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SUMGERI > GERI-ER.Surgery (QL-SS) > Flashcards

GERI-ER.Surgery (QL-SS) Flashcards

1
Q

Should you refer a patient directly to the hospital?

A

YES! Pts INC mortality thru ED

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2
Q

how do patients survive in ED Visit?

A
  • 5% of d/c elderly patients will die.
  • 20% will require admission
  • 20% require another ED evaluation
  • 10-48% suffer decline in functional abilities.
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3
Q

What are the ABCDs of an ED visit?

A
  • A= airway compromise
  • B= breathing
  • C= circulation, shock<90mmHg
  • D= neurologic Disability
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4
Q

What is your DDX of SOB?

A
  • MI: MC elderly
  • Pneumonia
  • CHF
  • PE
  • Cardiac dysrhythmia
  • COPD
  • Asthma
  • Anaphylaxis
  • Bronchitis
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5
Q

What is plan, if you cannot exclude or you cannot stabilize an acute exacerbation of disease, a life threatening cause of dyspnea?

A

Send to the ED!!

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6
Q

What are the MCC of COPD exacerbations?

A
  • Viral or bacterial infection
  • CHF
  • Cold weather
  • Narcotic use
  • Anemia
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7
Q

What are the most life-threatening components of a COPD exacerbation?

A

Hypoxemia and hypercarbia/capnea. INC CO2

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8
Q

What is the treatment of a COPD exacerbation?

A
  1. Oxygen
  2. Bronchodilators: albuterol and ipratropium
  3. Corticosteroids:
  4. Antibiotics for sputum or fever).
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9
Q

What is your next step If a pt continues to deteriorate despite NPPV and other interventions,

A

Endotracheal intubation

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10
Q

What types of syncope have no increased risk?

A
  • Vasovagal syncope

- Orthostatic hypotension syncope

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11
Q

How should you treat a patient with orthostatic hypotension syncope in the ED?

A

Hydration and re-evaluation.

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12
Q

What types of syncope are associated with a high risk and hospitalization?

A

structural heart disease,
heart failure,
abnormal ECG,
anemia.

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13
Q

What brain abnormality is common in the elderly?

A

Cerebral atrophy.

INC risk of brain injury and hemorrhage.

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14
Q

why are intracranial hemorrhage hard to DX in elderly?

A

elderly have little or no neurologic deficits!

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15
Q

what is happening If a pt present to the ED s/p minor head trauma with associated vomiting?

A

INC intracranial pressure from hemorrhage.

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16
Q

What medication is SO important to note if a patient presents with a head trauma?

A

ANTICOAGULANTS! **Dramatically increases morbidity, mortality, and difficulty of treatment.

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17
Q

What BP is concerning In an elderly trauma patient w/ severe organ damage than the rest of the population?

A

Systolic < 110!

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18
Q

Patients with what characteristics after a trauma should prompt an ER visit?

A
  • > 55 y/o - SBP <110 in pt over 65. - Low impact mechanism in an elderly patient. - Pt on anticoagulation with a head injury.
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19
Q

what type are majority of strokes are ?

A

Ischemic NON CON CT
TX- RtPA administration W/IN 1 hour of symptom onset goal!

EARLYL TO Prevent or decrease damage to critical brain structures preserving function.

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20
Q

What are the traditional symptoms of stroke?

A
  • Unilateral paralysis of face, arm, legs.
  • Sudden confusion
  • Aphasia
  • Memory deficits
  • Severe headache
  • Dizziness
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21
Q

What are atypical symptoms of stroke?

A
  • LOC
  • Pain -
    Palpitations
  • Altered mental status
  • SOB
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22
Q

What is the most common mimic of a stroke? What test should you perform to rule this out?

A 
Hypoglycemia! Get a finger stick! MC-
- Seizures 
- Confusional states 
- Syncope -
 Toxins 
- Neoplasms 
- Subdural hematoma
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23
Q

What are your first steps after stroke diagnosis?

A
  1. Point of care glucose
  2. transfer to stroke center
  3. Oxygen
  4. Obtain IV access fluids
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24
Q

What are the 4 main categories of a surgical acute abdomen?

A
  1. Peritonitis (i.e. appendicitis, cholecystitis, diverticulitis)
  2. Perforated viscus (diverticulitis, duodenal or gastric ulcer, LBO with perforation)
  3. Bowel obstruction (large bowel- incarcerated hernia, malignancy, volvulus, small bowel- adhesions, incarcerated hernia).
  4. Vascular (aortic dissection, GI hemorrhage, mesenteric infarction, ruptured or symptomatic AAA)
25
Q

what causes must you consider first If a patient comes in complaining of abdominal pain, ?

A

4 causes of a surgical acute abdomen! Perforation,
obstruction,
peritonitis,
vascular.

26
Q

What are the symptoms of a AAA?

A

asymptomatic, and discovered during routine abdominal exam. symptoms range from
vague epigastric discomfort
back and abdominal pain.
HEMATURIA.

27
Q

What are common symptoms of a ruptured AAA?

A

Hypotension, ill appearance.

28
Q

what are they at a higher risk foR If a patient has a symptomatic AAA, r?

A

Rupture of the AAA.

ASAP-Bedside US. ** stable, obtain a CT.

29
Q

How should you manage a AAA in th eED?

A

LOWER BP SAFELY

Hemodynamic support that provides adequate perfusion -90/60mmHg in stable patients

30
Q

What medications must you look out for in patients with an acute abdomen?

A
  • NSAIDs
  • Warfarin or Dabigatran
  • bleeding
  • Steroids immunosuppression
  • Beta-blockers -blunt tachycardia.
31
Q

What parts of the abdominal exam must you perform if you are concerned for a patient to have an acute abdomen?

A
  • Inspect abdomen for scars
  • Auscultate for absence (i.e. ileus) or presence of bowel sounds (high pitched -> obstruction).
  • Percuss for presence of tympany (bowel obstruction), pain (peritonitis), or dullness from fluid (ascites)
  • Palpate for mass
  • Evaluate for hernia
32
Q

If a patient has vomiting before abdominal pain, what causes should you think of? For pain before vomiting?

A

Medical/ Clininal

! Surgical causes.

33
Q

What 2 factors are associated with mortality in abdominal complaints?

A

Old age and hypotension.

34
Q

What is the best test to perform on an elderly patient with abdominal pain?

A

CT!

35
Q

When should you treat an influenza patient with Tamiflu?

A 
When patient is <2 y/o, 
>65 y/o, 
morbidly obese, 
pregnant, 
 nursing facility.
36
Q

When can an influenza patient return to work?

A

afebrile for 48 hours without an antipyretic.

37
Q

Patients living in a long-term care facility have a higher risk of what types of pneumonia?

A

Pneumonia necessitating broader antibiotic coverage:

  • Gram negative bacilli (Klebsiella)
  • Anaerobic organisms
  • Staphylococcus species
38
Q

What is the CURB-65 and how does it relate to your pneumonia patient?

A
  • C: confusion
  • U: blood Urea nitrogen >19 mg/dL or >7 mmol/L
  • R: high respiratory rate
  • B: low BP - >65 y/o Used to determine suitability for outpatient management for pneumonia.
39
Q

When should you consider steroid use in CAP patients?

A

In SEVERE pneumonia only in seriously ill patients!

40
Q

What are the biggest comorbidities to think about prior to surgery?

A
  • CAD
  • Prior MI
  • CHF
  • Arrhythmias
  • Pacemaker
  • Orthostatic intolerance
41
Q

What medications increase a patient’s risk during surgery?

A
  • Antibiotics
  • Theophylline
  • Sedative hypnotics
  • Analgesics
  • Digoxin -
    Anticholinergics
  • Antiarrhythmics
  • Anti-seizure Rx
  • Antihypertensives
  • Anticoagulants
  • Antihistamines
42
Q

What medications should be stopped prior to surgery?

A
  • ASA —> 7 days
  • NSAIDS —> 7 days
  • Benzos —> slow taper
  • Diuretics —> 48 hours
  • Hypoglycemics —> night before
43
Q

What should you recommend in a COPD patient prior to surgery?

A
  • Stop smoking
  • Deep breathing techniques
  • Incentive spirometry
44
Q

What should you recommend in a CHF patient prior to surgery?

A
  • Stabilize the pts medications
  • stay hydrated.
  • electrolyte imbalance
45
Q

What should you do in a patient needing surgery who has mild-moderate HTN?

A

should not delay surgery.

46
Q

If a patient with severe HTN needs emergent surgery, how should you control their BP?

A

IV HTN medications.

47
Q

What procedures are higher risk for developing a DVT?

A

Orthopedic

48
Q

How should you control a risk for DVT post surgery?

A
  • Elastic stockings
  • Low dose unfractionated heparin
  • Low-molecular weight Heparin
  • Intermittent pneumatic compression
  • Warfarin
  • Eliquis/xarelto
49
Q

If a low risk patient on Warfarin is going in to surgery?

A

Discontinue 5 days prior to surgery,
INR to fall below 1.5 and
resume 12-24 hours post-op.

50
Q

If a MEDIUM risk patient on Warfarin is going in to surgery?

A

Discontinue warfarin 4 days prior to surgery
INR to fall below 1.5.
Use IV heparin if warfarin cannot be resumed within 48 hours.

51
Q

If a HIGH risk patient on Warfarin is going in to surgery?

A

Discontinue warfarin 4 days prior to surgery when INR drops to less than 2.0 —> begin Heparin.
Resume Heparin 12-24 hours post-op.

52
Q

What is the goal blood glucose level for a diabetic patient going into surgery?

A

Glucose 100-200 through the perioperative period.

AVOID surgery RPG- >300

53
Q

Should you use a diabetic patient’s normal insulin dosage post-op?

A

NO! Use 1/2 dose,

restart oral hypoglycemics when full diet is resumed.

54
Q

What surgeries have an associated high delirium risk?

A
  • Cardiac
  • Hip -
    Thoracic
  • AAA repair
  • Opthamological -
    Emergent surgery
55
Q

What intraoperative factors increase a patient’s risk for delirium?

A
  • Pre-existing dementia
  • Parkinson’s
  • Low cardiac output
  • Hypotension
  • Anticholinergic medications
56
Q

What post-op changes can increase a patient’s risk for delirium?

A
  • Hypoxia
  • Visual/auditory impairments - Polypharmacy
  • EtOH
57
Q

What is the mortality rate in patients who develop delirium s/p surgery?

A

26% mortality at 6 months

58
Q

What medical issues can occur post-operatively and we therefore must monitor patients for?

A
  • Silent Ischemia
  • HTN - Arrhythmias
  • Hypoxemia
  • Venous thromboembolism
  • Urinary tract infections
59
Q

What surgery has 6x greater mortaillty for >65yo?

A

Emergent diverticulitis

SUMGERI (14 decks)

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