GenSurg Flashcards
? is the name of the duodenal/jejunal feeding tube
How are positions verified
What are the E+ abnormalities seen w/ refeeding syndrome
Dobhoff tube
KUB films
Hypo K, Mg, Phos
What surveillance order is needed on Pts receiving TPN
Feeding tubes can be placed/started ? soon after surgery
Define Visceral vs Parietal pain
Weekly liver enzymes
Day 2 post-op
V: afferent fibers, pain MC midline d/t bilateral innervation
P: sharp/precise pain d/t peritoneal irritation
Sequence of x-ray assessment
What is a 3-way abdomen image and what is it used for
Abdominal x-rays normally show air in ? three areas
Adequacy Bones Calcifications Deformity/Density Extra air Foreign body/Fx
Flat, Upright, CXR for hemo/pneumo-peritononeum
Stomach Small bowel, Rectosigmoid
How are mechanical obstructions distinguished from ileus’
Ileus are more common after ? d/t ?
Sub-diaphragmatic air on x-ray suggests ? issue
Mechanical- more localized, severe pain
Ileus- diffuse and milder
Post-op d/t inc sympathetic nerve activity
Perforated viscous
Where does the appendix arise from
What land mark is used to locate it during removal
What causes this to become obstructed in adults/peds
Postero-medial cecum, 2cm inferior of IC valve
Taeniae of colon converging at base
Adult: fecalith Peds: lymphoid hyperplasia
What are the 3 PE tests performed to locate appendicitis
Mnemonic for Alvarado Score
McBurney: iliac fossa
Obturator- pelvis
Psoas- retroperitoneal/cecal
Migration to R iliac fossa- 2pts Anorexia N/V Tenderness in R iliac fossa Rebound pain Elevated temp Leukocytosis- 2pts (>75% neutrophils) Shift to left of WBCs
5-6: compatible 7-8: probable 9-10: very probable
What ABX are used during appendicitis
Appendix are routinely removed even if not inflamed during ? GI surgery
What PE test is used for rectus sheath hematoma
Cipro+Metronidazole: Perf’d
Cefoxitin: non-perf’d
Meckels Diverticulum
Neg Fothergill sign
Where are Boerhaave perfs most likely to occur
What images are done
What lab result would be elevated from thoracentesis after Boerhave perfs
Left posterolateral wall- causes Hamman crunch
Cervical x-ray
Esophagogram w/ contrast
Chest CT to localize
Amylase
? is the most sensitive imaging study for suspected esophageal cancers
How are Pts managed
? is the most important prognostic factor
Endoscopic US w/ FNA of lymph nodes
Neoadjuvant chemo and rad
Stage of Dz
What are the 2 MC complications to occur within 30days after bariatric surgery
What is the most concerning early complication
? is the MC performed bariatric surgery
Dehydration, E+ imbalance
Anastomotic leak
LSG
? is the most accurate method to Dx gastric ulcers
When is a Dx of Zollinger Ellison Syndrome considered
What lab test is used for Dx
Endoscopy
Ulcer refractory to PPI
Ulcer in distal duodenum/jejunum
Recurrent ulcers despite Tx
Fasting gastrin, d/c PPI one week prior
? pre-op image is used to localize Zollinger Ellison tumors and all are Tx w/ ?
? triple therapy is used for Tx
Why is maintenance therapy done w/ Omeprazole
Somatostain receptor scintigraphy; Resection
Amox Clarith w/ PPI
Inhibits parietal cell ATP tor educe ulcer recurrence
Test of choice for post-gastric ulcer Tx eradication
What procedures done to Tx high risk Pts w/ gastric ulcers
How are perforated duodenal ulcers Tx
Urea breath test
Billroth I- gastroduodenal anastomosis
Bilroth 2- gastrojejunal anastomosis
Roux en-Y gastrojejunostomy
Omental/Graham patch
Complications after antrectomy
Complications after Truncal Vagotomy
? type of diet do Pts adopt to Tx Dumping Syndrome
Leakage from duodenal stump
Delayed emptying, Dumping syndrome, Diarrhea
Low carb, High fat/protein
What is the most sensitive and specific test for suspected Pyloric Stenosis and how is this Tx
? type of ulcer is not associated w/ Ca risk
These ulcers can be Tx by ? methods
US; Laparoscopic pyloromyotomy
Duodenal
EGD <24hrs if hermorrhaging, Selective vagotomy
? is the MC form of volvulus
How are these Dx
Pts w/ ? signs need immediate surgery or ? if no signs are present
Sigmoid then Cecal
Colonic- X-ray; Small bowel- CT
Toxic, Bloody d/c, Fever, Leukocytosis, Peritonitis- surgery
None- sigmoidoscopy
Define Rigler Triad
How is this Dx
How is this Tx
Abdominal radiograph findings for gallstone ileus: Pneumobilia Obstruction Gallstone
CT
Enterolithotomy- incision made proximal to obstruction for relief and removal
Meckel’s Diverticulum is d/t a remnant of ?
What is the Rule of 2s
Omphalomesenteric duct
2% of peds population
2 tissue types: gastric, pancreatic
2 feet from ileocecal valve
? are the MC benign tumors of the small bowel
? are the MC malignant tumors of the small bowel
? are the MC endocrine tumors of the small bowel
Leimyoma, Adenoma
Adenocarcinoma
Carcinoid tumor: hot flash, bronchospasm, arrhythmias
Define Bezoar
How are these conditions Dx by images
How are they Tx
Compacted, retained foreign material in GI tract: Phyto- fiber Lacto- milk Pharma- meds Tricho- hair
AP films
Endoscopy then surgery
? is the most sensitive and specific study to Dx acute cholecystitis
MCC of cholelithiasis
What are the RFs to develop this MCC
Cholescintigraphy: Hida scan
Cholesterol stones
Age Female Obesity Parity
What causes pigmented stones in the gallbladder
When are pigmented stones seen
What are the non-surgical Tx options for cholecystitis in Pts inelligible for surgery
Inc unconjugated bilirubin, turns into Ca bilirubinate
Sickle Thalassemia Spherocytosis
Ursodeoxycholic acid: stones <15mm
ESWL- breaks stones <2mm for passing
Optimum time for cholecystectomy or ? is performed
What is the MC complication that arises from acalculous cholecystitis
Choledocholithiasis leads to ? Dx
<72hrs from Sx onset; Percutaneous cholecystostomy
Gangrene > Perf, Empyema
Cholangitis
Common Bile Duct dilation more than ? suggest choledocolithiasis
What are the high risk features for suspected choledocholithiasis
How are mild or mod/sev cases of cholangitis Tx w/ ABX
> 10mm/1cm
Age >55y/o Bili >30mmol CBD >6mm Dx US w/ stone
Mild/Mod: Cefazolin/Cefoxitin
Sev/Deterioration: Aminoglycoside + Clinda or Metro
Severe or unremitting cholangitis despite ABX are best Tx w/ ?
How much gas is used to inflate the abdomen during lap procedures
What is the name of the incision used for open cholecystectomy procedures
Endoscopic sphincterotomy then to laparotomy
15mmHg of CO2
Kocher’s in RUQ
Post-cholecystectomy ABX are continued for how long
When are Pts f/u w/ and when can they return to normal activity
What system breaks up the liver into segments
Until afebrile and normal leukocytosis
F/u 1wk, normal routine in 6-8wks
Couinaud into 8 sections
Common hepatic artery arises from ? structure
What structure marks the point of origin for the artery
Why is vascular control within the abdomen difficult
Celiac axis
Gastroduodenal artery
Hepatic veins are very short prior to entering IVC
What 3 structures make up the portal triad
These three structures enter the liver through ?
Bile is composed of ? four components
Hepatic artery, Portal vein, Biliary duct
Hepatic hilum
Formed in hepatocytes out of:
Conjugated bile acid, Cholesterol, Phospholipid, Protein
What are the Vitamin K dependent clotting factors
MC injured organ w/ abdominal blunt trauma and w/ ? MC sequelae and ? is the Tx strategy for this injury
What is a rare sequelae to liver trauma
2 7 9 10
Liver- biliary fistulae after central injury pattern:
Non-op management
Pneumobilia
Define Bilioma
How are these Tx if major leakage occurs
MC type of liver cyst
Loculated collection of bile
ERCP and spincterotomy
Simple hepatic: anechoice lesion w/ smooth contours
What is the name of the pre-malignant liver cyst and how are they Tx
Polycystic Liver Dz occur in Pts w/ ? MedHx
How are the different types Tx
Cystadenoma- internal septae w/ irregular lining and papillary projections; Tx: resection
PCKDz
Type 1: cyst fenestration w/ <10 cysts >10cm
Type 3: transplant d/t parenchymal involvement
? is the MC liver tumor
How are these results different on imaging
Hepatic adenomas are associated w/ ? RFs and managed how
Hemangioma d/t congenital vascular malformation
T1: hypointense T2: hyperintense Cold: NucMed scan
OCP/Androgen steroid use;
<3cm: observe while d/c OCPs
Resection: >5cm, expanding, malignant suspicion
Histologically, Hepatocellular Adenomas consist of ?
How are Focal Nodular Hyperplasia growths of the liver ID’d w/ imaging
What is the major RF for developing Hepatocellular Carcinoma
Benign hepatocytes
Hot on NucMed imaging
Chronic Liver Dz: Chronic hep B/C
How is Hepatocellular Carcinoma Dx
After Dx of Hepatocellular Carcinoma, what f/u schedule do Pts have
What are the 4 palliative options for these Pts
High resolution CT/MRI
US w/ A-fetoprotein q6mon
TACE TARE SBRT Sorafenib
What is the MC classification system used for liver failure
How are Pts w/ Chronic Liver Dz Tx
What is the name of the main/accessory duct in pancreas
Child-Pugh: Class C is c/i for hepatic resection
TIPSS: shunt placed and BBs to reduce risk of first bleed
Main Wirsung Accessory: Santorini
Define Budd Chiari Syndrome
When is this MC seen
Initial Tx is ? followed by ?
Hepatic vein thrombosis
Hypercoagulable female w/ RUQ pain, Ascites, Megaly
TIPS then portal decompression before hepatic necrosis occurs (Fullament failure Tx w/ transplant)
Why does Acute Pancreatitis prominently present w/ N/V
What are the 6 parts of the Ranson Criteria
What scoring system is used as a bed side index of severity
Accompanying paralytic ileus
GA LAW:
Glucose>200 Age>55 LDH>350 AST>250 WBC>16K
BASAP:
BUN>25mg AMS SIRS Age>60 Pleural effusion
Pancreatic Pseudocysts form d/t and occur more commonly in Pts w/ ?
What complication can occur as a result of severe pancreatic inflammation
D/t fluid sequestration, how is hypovolemia Tx during acute pancreatitis
Acute pancreatitis fails to recover after 1wk of Tx; Duct abnormalities
Pseudoaneurysm- acute exacerbation of abdominal pain
3-6L 9% NS or LR over first 24hrs
MCC of Chronic pancreatitis
What is the clinical tetrad for this condition
Name of Tx operation for large/small pancreatic duct chronic pancreatitis
Alcoholism
Pain Weight loss Diabetes Steatorrhea: assess A1c, fecal elastase, check for HyperCa/Tglc
Large: Puestow Small: Whipple, Beger
What is the traditional resection operation to Tx chronic pancreatitis
MC type of pancreatic neoplasms
What is the defining characteristic of this neoplasm
Pancreaticoduodenectomy- removed pancreatic head, duodenum and distal CBD (Whipple)
Ductal adenocarcinoma (2nd MC GI tract malignancy), Bili levels average 18mg/dL
Aggressiveness- early dissemination
How is pancreatic cancer Tx surgically
What is the MC type of functional PNETs
What triad is used for Dx of this MC
Pancreaticoduodenectomy- whipple procedure removing pancreatic head, duodenum, distal biliary system
Insulinoma- Sxs of cerebral glucose deprivation
Whipple Triad:
Symptomatic fasting hypoglycemia w/ glucose <50 that is relieved w/ IV glucose
How are Insulinomas Dx
? is the MC PNET of MEN-1
These are MC found in ? anatomical triangle
72hr monitored fasting
Gastrinoma- abdominal pain, diarrhea, refractory PUDz
Pancreatic neck
Junction of 2nd and 3rd duodenum
Junction of cystic and common ducts
How are gastrinomas Dx
All Pts w/ MEN-1 and gastrinomas should be screened for ?
What is the most important determinant for Pt survival
Fasting serum gastrin >1000
Borderline: order secretin provocative test
Parathyroid adenoma/hyperplasia/hyperCa
Liver mets
Where are the majority of accessory spleens found
What are the 3 zones and their function
What are the two MC reasons for splenectomy
Splenic hilum- persistent dz if unrecognized
Red: hematologic
White: immunoglobulins
Marginal: macrophages B-cells
Sx relief of splenomeglay, ITP unresponsive to Pred
When are post-splenectomy Pts vaccinated
What microbes are the vaccinated against and why are these needed
Splenectomy can induce ? increase in heme results that is managed w/ ?
2wks prior to elective ectomy
2wks after emergent ectomy or at d/c if <2wks
3mon after chemo/rad
H-flu Strep pneumo Meningococcus- avoid Overwhelming Post-Splenectomy Infection
Thrombocytopenia induced risk for emoblisms- Tx w/ ASA and anti-platelet when Plt >600K
What are the 5 layers of the colon from in to out
What are the only two parts of colon w/out taenia coli
? parts of the colon are retro/intra-peritoneal
Mucosa Submucosa Circle/Long muscle Serosa
Longitudinal ribbons of smooth muscle outside of intestines: Appendix, Rectum
Retro: ascending, descending
Intra: transverse
What causes diverticulosis to bleed
? is the most optimal imaging modality for lower GI bleeds
What are the indications for surgery
Thinning of out pouching of superficial vasa recta
Colonoscopy
Persistent/Massive hemorrhage
Transfusion or >4units <24hrs
Recurrent bleed
Colorectal polyps are classified per ? criteria
? tumor marker is used post-op for colorectal recurrence
What Dx initiates colonoscopies regardless of age
Haggitt
CEA
UC- risk for Ca
Colonic obstruction d/t ? tends to be more localized and severe
Pain from ? part of the colon is diffuse and milder
? image finding is highly suggestive of colon cancer
Mechanical obstruction
Ileus
Barium enema w/ apple core lesion- can be Dx and therapeutic
Crohns Dz causes ulcers in ? shape
? histology results will be seen
How is UC surgically cured
Bear claw
Non-caseating granulomas
Total proctocolectomy
What are the 3 zones where hemorrhoids can develop
Internal hemorrhoids are lined by ?
External hemorrhoids are lined by ?
R-anterior, R-posterior, L-lateral
Columnar mucosa epithelium
Squamous epithelium
? med is a stool softener
? med is fiber
Define Rectal Procidentia
Colace
Metamucil
Rectal prolapse- full thickness protrusion through anus
What are the 4 RFs for rectal prolapse
Majority of cancers at the anal margin are ? type
Neoplams of the anal margin appear as ?
Post-menopause Female Constipation Surgery
SCC- well differentiated and rarely w/ distant mets
Rolled, everted edges w/ central ulcerations
What is the best initial management strategy for malignant neoplasms at the anal margin
Majority of anal fissures are found ?
What type are more commonly found in females
Chemoradiation
Posterior anal canal
Anterior fissures
Why are lateral internal spincterotomys preferred over posteriors
Why do Pts not experience incontinence after surgery
? type of anal abscess tend to be larger and complex
Avoid keyhole deformities
Intact external sphincter
Ischirectal- cryptoglandular infection w/in anal canal
? type of anal abscess have increased rates of fistulas
Pilonidal dz is AKA ? Dz
What is the name of the procedure for Pilonidal Dz
Horse shoe abscesses
Jeep seat dz- hair follicles in gluteal cleft infected w/ keratin leading to infection/abscess formation
Bascom
Define the Chamberlain Procedure
What procedure is used as an alternative
MC indication for needle biopsy of the lung
Anterior mediastinotomy for biopsy x3
VATS
Solitary pulm nodule
? form of imaging is particularly good for evaluating Pancoast Tumors
? image is used to detect cancer spread to mediastinal lymph nodes
Define Infiltrate and Effusion
MRI
PET
In: fluid in lung; Eff: fluid in pleural space (meniscus sign on CXR)
? is the standard image to Dx Ptx
Ptx are the MC ? problem
? are the MC Sxs of pleural Dzs
PA and Lat CXR w/ exhalation
Pleural- no innervation to visceral layer
Pain, Dyspnea d/t innervation from somatic intercostal/phrenic nerve
Pleural effusions develop d/t ? changes
How much fluid does it take to blunt CV angles or an entire hemithorax on CXR
How much fluid is needed on thoracentesis for evaluation
Inc hydrostatic press, capillary permeability
Dec colloid oncotic press, intrapleural press, lymph drainage
CVA: 300-500mL Hemi: 2-2500mL
20mL at least
Transudate and Exudates are caused by ?
What lab results are seen in Transudate results
Once full lung expansion is achieved after pleural effusions, ? is the next step
Trans: CHF, LF Ex: Ca, Pneumonia, PE
Total protein <3g (ratio <0.5)
LDH ration <0.6
SpecGrav <1.016
Pleurodesis w/ Doxy/Talc
? size tube are used for malignant effusion, hemothoraces Tx
MCC of exudative pleural effusion is ?
? microbe is the MCC of empyema
Ca: 20-28F Heme: 32-36F
Malignancy
Staph A
? parasite can induce thoracic empyema
? is the most important non-invasive test for thoracic empyema
All PTs need ? procedure and ? is the procedure of choice for Dx
Entamoeba histolytica
CXR
Bronchoscopy; Thoracentesis
? is the MCC of death in men and women in the US
Pancoast tumors are more likely to be ? type
? is Horners Triad
Lung Ca
Squamous cell Ca in apex
SCC in apex causing Mitosis Anhydrosis Ptosis
? types of lung Ca are more likely to be peripheral or central
Non-Small Cell Lung Ca is more likely to secrete ? while Small Cell Lung Ca is more likely to secrete ? substance
? nerve can become compressed by pancoast tumors in the apex
Peripheral: adenocarcinoma (painless)
Central: Small Cell
Non: PTH-like: HyperCa
Small: ADH-like: SIADH, MSH, ACTH
Ulnar
CT scans for lung neoplasms include the upper abdomen because of ? two common met sites
? lab result is essential because then ? tests are ordered
? is used for the staging test and is most effective for assessing distant/occult Dzs
Liver, adrenals
AlkPhos- bone scan brain MRI/CT
Fluorodeoxyglucose PET scan
Lung neoplasms are more likely benign w/ ? characteristics
? is the most predictive factor for successful surgical outcome in these Pts
Difference between Neoadjuvant and Adjuvant chemo
<2cm, Concentric, Smooth, Solitary
CardioPulm reserve, Fitness
Neo: pre-op to shrink tumor,
Adj: after Tx to prevent recurrence
TNM Staging
What is the difference between Unresectable and Inoperable
T- 1: <3cm 2: 3-7cm 3: >7cm 4: invasive
L:
0: none 1: ipsilat broncho/hilar 2: ipsilat mediastinal/subclavicular 3: contralateral
M: 0: none 1: mets
Un: invaded structures In: unstable Pt
MCC of arterial aneurysm
What are the 3 types of pseudo-aneurysms
? is the MCC of pseudo-aneurysms
Atherosclerosis
Saccular: out-pouch of vessel wall
Fusiform: diffuse
Mycotic: MCC Staph infection
Trauma
? law of physics is applied to AAA
MC Sx of AAA leak
Image modality for tracking, Dx and elective planning
Law of Laplace:
Back pain d/t leak in left posterior corner below L-renal artery origin
Track: US
Dx at rupture: CTA
Elective: Aortogram
AAA characteristics at increased risk for rupture
Repair is indicated in ? 3 conditions
Define Blue Toe Syndrome
> 5.5cm
Expands >0.5cm/6mon
Female > Male
Saccular > Fusiform
ASx and >5.5cm, Sx, Expands >1cm/yr
Distal embolization from AAA
Aortic Transections are usually d/t ? mechanism and occur ?
Pts can survive this injury if ? structure holds
Best image for Dx and best method to control/dec shearing forces
Deceleration, Distal to subclavian artery
Adventitia
CTA; BBs then dilators
? is the MC catastrophic event involving the aorta
Ruptures are more likely seen w/ ? Stanford type and have ? murmur
Name of procedure to Tx mesenteric ischemia
Acute dissection- AR
Type A
Percutaneous Transluminal Angioplasty w/ stenting
? is the MCC of carotid related CVAs
? may be the first Sx of carotid artery dz
? is the most useful test for carotid artery dz assessment while ? is the gold standard but only used if surgery is planned
Emboli- MC
Frank CVA
Duplex US; Carotid arteriography w/ >75% occlusion= need for surgery
(MRI/A- better for ischemic CVAs)
What medication is needed after carotid endarterectomy procedures
Subclavian Steal Syndrome causes blood to be ‘stolen’ from ?
Periphral Vascular Dz pain in calf, butt, groin means source is ?
Clopidogrel x 6wks
Subclavian steals from vertebral artery
Calf: femoral artery
Butt/Thigh: iliac
Impotence: aortic
What are 3 critical characteristics of limb ischemia
AMI measurement below ? means occlusive Dz present
What is the most important RF
Pain w/ rest
Inc pain at night
Hanging leg off bed/chair to dec pain
<1.0
Smoking
What 3 meds are used for peripheral vascular dz and what are their MOAs
What are the 6 Ps of acute arterial occlusions
Which one indicates the beginning of irreversible ischemic changes
Cilostazol: PD-5 inhibitor to dilate vessels
Anti-platelets: ASA
Pentoxiphylline: dec blood viscosity
Statins
PooP Color Pulse Movement Temp Numb
Sensory deficit
Arterial transections must be repaired within a few hrs to prevent ?
How are arterial occlusions Tx
? type of knee injury leads to an arterial stretch injury
Gangrene
Heparin- atraumatic
Arteriorgram if light touch intact
Thrombolytics or Embolectomy- emergent if neuro compromise present
Anterior dislocation
What causes popliteal artery entrapments
How does this entrapment present
Thromboangiitis Obliterans is AKA ? Dz
Medial head of gastrocnemius w/ abnormal insertion causing medial deviation of artery
ASx w/ rest, Ischemia w/ exercise
Buerger Dz
What causes venous dilation in AV fistulas
? thyroid Ca follows a FamHx path
Radiation during childhood puts Pts at risk for ? type of thyroid Ca
Arterial pressure
Medullary carcinoma in MEN-2
Papillary- MC type of thyroid Ca MC d/t iodine deficiency
? is the first line investigation test for solitary thyroid nodules
? scintigraphy result means nodule is likely benign
Toxic adenomas need to be removed if ? size
US guided FNA
Hot- hormonally active (low TSH, high T3/4)
> 4cm
How are the two MC types of thyroid cancer spread
MEN-1 is AKA while MEN-2 is AKA ?
? medication is used during thyroid tumors to suppress mets
Pap: lymph Foll: heme
1: Werner’s 2: Sipple’s
Thyroxine
MC neoplasm in mediastinum
MC neoplasm in mediastinum w/ clinical presentation
What are the 2 MCC of thryotoxicosis
Thymoma
Substernal thyroid
Graves: hypersecretory goiter
Plummer: toxic multi-goiter
Achilles DTR response to hyper/hypo-thyroidism
How is Thyrotoxicosis Tx
What study is used after Pt returns to euthyroid status after thyrotoxicosis
Hyper: shortened; Hypo: prolonged
Methimazole/PTU
Lugol iodine/Ipodate sodium
BBs
R-131
Where are Pts referred to after thyroid nodule work up
Hyperparathyroid Pts are at ? risk
? type of acid-base d/o can hyperparathyroidism develop
IM- hyper/thyroiditis
GenSurg/ENT- nodule/goiter/cyst
Premature death d/t CV/malignancy
Hyperchloremic metabolic acidosis
What other DDx need to be r/o w/ lab results consistent w/ hyperparathyroidism
What type of rad findings may be seen during hyperparathyroidism
? advanced imaging is used for finding sub-sternal glands
Breast Ca
Hands: osteitis fibrosa cystica, Mottled skull
Sestamibi; Gamma probe for small nodes
Difference between Primary/Secondary hyperparathyroid growth
Define Mondor’s Dz
Primary: benign
Secondary: malignant
Chest wall trauma induced vein formation
MEN-1 Werner’s Syndrome
MEN-2a Sipple’s Syndrome
MEN-2b
Hyperparathyroid
Gastrinoma>insulinoma
Pituitary tumor
Medullary thyroid Ca
Pheo
Hyperparathyroidism
Medullary thyroid Ca
Pheo
GI ganglioneuromatosis
Mucosal neuroma
What are the 3 layers of the adrenal cortex and what do they release
What does the adrenal medulla produce
What causes adrenal cortical hyperplasia
Glomerulus: aldosterone
Fasciculata: cortisol
Reticularis: testosterone
Catecholamines- sympathetic stimulation
Malignancy in fasciculate causing excess cortisol secretion (Cushing syndrome)
What is the next Tx step for pituitary adenomas if pituitary surgery fails
What part of the kidney are pheo’s found in and what do they secrete
What is the classic Pheo Triad
Adrenalectomy
Medulla- Epi
HA, Palpitation, Diaphoresis
What are the two possible intra-operative complications during pheo removal
What are the indications to remove hormonally inactive pheos
What is the f/u procedure if surgery is not indicated for hormonally inactive pheos
Pheo: HTN d/t tumor handling
HOTN after tumor devascularized
Encroaching on surrounding structures
>5cm
<5cm= repeat CT in 3-6mon
What is the difference between lobe and duct of breasts
? is the MC carcinoma
Rarely, ? meds are used to Tx fibrocystic breast changes
L: functional unit that produce milk
D: store milk and connect to nipple
Ductal
Tamoxifen, Danazol w/ tenderness during luteal phase
What are the indications to excise fibroadenomas
What are the two benign conditions that cause nipple d/c
How are these Pts managed
> 35y/o or Pt request
Intraductal papilloma, Mammary duct ectasia
F/u q 3mon w/ MMG and US
Define Galactorrhea
What PE test needs to be done
How is this Dx and when are pts f/u
Bilat milk d/t in non-lactating women
Visual field: Bitemporal hemianopsia
Dx mammogram; F/u q3-4mon x12mon w/ MMG and US
Chronic breast abscesses normally arise from ?
How are these Tx
Where are supernumeray nipples found and how are they Tx
Duct ectasia
Stop nursing, Admit w/ IV ABX, OR I&D
Anywhere on milk line; Excision
What are the two views of a screening MMG
How are findings classified
Craniocaudal, Mediolateral
BiRADs: 0- more images needed 1- neg/normal 2- benign finding 3- probably benign 4- suspicious, biopsy 5- suggests malignancy, definite biopsy 6- biopsy proven malignancy
What Pt population would receive pre-operative breast MRI
? is the MC lump found on self breast exams
What is the worst pathological report for breast ca biopsy
Dense tissue, Implants
Ca: painless, unilateral w/out d/c
Triple negative: Tx w/ Chemo
How is HER-2 positive breast Ca Tx
? is the MC breast Ca type
What is a pre-invasive marker of Ca
Poor prognosis 2/2 mets: Tx w/ monoclonal Abs
Infiltrating ductal carcinoma
Lobular Ca in situ
MCC of bilateral breast Ca
Define Paget Carcinoma
How are these Pts managed/Tx
Primary lobular tumor
Ductal carcinoma causing nipple itch/burn and crusted lesions
ABX/Topical steroids x 7d then refer to GenSurg
How does Inflammatory Breast Ca present
How is this Tx
Men w/ breast Ca present at ? age and w/ ? Medhx
Erythema/Edema w/out palpable mass in non-lactating female
Neoadjuvant chemo, Surgery, Radiation
70y/o w/ prostate Ca
What is an ominous finding for men w/ suspected breast Ca
How are these Tx
Difference between Modified Radical Mastectomy and Radical Mastectomy
Nipple d/c
Modified radical mastectomy
Mod: spares muscle w/ skin retention
Rad: dec function of arm d/t structure removal
What is the most important prognostic factor for breast ca
Post-surgical drains are removed at ? point of recovery
What two nerves can be injured during Modified Radical Mastectomy
Mets to axillary nodes
<30ml/day
Long thoracic: winged scapula
Thoracodorsal: lat dorsi paralysis
? type of radiation therapy is used for breast Ca Tx
What structure is used to reconstruct breast mounds after mastectomy
Difference between Femoral and Inguinal Hernias
Tangential: dec body irradiation
Transverse Rectus abdominus muscle
Inguinal: arises above inguinal ligament
Femoral: arises below inguinal ligament
Inguinal hernias develop laterally to ? structure
Direct Hernias develop through ? structure
What causes a congenital indirect hernia
Inferior epigastric artery
Hesselbach Triangle:
Medial: rectus muscle
Lat: inferior epigastric artery
Inferior: inguinal ligament
Patent processus vaginalis (same as hydrocele)
? is the MC hernia in both genders
? nerve may be prophylactically seperated during hernia repair
? type of repair makes the recurrence rate higher
Congenital indirect
Ilioinguinal hernia
Laparoscopic: usually done for bilateral hernias (open for unilateral hernia)
? type of hernia is more common in women
Epigastric hernias protrude through ? structural defect
Umbilical hernias in infancy are repaired after ? age
Femoral: inferior to inguinal ligaments, medial to femoral vein
Epigastric fat through linea alba
2y/o
Post-hernia repair wound dehiscence appears as ?
How are these managed?
Untreated, this will progress to ?
Salmon colored peritoneal fluid
Return to OR for fascial repair
Acute: Evisceration
Delayed: Incisional hernia
Sports hernias are not true hernias but are result of microtears to ?
This can also be a manifestation of ? Dx
Define Hydrocele, Spermatocele, Varicocele
Femoris Adductor Rectus
Hip flexor Obliques Psoas
Osteitis pubis
H: patent vaginalis allowing peritoneal fluid collection
S: fluid filled mass on epididymis
V: dilated pampiniforms (L > R)
Smoking cessation ? long prior to surgery can help reduce atelecatsis development
If intubation for post-op pneumonia is done, keep sats at ? level
Aspiration pneumonia is avoided by Pts being NPO for ? long
> 2wks
PCO2 35-45
O2 >95%
> 6hrs prior for surgery
What PE finding is associated w/ a suspected DVT
PERC criteria
Wells score criteria
Homan’s sign
HAD CLOTS:
Hormone Age >50 DVT/PE Sxs
Coughing blood Leg swelling O2 <95%
Tachy >100bpm Surg/Trauma <4wks
EAT CHIPS: Edema/Leg pain/DVT Sxs: 3 Alt Dx less likely: 3 Tachy: 1.5 Cancer: 1 Hemoptysis: 1 Immobile >3 days: 1.5 Previous DVT/PE: 1.5 Surgery <30d: 1.5
How is C Diff Tx
Mnemonic for trouble shooting catheters
? nerve injury can occur during hernia repair
PO Vanc or Metronidazole
DOPE: Displace Obstructed Position Equipment
Ilioinguinal- skin numbness
? nerve injury can occur during mastectomy
? nerve injury can occur during para/thyroid surgery
? nerve injury can occur during carotid endarterectomy
Long thoracic- winged scapula
Recurrent laryngeal- hoarseness
Hypoglossal nerve- deviated tongue
How is DIC Tx
Why do blood transfusions result in HypoCa
What is the lethal triad of hypothermia
FFP
Citrate from banked blood binds to Ca
Hypothermia
Metabolic acidosis
Coagulopathy
What are the 4 stages of Decubitus Ulcers
What is the criteria for Systemic Inflammatory Response Syndrome
MOA of local anesthetics
1: Intact, non-blanching skin
2: shallow ulcer w/ red wound bed
3: adipose visible
4: underlying structures visible
Temp >101.5* Tachy/Tachy Leukocytosis
Na channel blocker to prevent AP
What types of nerve fibers are easily blocked by local anesthetic
Why do these not work well in infected tissues
What are the two classifications
Thinner, Myelinated
Inc acidity (normally pH 5.5-6.0
Amides: metabolized by liver (MC used)
Ester: metabolized by cholinesterase into PABA- common allergen
How are amides identified on visual assessment
Four methods local tissue inflammation effects anesthetic activity
What are the benefits of adding Epi
“i” before -caine
Dec blood flow slows clearance
Acidosis dec active anesthetic
Macrophage inactivation
Temp inactivated anesthetic
Inc duration, Dec bleeding/volume needed
What are the 3 disadvantages of adding lidocaine to local anesthetics
Avoid Epi in Pts w/ ? MedHx
What are the MC adverse effects
Tachy, THN, Dysrhythmias
Cardiac dz HTN DM Hyperthyroid
Urticarea Dermatitis Edema Erythema
What PE finding suggests CNS toxicity from lidocaine w/ epi
Max amount of lidocaine w/ and w/out epi
How much lidocaine is in 1% lido
Tonic clonic activity- Tx w/ benzo
4mg/kg w/out, up to 300mg
7mg/kg w/, up to 500mg
1%= 10mg/ml, 2%= 20mg/ml
Max dose of Bupivacaine
Don’t use in ? Pts
How are toxicities Tx
2mg/kg up to 100mg
<12y/o
Hyperventilate dec pCO2, Benzo for seizure
Malignant Hyperthermia MC occurs after ?
How is this Tx
What is the sequence of clinical anesthesia
Volatile agents, Succinylcholine
Cooling, BiCarb, Dantrolene
Dilation: loss of sympathetic tone
Pain/Temp
Pressure
Motor
Define Spinal block
What is this MOA
What is the MC complication from use
Anesthetic in sub-arachnoid CSF
Sympathetic/sensory/motor blockage
Post-spinal HA; Tx w/ Blood Patch
Define Epidural Anesthesia
What is the MOA
This type of block is good for ? injury
Anesthesia injected to epidural space w/ catheter left in place
Blocks sensory > motor
Rib Fx
C5, T4 and T10 are located at ? landmarks
? complication arises from central nerve blocks
? complication can arise from high spinal blocks
5: clavicle 4: nipple 10: umbilicus
HOTN d/t neurogenic shock; Tx: pressor and fluid
Bradycardia, HOTN, Arm tingling
How are high spinal blocks Tx
MC complication from central nerve blocks
How are spinal HAs Tx
IV naloxone w/ ventilation
Urinary retention
Fluids, Caffeine, Blood patch from autotransfused blood into epidural
What adverse complication arises from central nerve blocks in Pts on anticoagulants
? type of amnesia does conscious sedation create
? is the name of cricoid pressure
Epidural hematoma: compresses spinal cord causing loss of neuro function below injection site
Antegrade
Sellick
? type of suture materials cause a more intense inflammatory reaction
How is the tensile strength determined
? type of configuration has more infection risk
Natural fiber > Synthetic
Larger integer= smaller diameter
Braided
Cutting needles are preferred for ? while tapered/round needles are used for ?
Define swaged needles
Define Double Armed needle
Cut: skin; Taper/Round: Vessel/Bowel
Suture is pre-attached to needle
Needles at both ends of suture for anastamoses
Absorbable sutures
Non-Absorbable sutures
How are needle drivers loaded
Gut Monocryl Vicryl
Ethilon Prolene Silk
50-75% past tip, perpendicular to driver w/ only first joint inserted in rings
Difference Adsons and Debakeys
Suture tension is inverse to ?
When are simple interrupted used
Ad: outside body w/ rat tooth ends for traction
Deb: inside body
Spacing: more bites, less tension
Almost all external closures, start in middle
Most simple interrupted sutures are left in place for ? days w/ ? exception
When are horizontal mattress sutures used and left in place for ? long
When are vertical mattress sutures used
7-10 days; Face x 5d
Larger lacerations x 7-10d
Lacerations w/ poor eversion
What type of knot is used to terminate a running suture
? type of suture is used to approximate deeper tissue prior to closure
What are the 3 types of scalpels and their use
Aberdeen/Fishermen knot
Subcuticular
10- large incisions, cut w/ hump of blade
15- small incision, smaller than 10 blade
11: puncture/cutting for suture removal
Extensor surfaces are sutured in ? direction
Flexor surfaces are closed in ? direction
? closing material has a higher tensile strength than sutures
Longitude
Transversely
Staples
Pts classified as Immediate during triage
PART I CUT: Pending limb loss Amputation Retrobulbar hematoma Tension Ptx
Intracranial hemorrhage
Compromised airway
Uncontrolled hemorrhage
Trauma w/ shock
Pts classified as Delayed during triage
Pts classified as Minimal during triage and why is this group so dangerous
Pts classified as Expectant during triage
Globe injuries Trauma w/out shock Facial injury w/ airway intact Burns, non-life threatening Stable lacs/VS needing higher level of care
Minor lacs/burns, Small bone Fx; Overwhelm resources during MASCAL
Severe burns High spine injuries Absent VS Transcranial w/ coma Shock
OPAs are inserted w/ the tip pointing ?
Flail chest can cause ? ventilation issue
Size of needle decompression needle
Up, rotate 180* at posterior
Inc pCO2, Dec pO2
14G, 3.25”/8cm
How is systolic BP estimated during primary survey
A Pts hemodynamic status is determined by ?
During trauma, type specific blood should be avail w/in ? time
Radial= 80 Femoral= 70 Carotid= 60
Level of consciousness, Skin perfusion
<20min
During Primary Survey, dilated pupil correlates w/ ?
A lateral gaze w/ dilated pupil indicates ?
9 line medevac
Ipsilateral injury
Brain stem herniation through tentorium cerebelli
1: location 2: frequency 3: Pt type 4: equipment 5: Pt ambulation 6: security 7: LZ marking 8: nationality 9: NBC threat
What are the components of the MIST report
When is AMPLE done during triage
? is the MC error during the secondary survey
Mechanism of injury
Injuries
Sx/VS
Tx given
Secondary survey
Failure to ID multiple injuries
? is the most valuable test during a penetrating trauma work up
What are the 3 zones of neck trauma
What zone injury may be managed expectantly
Plain radiograph
3: lower lip and up
2: cricoid to lower lip
1: cricoid to clavicle
Zone 2
What are the indications for a thoracotomy
Penetrating trauma can be d/c home as long as ? structure is not violated
Most retroperitoneal injuries are identified how
Persistent output despite bilat tubes
Initial output >1500ml
Persistently >200ml x 3hrs
Anterior fascia
Extra luminal gas/fluid
? type of Dx image is performed for suspected traumatic rectal injuries
Best imaging to screen for intrathoracic bleeds while ? is the most reliable to find free intrabdominal blood
Peritoneal cavity can hold ? much fluid
Sigmoidscopy
CXR; EFAST
3L
Life threatening hemorrhage from pelvic trauma means ? structure is damaged
What do Pts need after external fixation
What two presenting findings suggest need for emergency craniotomy
Posterior columns
Angioembolization
GCS <9 w/ lateralizing neuro exam
Closed head trauma is rarely the cause of HOTN except for ?
? is the best imaging for blunt cerebral vascular injuries
How are pericardial tamponades Tx
Final phase before herniation
CTA
Temporary: centesis
OR: Sternotomy w/ repair
What is the MC location for aortic injuries
What two CXR findings aid w/ Dx
Diaphragm ruptures MC occur on ? side w/ ? CXR finding as pathognemonic
Distal to LSCA
Wide mediastinum >8cm,
Obscured apex of chest- apical cap
Left: Coiled gastric tube in chest
? if the MC injured GU organ
? is the most reliable sign this MC has occurred
Pelvic injuries need ? study prior to cannulation
Renal injuries
Hematuria
Cystogram
What PE findings suggest a urethral injury is present
What is the next step if these are found
Define ECMO
High riding prostate
Blood at meatus
Hematochezia
Retrograde urethrogram w/ fluoro
Extra Corporal Membrane Oxygenation
Initial imaging for blunt/penetrating chest trauma
? side of the diaphragm is most likely to be injured
C-spine films need to encompass ? land marks and ? angle can help visualize this land mark
Portable x-ray
L > R
C7-T1; Swimmer’s view
What parts of the C-spine are evaluated for soft tissue edema
Loss of the cervical lordotic curve can indicate ?
Hangman Fx is AKA ?
C2: 6mm
C6: 22cm
Soft tissue swelling, Muscle spasms
Traumatic spondylolisthesis- axial compression w/ hyperextension= bilat Fx of pars interarticularis
? type of immobilization is used for Pts w/ C1-2 Fxs
Jefferson Fxs are AKA ?
Define Clay Shoveler’s Fx
Halo-vest immobilization x 12wks
Atlas Fx- d/t axial loading, usually w/out neuro injury
Isolated spinous process Fx; unilateral lamina/pedicle Fx
? type of cervical Fx usually leaves Pts as quadriplegics
Hyperflexion injuries are usually from ? mechanism
Hyperextension injuries are usually from ? mechanism
Tear drop- hyperflexion and posterior displacement compared to inferior vertebrae
Flexion and Distraction- occiput blow
Extension and Compression- forehead blow
Hyperextension neck injuries most often have ? neuro complain
? part of the neck is MC Fx
What are the 3 types of this Fx
Radiculopathy
Odontoid
Type 1: tip, uncommon
Type 2: neck
Type 3: junction and axis body
What two types of neck injuries are most likely to be immediately fatal
More than half of L-spine Fxs occur where
Seat belt Fxs of the L-spine are AKA ? Fxs
Atlanto-occipital dislocaiton
Atlanto-axial dislocation
T12-L1
Chance Fxs
L-spine compression Fxs can be Tx w/ pain and bed rest if ? two criteria are met
All ? Fxs of the L-spine are unstable regardless of neuro exam
What are the indications for surgical Tx
<50% loss of height, <30* angulation
Burst
> 50% height
Retropulsion narrows canal >50%
Kyphotic angulation ≥25*
? classification system is used for pelvis Fx
Young-Burgess- A: mechanically stable and MC type B: partial posterior (rotation unstable, vertical stable) B1: open book B2: lateral compression C: A/P instable
Pts w/ intracapsular (femoral neck) pelvic Fxs will look like ? on PE
How much blood can the abdominal cavity sequester
Sequence for studying abdominal films
Shortened, externally rotated, abducted
> 3L
1: gas pattern
2: extraluminal air
3: calcifications
4: soft tissue masses
What abdominal x-ray finding for the spleen is abnormal
? chest wall injuries are Tx w/ surgery
MC injury from blunt chest wall trauma
Below rib 12 and/or displaced stomach bubble to midline
> 1L blood loss
Diaphragm rupture
Aortic transection
Tamponade
Rib Fx
Ptx are dx w/ x-ray and ? breathing pattern
Axial injuries to chest/spine can lead to ? thoracic issue
Aortic transections may live to hospital if ? structure holds during injury
Exhalation
Chylothorax
Adventitia
Great vessel injuries are most often exposed by ? procedure
First test performed for Pts w/ high risk penetrating chest wounds
Pts w/ obvious tamponade but no imminent arrest have ? next step
Median sternotomy
eFAST
Directly to OR for sternotomy
Indications for resuscitative thoracotomy
? is the Triangle of Safety for chest tubes
Penetrating trauma CPR <15min
Rapid deterioration
Organized rhythm, even PEA
Blunt trauma CPR <10min
Medial: pec muscle
Lat: lat dorsi
Inferior: 4-5th ICS
? is the insertion site for thoracostomy
? type of suture is used for securing
What is the adverse outcome of placing a chest tube initially on wall suction
5th rib at anterior axillary line
No 0-1 silk
Pulmonary edema refractory to diuretics
Indications to remove chest tubes
? organs are located retroperitoneum
3 main indications for Ex-Lap
No air leak on water seal
<200ml drainage/24hrs
No PTX
Duodenum Pancreas
Kidney Aorta Vena cava
Peritonitis, Hemorrhage, Injuries
? is the exception to gunshot wound Ex-Lap rule
How are liver injuries graded
Tangental wounds= laparoscopy for peritoneal penetration
1: <10% surface area
2: 10-50% surface area
3: >50% surface area
4: 25-75% parenchymal disruption
5: >75% parenchymal disruption
How are liver injuries managed after d/c
? type of drain is used after abdominal/pelvic trauma surgery
What is another type of drain that may be used
Re-image 4-8wks after
High grade: reimage at 3mon prior to returning to sports
Jackson pratt- grenade shape, keeps area under pressure
Penrose- prevent would healing, allows drainage
What are the three sequential stages of wound healing
Abnormal wound healing occurs when ? stage is prolonged
What phase causes wound contraction
What phase includes remodeling
Inflammation
Migration/Proliferation
Maturation
Inflammation
Migration and proliferation
Maturation
What are the 3 closure types
Debris can lead to traumatic tattooing if not removed in ? time frame
Pressure exceeding ? is Dx for compartment syndrome and Tx w/in ?
Primary: <8hrs of injury w/ suture/staple
Secondary: self healing w/ packing
Tertiary: delayed primary
<48hrs
> 30mmHg; Fasciotomy <6hrs
? type of fluids should be used during compartment syndrome
? type of venom do Elapids have
? type of venom do Vipers have
Mannitol-Alkaline
Cobra/Mamba: neurotoxin
Rattler/Viper: cytotoxin- can lead to compartment syndrome
Secondary intention healing occurs through ? three mechansism
Do not use ? item to cover healing tissue
Difference between contraction vs contracture
Base granulation
Edge contraction
Re-epithelialization
Cover sponges
- ction: linear wound becomes shorter
- cture: circle becomes smaller
Best type of ulcer dressing for absorbency, comfort and hydrocolloids
? type of dressing is water resistant
? type can absorb alot of exudates
Foam Alginate Debridement
Films
Alginate
? type of dressing can be changes w/ minimal pain
? type of dressing change can’t be used on infected or exudative wounds
? type of dressing must be protected by a secondary dressing
Foams
Hydrocolloid
Hydrogel
What 3 factors determine an infectious process
What are the two MC microbes in surgical Pt infections
Organism
Environment/local response
Host defenses
Gram Pos cocci > Gram neg bacilli
? surgical infection microbe is MC enteroccoccal species
? surgical infection microbe is MC Vanc resistant
How many brush stroked when scrubbing for surgery
Enterococcus epidermis
Enterococcus faecium
Finger tips: 30 strokes
Finger/Palm/Wrist: 20 strokes
What is the BBB of the OR
? type of burn injuries can heal w/out scars
What are the names of the ridges found within the Basement Membrane Zone
Area between Anesthesia and Operative Field
Pure epidermal injury
Rete ridges- aid w/ protecting from shearing forces
When looking at a burned area, ? area is most damaged
What are the next two areas surrounding this most damaged area
Rule of 9s
Center- zone of coagulation
Stasis then Hyperemia
Don’t count 1st degree:
Arm/Head: 9% each side
Leg/Trunk: 18% each side
Second Degree burns extend into ? layer
What is the hallmark of this type of burn
Deep Partial Thickness extend to ? layer
Papillary dermis
Blisters
Reticular layer of dermis
Partial thickness burns that have not healed w/in 3wks need ? Tx
? ABX is used for burns but w/ ? s/e
Third degree burns can only heal via ?
Excision and grafting
Silvadine: silver sulfadiazine: leukopenia
Contraction
Second degree burns are Tx w/ occlusive dressings w/ ? exception
? type of ABX has no role in the Tx of burns
What is the position that extremities are splinted in
Face: Tx open w/ ABX ointment
Systemic ABX prophylaxis
Function, not comfort
Define Autograft
Define Allograft
Define Xenograft
Skin graft from self
Skin graft from same species
Skin graft from another species
Full Thickness graft are AKA ?
Split Thickness graft are AKA ?
What are the benefits of each
Sheet graft
Meshed graft
Sheet: dermis w/ superior cosmesis
Meshed: max surface area allows egress of serum/blood
UOP is used to guide burn resuscitation but only after ? long
Why do burn Pts have so much edema
How is fluid resuscitation determined
8hrs
Hypoproteinemia
Baxter/Parkland formula:
4ml x TBSA x Kg
Half in first 8hrs, other half over 16hrs
How are circumferential burns Tx
How can the increased catabolism rate be decreased after burns
What 3 meds have dec catabolism and incrased anabolism
Escharotomy
BBs
Insulin Growth hormones, T analogues
Post-burn contractions are Tx via ?
3 kinds of electrical burns
Acid burns lead to / while alkaline burns lead to ?
Z-plasty once healed
Current Flame Thermal- arcing currents
Acid: coagulation necrosis
Alkaline: liquefaction necrosis
Goal UOP after burn injuries
Define Consciousness
What are the two components
> 0.5ml/kg/hr
Subjective experience of environment and self
Arousal/wake- defines level of consciousness
Awareness/perception- defines content of consciousness
What are the 5 terms used for defining levels of consciousness
Alert- awake, responsive
Stupor- responds w/ stimulation
Obtunded- asleep but responds to stimuli
Vegetative- arousal w/out awareness
Comatose- asleep, no response to stimuli
Scalp vessels are below hair follicles at the level of ?
What is the acronym for structures of the SCALP
First responder intervention can help reduce ? type of brain injury
Galea
Skin CT Aponeuorsa Loose tissue Pericranium
Secondary- brain injury from sequelae from primary injury
Intubation is recommended for GCS <8 or motor score below ?
What are the two worse secondary insults that occur after a TBI
What is an independent predictor of mortality
4 or lower
Hypoxia, HOTN
In-hospital O2 desat <90%
Brain injuries need SBP maintained <90mmHg w/ ? PE test indicating adequate MAP
Equation for MAP
Equation for CPP
Radial pulse
1/3 (SBP + 2DBP)
CPP= MAP - ICP
ICP measured w/ ventriculostomy
ICP monitor is called ?
Requirement prior to placement
Head CT w/ midline shift indicates ? damage and will have ? PE finding
Bolt
GCS 8 or greater and abnormal head CT
Brainstem herniation; Pupil changes ipsilateral side
What causes Diffuse Axon injuries
What will be seen on CT
What med can be used for BP control during ICP
Shearing force from acel/decel
Normal
Phenylephrine
ICP w/ agitation is intubated w/ ? combo of RSI meds
? is used for seizure prophylaxis
? is the safest and most prudent Tx for TBI Pts
Propofol w/ Fentanyl
Levetiracetam- Keppra
Euvolemia w/ ICP <20
What does a brain stem/uncal herniation look like
What does a tonsillar herniation look like
While intubated, keep Pts capnography between ?
Dilated, unresponsive pupils w/ lateral gaze
Cushing Triad
35-45
MCC of acute liver failure
? is a common complaint w/ no significance to a surgical Hx
What is the MC error that occurs w/ hematochezia
Acetaminophen toxicity
Changes in bowel habits
Assumption of hemorrhoids
True liver function is assessed w/ ? three labs
Pre-op ABX are given ? far prior to surgery and redosed ? often
? perioperative stratification tool is used for risk assessment
Coagulation Albumin Total bili
<1hr of surgery; q2 t1/2 lives
ASA:
1: healthy
2: mild/mod systemic d/o
3: sev systemic dz
4: incapacitating
5: moribund/life expectancy <24hrs
How is Mallampati classification done
Pre-op serum creatinine higher than ? has inc M&M
6 Major Adverse Cardiac event criteria
Mouth open, Tongue out, No Ah sound
> 2.0mg
DM insulin, RF, CHF, High risk surgery, Ischemic heart dz, TIA/CVA
Chronically hyperglycemic Pts are more dehydrated and will be exacerbated while NPO for surgery, so use ? fluid
How is their insulin dosage calculated
Albumin <3g suggests while pre-albumin <16mg suggests ?
Dextrose solutions
Sliding scale
A: chronic malnutrition, P: acute malnutrition
FENa equation
How is a Pts hydration status assessed
Colloid transfusion therapies include ? 5 fluids
100 x (Na.u x Cr.p/Cr.u/Na.p)
Edwards EV1000 w/ serum lactate
FFP (30min thaw wait time) Whole blood PRBCs Albumin- LF, burns, nephrotic syndrome Platelets- bleeds w/ <50K Plt count
IO infusions target ? structure
Locations for central line placements
? is the femoral triangle landmarks
Medullary sinus
Cephalic Jugulars Femoral Subclavian via Seldinger technique
Medial: adductor longus
Lat: sartorius
Superior: inguinal ligament
IV rehydration is good for ? long
What 3 alternative methods of delivering nutrition are considered if this time line is met
Pts receiving total enteral nutrition need ? daily lab and ? weekly lab
One week
Peripheral parental nutrition
Enteral G/J tube
Total parenteral nutrition
Daily: E+ Week: pre-albumin
NG/OG tubes are used to decompress stomach in Pts that have eaten w/ ? time from surgery
? structures differ D1 from D2
Define Phleboliths
<6hrs
Kerckring folds
Calcified venous thrombi w/ lucent center in pelvic veins of women
What does the mnemonic ADC VAN DISMEL stand for
Admit to
Dx
Condition
VS
Activity
Nursing
Diet IVF Studies Meds Allergies Labs
Appendectomy performed during pregnancy often lead to ? adverse reaction
Open appendectomy uses ? incision
? artery supplies the appendix
Pre-term labor but not delivery
McBurney’s
Mesoappendix
? is the MC rare pathology of appendicitis
? part of the small bowel is straight vasa recta
Define Internal Hernia and what can cause these
Carcinoid
Jejunum
Strangulated bowel d/t bucket handle mesenteric defect; High speed MVCs
Why does fertility increase risk for gallstones
Hepatocytes conjugate bilirubin w/ ? for secretion in bile
Liver metabolism of serum proteins provide the only source of ? two products
Estrogen- inc cholesterol secretion
Progesterone- dec bile acid secrettion
Glucuronide
Albumin, Alpha globulin
What can cause splenomegaly
What causes hypersplenism
Why are vascular structures ligated as close to the spleen as possible during splenectomy
EBV, T-cell lymphoma
Pancytopenia sequestration
Avoid vascular injury to stomach/pancreas
Why are a majority of diverticula actually pseudodiverticula
Colorectal screenings start at age ? and include ? tests
Rectal cancer can present on DRE w/ mets in ?
Missing mucosal layer
50y/o w/ annual occult blood and Flex-Sig q5yrs
Blumer shelf: pouch of douglas
Pt w/ hemorrhoids and Fe anemia need ? two examinations
? is the standard approach for open lung biopsy
? lung neoplasms causes clubbing and hypertrophic osteoarthropathy
Anoscopy and Proctosigmoidscopy
Thoracoscopy
Paraneoplastic syndromes d/t proliferation of growth factors
