Answer 8

Severe sepsis with hypotension not responding to fluid resuscitaiton Results from over activation of the immune system due to infective cause The first stage is extensive peripheral vasodilatation and this is compounded by endothelial dysfunction causing fluid loss into the interstitial space (hypovolaemic)

Answer 9

A-E Sepsis 6: In: oxygen, fluid, abx Out: catheter, lactate, cultures Urgent senior review. Once stabilised, source control is the next priority

Answer 10

Type 1 IgE mediated hypersensitivity reaction, occurring in response to an antigen that the body has previously been sensitised to Degranulation of mast cells leads to release of vasoactive mediators such as histamine that cause excessive vasodilation of the venous system This is compounded by bronchoconstriction and laryngeal oedema

Answer 11

``` A-E 0.5mg 1:1000 adrenaline (0.5ml) repeat every 5 minutes Chlorphenamine 10mg IV Hydrocortisone 200mg IV ``` ?ITU ECG Epipen and skin prick

Answer 12

``` A-E Fluid loss source?? Bolus 500ml Inotropes if consistently hypotensive Tranexamic acid ``` Class 1-4: 15% 30% 40% 40%

Answer 13

MASSIVE transfusion protocol: 2222 | get delivery of packed cells, fresh frozen plasma and platelets in 2:1:1

Answer 14

A-E Morphine Swan-Ganz catheter, central line and arterial line PCWP low - give 100mg plasma expander every 15 mins If ok, give inotropic support renal dose dopamine

Answer 15

Inhibition of sympathetic outflow from spinal cord, leading to vasodilation Maybe due to epidural anaesthesia or spinal cord injury above T6 Will present with hypotension and bradycardia not responding to fluid resuscitation so consider the is a mechanism of spinal injury

Answer 16

Fluid resuscitation and vasopressors

Answer 17

Spinal shock is a transient 'concussion' of the spinal cord, leading to flaccid arreflexia, that resolves as the soft tissue swelling decrease There may be priapism, and there will be no reflexes below the level of injury

Answer 18

Coagulopathy Hypothermia Metabolic acidosis bit of a vicious cycle - hypothermia leads to coagulopathy as the clotting factors cannot work effectively, which leads to a metabolic acidosis which then leads to decreased myocardial performance and further hypothermia

Answer 19

General factors: Age, malnutrition, immunosuppression, malignancy, obesity, hypoxia, anaemia Local factors: type of surgery (clean vs contaminated), length of procedure, residual local malignancy, foreign body insertion, ischaemia Microbiological factors: lack of antibiotic prophylaxis, virulence of the organism

Answer 20

Superficial incisional SSI: infection of the skin and subcutaneous tissue of the incision (most common) Deep incisional SSI: infection also involving deep tissues such as muscle / fascial layers. This includes organ / space SSIs draining through the incision Organ / space SSI: infection involving any site involved in the operation, other than the incision

Answer 21

Patients at high risk of infection, or in whom the risk may be low but the consequences of an infection would be serious

Answer 22

Operative factors: contaminated/dirty surgeries Patient factors: immunosuppression, previous foreign body implants, heart valve disease or peripheral vascular disease Choice of abx Dose and timing factors e.g. highest tissue concentration required at the moment of tissue contamination (IV administration at moment of incision) Often 2 further doses are given at appropriate times (24 hour Course)

Answer 23

Superficial purulent infection caused by staph aureus, with a characteristic golden crust on an erythematous base Should always be swabbed, and treatment = topical mupirocin / fusidic acid

Answer 24

Purulent skin infection caused by staph/strep characterised by ulceration under a crust Associated with poor hand hygiene and malnutrition (commonly seen in drug addicts)

Answer 25

Mildly itchy eruption between the toes or in the flexures, caused by Corynebacterium (fluoresces pink with Wood's light) Treatment is topical miconazole or oral erythromycin

Answer 26

Generally caused by staph, and pustules heal in 7-10 days in superficial folliculitis (oral flucloxacillin). Deep folliculitis most commonly occurs in adolescence, with furuncles and carbuncles developing, needing longer courses of tetracycline / erythromycin

Answer 27

Fever, irritability and skin tenderness before erythema and skin blistering develops after 24-48 hours, due to toxins from a focus of infection with S aureus. This most commonly occurs in children and a bacterial swab should be taken from the nose/throat with immediate IV flucloxacillin started alongside supportive measures

Answer 28

Infection of subcutaneous tissue, most commonly due to streptococcal infection Erysipelas is more superficial dermis infection, often with a raised erythematous edge and affects the face

Answer 29

Smooth, skin-coloured papules that enlarge to have an irregular hyperkeratotic surface. Usually resolve spontaneously

Answer 30

poxvirus leading to classically umbilicate papules that resolve spontaneously over many months

Answer 31

Erythematous annular lesions with central clearing, with treatment generally topical terbinafine or ketoconazole, however, systemic terbinafine or itraconazole may be needed in widespread disease

Answer 32

Diagnosis made by identifying the scabietic burrow, usually on the edges of the fingers or sides of the hands/feet. Topical treatment (permethrin/malathion) is required for all physical contact

Answer 33

Clostridium per fringes found in soil/faeces Can arise from trivial injury, often in immunocompromised patients Initially gas in the tissues and skeletal muscle (crepitus) with oedema and spreading gangrene plus systemic upset

Answer 34

May need resuscitation | Aggressive debridement and IV penicillin + metronidazole

Answer 35

Aerobes and synergistic anaerobes infect an initial wound / surgical site, leading to severe wound pain and gas in the tissues There may be extensive subdermal gangrene

Answer 36

Debridement, antibiotics and systemic support

Answer 37

response to tissue injury and stress

Answer 38

Review general observations, urine output Insepct the wound for superficial infection/haematoma Inspect cannula sites for thrombophlebitis/infection Examine the chest to exclude infection, infarction or acute heart failure Examine the legs for DVT Consider other sources of infection e.g. urine/GI infection

Answer 39

To protect other patients / staff from a patient's infection e.g. TB (special masks also required) and MRSA

Answer 40

Protect patients from getting an infect carried by staff/visitors / other patients These are used in those with decreased natural immunity e.g. transplant recipients, chemotherapy patients

Answer 41

Alongside the organ or origin e.g. parabolic, parapancreatic Pelvic e.g. post-pelvic sepsis (appendicitis) Subphrenic e.g. post GI perforation

Answer 42

Malaise, anorexia, swinging pyrexia, tachycardia and a possible mass

Answer 43

CT abdo / pelvis Management: IV empirical Abx as well as radiologically (CT/USS) guided drainage where possible Surgical drainage is a last line measure

Answer 44

Often performed under GA Point of maximum fluctuance is incised and then blunt probing ensures all loculi are drained Small abscesses - dry dressing, whereas deeper abscessed require frequent packing with antiseptic ribbon gauze / use of a corrugated drain to keep them open until they have filled with granulation tissue