Holliday Flashcards
The biggest absolute contraindication to surgery
DKA or diabetic coma
-blood sugars sky high, too many complications, infections, etc…
quantitative signs of poor nutrition, relative contraindications to surgery, eg delay if not emergent
alb v3
20% weight loss 3 mos
prealbumin/transferrin v200
ways to rescuscitate nutrition in order of preferability
po
enteral (g tube)
tpn (IV)
quantitative signs of severe liver failure, relatively contraindicating surgery, eg delay if not emergent
bili ^2
PT ^16
ammonia ^150
(or clinical encephalopathy)
how long must stop smoking for non emergent surgery
8 weeks
why is smoking a relative contraindication to surgery
impairs wound healing
especially in plastics… so must quit ^8wks for non-emergent surgery
what to watch out for in smoker waking up from anesthesia
don’t artificially sat O2 too high
in smokers/COPDers, chronic CO2 retainers, hypoxia is last respiratory drive, don’t suppress it by artificially satting too high
what does goldman’s index do and what are the most important factors
assesses cardiac risk of surgery
CHF (EF v35%) - check w echo
MI (MI v6mos ago) - check w EKG, stress test, cath (angio basically?), revascularize
arrrhythmias, elderly, aortic stenosis (late systolic crescendo decrescendo murmur), emergency surgery, also factors
what to expecially listen for on heart auscultation in preop patient`
late systolic crescendo decrescendo murmur - aortic stenosis
not good for goldman index, cardiac risks for surgery
medications to stop prior to surgery
aspirin (1-2wks prior)
NSAIDS, vitamin E (bleeding issues)
warfarin (want INR v1.5, can use Vit K)
Insulin - take half the morning dose because NPO after midnight
metformin (risk lactic acidosis)
when to get dialysis prior to surgery if CKD
24 hours prior
why do we check BUN and Cr prior to surgery?
uremic platelet dysfunction
BUN ^100 a risk for postop bleeding
numbers if preop patient at risk for uremic platelet dysfunction and postop bleed risk
BUN ^100
normal platelet count
prolonged bleeding time
Vent settings to know in SICU
Assist-Control - set TV and RR, if pt takes breath on their own the vent still gives the same TV… aka vent supports every breath whether pt or vent initiated… not good if pt tachypnic
Pressure Support - pt RR but boost of pressure (8-20) from vent, *important in weaning
CPAP - pt RR and TV but vent pressure all the time to keep alveoli open
PEEP - pressure given (5-20) at end of cycle to keep alveoli open *used in ARDS and CHF
vent setting important in ARDS and CHF
PEEP pressure given (5-20) at end of cycle to keep alveoli open
vent setting important in weaning
Pressure Support
pt RR but boost of pressure (8-20) from vent, *important in weaning
routine test to check while pt on vent
ABG
PaO2 PaCO2 pH
pt on vent
PaO2 too low
PaO2 too high
PaCO2 too low, pH is high
PaCO2 too high, pH is low
inc FiO2 dec FiO2 (free radical damage can worsen ARDS)
dec TV more than RR
inc TV more than RR
(TV multiplicative, also, changes ventilation of functional space only, whereas RR changes ventilation of dead space as well… but consider adjusting RR if lung perf or something a concern… i think…)
adjust minute ventilation
RR or TV
MV = RR x TV
adjust vent for PaCO2 and pH off balance
PaCO2 too low, pH is high
-dec TV (preferred to dec RR because more bang for buck, no dead space involvement)
PaCO2 too high, pH is low
-inc TV (preferred to inc RR)
Which is more efficient, adjusting TV or RR?
TV, changes functional ventilation only
while RR involves dead space as well as functional volume
Approach to acidosis
pH v7.4
check HCO3 and pCO2
-if both high, respiratory acidosis
-if both low, metabolic acidosis
check anion gap (Na - Cl - HCO3… 8-12 wnl) if metabolic
- GAP metabolic acidosis MUDPILES methanol uremia dka polyetheleneglycol/peraldehyde isoniazid lactate ethanol/etheleneglycol salicylates
- NONGAP metabolic acidosis Diarrhea, Renal Tubular Acidoses, abuse of Diuretics
MUDPLES
for anion gap (Na - Cl - HCO3 = ^12) metabolic acidosis
methanol uremia dka polyetheleneglycol/peraldehyde isoniazid lactate salicylates
non-gap metabolic acidosis etiologies
diarrhea - pooping out anions (HCO3…)
renal tubular acidoses
abuse of diuretics
approach to alkalosis
pH ^7.4
check HCO3 and pCO2
-both low, respiratory alkalosis
-both high, metabolic alkalosis
check urine chloride for metabolic alkalosis
-if low uCl v20, vomiting (ejecting via mouth, not via urine) NGT suction, antacids, diruetcis
-if high uCl ^20, Conn’s (hyperaldosteronism), Bartter’s, Gittleman’s
when to check urine chloride in acid/base disorder
for metabolic alkalosis (pH ^7.4, HCO3 and pCO2 both high)
- if low uCl v20, prob due to vomiting (ejecting via mouth, not via urine)
- if high uCl ^20,
what causes hyponatremia
next best step?
too much water
check plasma osmolality (rule out eg hyperglycemia making plasma sodium seem low)
assess fluid status clinically
- (edema, lung crackles), Hypervolemic hyponatremia think CHF, nephrotic syndrome, cirrhosis
- (dry mucous membranes, flat neck veins), HypOvolemic hyponatremia think diuretics, vomiting
- normovolemic hyponatremia think SIADH (get CXR! paraneoplastic of lung cancer), Addison’s (primary hypoaldosteronism… hypocortisolism…), hypothyroid
3 common causes of hypervolemic hyponatremia
CHF
nephrotic syndrome
cirrhosis
next step if suspect SIADH
CXR
paraneoplastic hormone of lung cancer…
how to treat hypervolemic hyponatremia?
fluid restriction, diuretics
common causes = CHF, nephrotic syndrome, cirrhosis
how to treat hypovolemic hyponatremia
IV normal saline
when to use 3% (hypertonic) saline
for severely symptomatic hyponatremia
eg seizures, AMS
or Na very low (eg v120)
how quickly to replete sodium?
why not faster?
.5-1 mEq / hr
or 12-24 mEq/day
careful not to correct too quickly (central pontine myolenolysis is life-threatening)
treat hypernatremia
what to watch out for
replete fluid with D5W or hypotonic fluid
don’t decrease more than 12-24 mEq / day because cerebral edemia
qt interval in calcium abnorms
prolongued qt - hypocalcemia
short qt - hypercalcemia
bones stones groans psychiatric overtones short QT
hypercalcemia
appropriate next best step if calcium too low or too high
ekg
to make sure pt not at risk for torsades (hyperca short qt, hypoca long qt)
paralysis ileus ST depression U waves
hypokalemia
treat hypokalemia
watch out for
replete K+ po or IV
check renal function first, if compromised you can make hyperkalemic pretty quick
signs of hyperkalemia
peaked T waves
prolonged PR and QRS
sine waves
treat hyperkalemia
Ca-gluconate to stabilize cardiac membrane
insulin and glucose to shift K+ into cells
K exlate to reduce GI absorption
dialysis last resort
Ideal maintanence IVFs
and how much to give
D5 1/2 NS
\+ 20 KCl if peeing
100ml/kg/day up to 10kg
50ml/kg/day next 10kg
20ml/kg/day all above 20kgwhy are enteral feeds preferred to tpn
maintains health of gut mucosa
prevents bacterial translocation
risks of TPN
acalculous cholecysitis hyperglycemia liver dysfunction zinc deficiency other electolyte issues
TF
pt w 3rd degree burn can’t feel it
Tish Fish
can’t feel 3rd degree burn - to fascia, nerves destroyed
but 2nd and 1st degree burns around it will hurt very much
so something will hurt
feared complication of circumferential burns
compartment syndrome
how to clinically check airway in burn patient, what to watch out for, how to react?
singed nose hairsm, wheezing, soot in mouth/nose
watch out for laryngeal edema
low threshold for intubation
burn patient with confusion, headache, cherry red skin
next best test?
Treat?
carboxy-Hb (CO poisoning)
give 100% O2
consider hyperbaric treatment if severe poisoning
clot in elderly think…
cancer
clotting in setting of edema, htn, foamy pee think…
nephrotic syndrome
antithrombin III one of the first proteins to be urinated out…
is nephrotic syndrome a risk for bleeding or clotting?
clotting
antithrombin III one of the first proteins to be urinated out…
young person with clot and positive family hx think…
factor V leiden…
coag factor V insensitive to activated protein C, which is an anticoagulant… so these pts hypercoagulable
what can’t we give someone with ATIII deficiency
heparin
because it won’t work
because heparin potentiates the action of antithrombin III, thereby preventing activation of factors II (thrombin), IX X XI XII
yount woman with multiple spontaneous abortions think…
lupus anticoagulant
postop pt with clots but low platelets think…
treat with…
HIT
heparin induced thrombocytopoenia
from antibody against heparin bound to platelet factor IV PF4
anticoagulate with a non-heparin anticoagulant, like argatroban or bivalirudin (direct thrombin inhibitors)
young women with bleed and isolated decrease in platelets think…
ITP
immune thrombocytopenia
idiopathic thrombocytopenic purpura
immune thrombocytopenic purpura
caused by acquired autoantibodies against platelet antigens
normal platelets but inc bleeding time and PTT think…
eg in woman with heavy periods, nose bleeds, easy bruising…
von Willebrand disease
(problem of platelet Function, not number)
inherited mut impairing von Willebrand factor function
low platelets high PT PTT BT low fibrinogen high d-dimer shistocytes on smear think...
DIC
disseminated intravascular coagulation
caused by gram negative sepsis (via LPS), OB stuff, carcinomatosis
define carcinomatosis
multiple carcinomas develop simultaneously, usually after dissemination from a primary source
implies more than spread to regional nodes and even more than just metastatic disease
rule of 9’s for burn victims
estimating body surface area
head and arms are 9%
torso front and back are 18% each
legs are 18% each
in kids,
head is 18%, so are torso front and back each
arms are still 9%
legs are 14%
abx for burn victim?
yes
but TOPICAL
NOT PO or IV because those breed resistance…
-Silver and Sulfadiazine Don’t Penetrate Eschar and cause Leuokopenia
-Mafenide Penetrates Eschar but Hurts like hell
-Silver Nitrate Doesn’t Penetrate Eschar and causes HypoKalemia and HypoNatremia
first best step for
chemical burn
electrical burn
wash/irrigate for 30 minutes
EKG, if abnormal, monitor on telemetry for 2 days (also if LOC loss of consciousness)
blood on urine dipstic but no RBCs on microscopic exam in burn pt think…
check…
rhabdomyolysis
(especially in electrical burn pt)
causing myoglobinuria
causing renal failure
check K+, if massively released from dying cells can cause arrhythmia
pressure diagnostic for compartment syndrome…
compartment pressure ^30mmhg
… but correlate clinically… 5 P’s…
trauma pt unconscious… what to do…
intubate!
trauma pt GCS v8… what to do…
intubate!
pt stung by bee, getting stridor, tripod posturing… what to do…
intubate!
guy stabbed in neck, GCS 15, talking to you, but expanding mass in lateral neck… what to do…
intubate!
guy stabbed in neck, subcutaneous emphysema w palpation… what to do…
intubate! carefully, with a fiberoptic bronchoscope, because may be an airway laryngeal tracheal bronchial injury
huge facial trauma, oral and nasal airways obscured and difficult to identify, GCS v 8… what to do…
crycothyroidotomy
don’t intubate if you can’t make out the airway at all due to trauma
you intubated your trauma pt, now auscultating for breath sounds, decreased on left… what to do…
pull back ET tube, you have intubated the Right manstem bronchus
once trauma pt intubated or not, auscultation clear, next best step…
assess oxygenation status
did A and part B, not done with B after just auscultation…
HVMVA, pt dyspneic, hypotensive, chest hurts, new murmur…. suspect…
aortic injury
physical exam findings in pneumothorax
decreased/absent breath sounds
hyperresonant to percussion
if tension pneumo…
distended neck veins, trachea deviated away from tension pneumo
treat hemothorax
chest tube
to OR if chest tube output ^1.5 L immediately, or ^200cc/hr over first 4 hours
when do you take hemothorax to OR?
HIGH OUTPUT through chest tube
to OR if chest tube output ^1.5 L immediately, or ^200cc/hr over first 4 hours
treat flail chest
O2 and NERVE BLOCK for pain control
- so they will keep breathing while ribs heal
- Don’t give opiods for pain because suppress respiration
trauma pt w confusion, petechial rash on chest and axilla, acute shortness of breath… think….
fat embolism
eg after long bone fracture, classically femur
4 sudden death situations to consider air embolus…
MS3 removes central line
lung trauma
vent use aggressive w TV
heart vessel surgery
TF
can have hemorrhagic or hypovolemic shock with flat neck veins and normal central venous pressure
T
treat hypovolemic/hemorrhagic shock
2 large bore peripheral IVs
2L LR or NS over 20 minutes
followed by blood if hemodynamics fail to stabilize
treat pericardial tamponade
needle decompression
EKG finding in pericardial tamponade
Electrical alternans
- alternation of QRS complex amplitude or axis between beats
- possible wandering base-line.
thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium, as the heart essentially wobbles in the fluid filled pericardial sac.
strong clinical suspicion of tension pneumothorax… next best step..
needle decompression
followed by chest tube
(don’t have to get cxr)
which way does trachea deviate in tension pneumo
away from tension pneumo
(duh, air filling that side, pushing everything away)
deviates away in non-tension pneumo as well… but deviates toward in lung collapse…
what happens to RAP/PCWP (right atrial pressure / pulmonary capillary wedge pressure) in these types of shock: hypovolemic vasogenic neurogenic cardiocompressive cardiogenic
hypovolemic - dec vasogenic - dec neurogenic - dec cardiocompressive - inc? cardiogenic - inc
what pCO to aim for when hyperventilating pt w inc ICP
28-32
what to watch out for when giving mannitol to pt w inc ICP
renal function
don’t dehydrate too much
treat epidural or subdural hematoma causing inc ICP
neurosurg ventriculostomy, burr hole, craniotomy
boundaries of the zones of neck trauma
above the angle of the mandible (III)
cricoid - angle of mandible (II)
below cricoid (I)
for which zone of neck trauma do you consider triple endocsopy
zone III (uppermost, above angle of mandible) -because multple passages there... airway, esophagus... why called triple... I don't know... evals... pharynx, larynx, esophagus, trachea, and bronchi
other than emergent exlap for gunshot to abdomen…
tetanus prophylaxis
stab wound but pt stable… next?
-stick a (sterile?) finger in there, see if penetrates peritoneum
FAST
DPL diagnostic peritoneal lavage
ex-lap if any of above are positive
what does a DPL diagnostic peritoneal lavage entail?
incision between umbilicus and pubis
attempt to aspirate any dependent fluid contents
if unable to aspirate, inject 1L NS and drain 5 minutes later and send for analysis
blunt abdominal trauma, pt hypotensive and tachycardic… next step…
to OR
maybe get FAST on the way… but answer is OR
Kehr sign
diaphragmatic irritation referred to left shoulder pain
handlebar sign
bruising and pain in handlebar pattern (eg. abdomen to steering wheel or bike handlebars) along epigastric/inferior rib border
-suspect pancreatic rupture
blunt abdominal trauma, pt stable.. next step…
CT abd
abdominal trauma, lower rib fracture, bleeding into abdomen, suspect…
liver laceration if R rib fxs
spleen laceration if L rib fxs
lower rib fracture with hematuria… suspect…
kidney injury
blunt abdominal trauma, pt stable, with epigastric pain… best test… dx to suspect…
CT abd (best test for any blunt abdominal pt stable)
if retroperitoneal fluid on CT abd - suspect DUODENAL RUPTURE
pancreatic rupture would show handelbar sign (epigastric ecchymosis)?
blood at urethral meatus, high riding prostate…
next best tes…
urethral or bladder injury from pelvic trauma…
retrograde urethrogram /cystogram
… looking for extravisating dye
tf
if blood at urethral meatus, foley is a good idea
FALSE.. well maybe, but not first thing to do
do not attempt to place foley for urethral injury… maybe if after retrograde urethrogram/cystogram you know injury is extraperitoneal….
if intraperitoneal will need ex-lap and surgical repair
extravisation on retrograde urethrogram/cystogram, how to react if extravisation is…
extraperitoneal?
intraperitoneal?
extraperitoneal - bed rest and foley
intraperitoneal - ex-lap and surgical repair
ortho fractures that definitely go to OR
depressed skull fx
severely depressed or angulated
open fx ANY OPEN FX
femoral neck or intertrochanteric
what is injured with numb deltoid shoulder pain and external rotation
axillary nerve
from anterior shoulder dislocation
fever how high with atelectasis
v101
fever ^104 postop
very ill appearing, suspect…
nec fasc
how does necrotizing fasciitis spread in abdomen
along scarpa’s fascia
common bugs in nec fasc
strep pneumo
clostridium perfringens
treat necrotizing fasciitis
Debride in OR
IV Penicillin
how to prevent postop atelectasis
scare the shit out of your patients – get out of bed and walk! Incentive spirometry! or else pneumonia and die!
differentiate postop
cellulitis
wound infection
dehiscence
and how to treat
cellulitis - pain erythema NO DRAINAGE - ABX
wound infection - pain erythema DRAINAGE - OPEN and REPACK… no abx necessary
dehiscence - salmon serosanguenous drainage - SURGICAL EMERGENCY OR for PRIMARY CLOSURE, IV ABX
OB/GYN pt late in postop course develops unexplained fever…
suspect. ..
tx. ..
pelvic thrombophlebitis
abx and heparin
unexplained postop fever (UTI, PNA, BCx, line infection, wound infection, etc all negative)…
suspect. ..
test. ..
tx. ..
abscess - CT… diagnostic lap - drain percitaneously, IR guided, or surgically
thrombophlebitis (eg late postop in OB/GYN) - CT? abx, heparin
thyrotoxicosis, adrenal insufficiency, lymphangitis, spesis all possible and rare…
tf
culture pressure ulcer
f
will just get skin flora
DO get BCx and CBC if worried about infection
treat pressure ulcer
stage 1 and 2 - soft mattress, rolls, creams…
stage 3 and 4 - need surgery, flap reconstruction
bacterial load and nutrition before surgery for stage 3 or 4 pressure ulcer…
Bacterial load v100K
Albumin ^3.5
when to tap (thoracentisis) pleural effusion
when ^1cm on lat decub xr
thoracentisis transudative think... transudative and: -low pleural glucose think... -high lymphocytes think... -bloody think...
- transudative think… systemic, CHF Nephrotic syndrome Cirrhosis
- low pleural glucose think… RA… random…
- high lymphocytes think… TB
- bloody think… Cancer or PE
if thoracentesis exudative think..
pneumonia
cancer
when to insert chest tube for drainage of pleural effusion
if “complicated”
thoracentesis demonstrates:
positive Gram Stain
low pH v7.2
low Glucose (cancer or bugs eating it)
lights criteria
for transudative pleural effusion
LDH ratio eff vs plasma v0.6
Protein ratio eff vs plasma v0.5
dx spontaneous pneumothorax
tx
CXR (in setting of tall thin young male, asthma, COPDer usually)
Chest tube
Surgery (VATS vs Pleurodesis) if:
chest tube does Not Decompress… incomplete lung expansion,
Recurrence (ipsilateral or contralateral… any recurrence),
scuba or pilot pressure changes
live in remote area low access to care if becomes complicated
drain lung abscess?
F
one of the few (two ish…) abscesses that you do not drain…
tx w Abx (Penicillin for staph, Clindamycin for anaerobes aspirated)
Surgery if
- Abx Fail
- ^6cm
- Empyema (pus in pleural space) present
treat lung abscess
Abx (Penicillin for staph, Clindamycin for anaerobes aspirated)
Surgery if
- Abx Fail
- ^6cm
- Empyema (pus in pleural space)
*Lung abscess is one of the few (two ish…) abscesses that you do not drain…
solid pulmonary lung nodule workup
find old CXR to compare
benign: popcorn calc - hamartoma concentric calc - old granuloma eg TB v40yo v3cm well-circumscribed - CXR or CT q2mos to assess change
malignant: calc not popcorn or concentric... ^3cm smoker, elderly -bx for path (bronch if central, open if peripheral...)
symptoms of lung cancer
coughing coughing blood hemoptosis sob recurrent pneumonia (post-obstructive pneumonia) lung collapse
most common lung cancer in non-smokers
adenocarcinoma
this cancer occurs in scars of old pneumonia
adenocarcinoma
lung adenocarcinoma mets to…
BBLA bone brain liver adrenals
characteristics of pulmonary effusion caused by adenocarcinoma
exudative with high hyaluronidase
is lung adenocarcinoma central or peripheral?
peripheral
pt with kidney stones, constipation, malaise, low PTH, central lung mass… think…
SCC squamous cell carcinoma of lung
-paraneoplastic PTHrp… low serum PO4 high Ca
pt with shoulder pain, ptosis, constricted pupil, facial edema… think…
pancoast tumor
aka superior sulcus syndrome
usually SCLC
what type of lung cancer causes pancoast tumor / superior sulcus syndrome?
SCC squamous cell carcinoma
TF
small cell carcinoma and squamous cell carcinoma of the lung are the same thing
F
squamous cell carcinoma is Non-small cell
TF
SCLC is a carcinoma
T
Small Cell Lung Cancer
Small Cell Lung Carcinoma
Small Cell Carcinoma
all the same thing
pt with ptosis better after 1 minute of upward gaze… think…
Lambert Eaton Syndrome
- autoantibodies against presynaptic VCaCs voltage gated calcium channels… so no calcium influx cannot release Ach vesicles
- THINK SCLC PARANEOPLASTIC.. strong association
old smoker presenting with Na 125, moist mucous membranes, no JVD, think…
SIADH
SCLC PARANEOPLASTIC
CXR shows peripheral cavitation and CT showing distant mets… think…
Large Cell Carcinoma
central vs peripheral lung cancers
squamous cell carcinoma
small cell carcinoma
(Sentral)
adenocarcinoma
large cell carcinoma
(peripheral)
paraneoplastic syndromes in lung cancer
PTHrp - squamous cell carcinoma
SIADH, Lambert Eaton - small cell lung cancer
name 4 lung cancers
adenocarcinoma
squamous cell carcinoma
small cell carcinoma
large cell carcinoma
name non-small cell lung cancers
why the small cell vs non-small cell distinction
squamous cell carcinoma
adenocarcinoma
large cell carcinoma
small cell not surgical treatment, chemo and radiation sensitive
non-small cell more surgical treatment
ARDS causes path dx, 3 criteria tx
gram negative sepsis gastric aspiration trauma low perfusion pancreatitis
inflammation - impaired gas exchange - hypoxemia
PaO2/FiO2 ratio ^200… ish…
bilateral fluffy infiltrates on cxr
PCWP v18 to rule out CHF
PEEP
systolic ejection murmur, crescendo decrescendo, louder with squatting, softer with valsalva. pulsus parvus et tardus
aortic stenosis
systolic ejection murmur, louder w valsalva, softer w squat or hand grip
HOCM
how to tell aortic stenosis and HOCM apart
valsalva
aortic stenosis gets quieter
HOCM gets louder
(valsalva decreases volume in heart)
late systolic murmur with a click, louder with valsalva and handgrip, softer with squatting
mitral valve prolapse
concept behind heart maneuvers
valsalva
hand grip
squatting
valsalva decreases volume in heart
hand grip increases resistance
squatting increases venous return, increases volume in heart
holosystolic murmur radiates to axilla
mitral regurge
holosystolic murmur with late diastolic rumble in child
VSD
continuous machine-like murmur in child
PDA
wide fixed split S2
ASD
TF
atrial septic defect requires surgical correction
F
usually not
rumbling diastolic murmur with opening snap
mitral stenosis
murmur most often caused by past rheumatic fever
mitral stenosis
rumbling diastolic murmur with opening snap
blowing diastolic murmur with widened pulse pressure
aortic regurge
key buzz for right sided heart murmur
louder with inspiration
bad breath and food in mouth in the morning think…
zenker’s diverticulum
is Zenker’s diverticulum true or false diverticulum?
false
mucosa only, through muscular layer… not full thickness muscle layer ballooning as well
how to treat Zenker’s diverticulum of esophagus
surgery
dysphasia to solids and liquids, bird beak sign on barium swallow
diagnosis
tx
associations
achalasia
CCB, nitrates, botox heller myotomy (if med mgmt fails)
chagas disease,
esophageal cancer
dysphasia worse with hot and cold liquids, chest pain that feels like MI, no regurge
diagnosis
tx
diffuse (aka all up and down) esophageal spasm
CCBs, nitrates
epigastric pain worse after eating or laying down, cough, wheeze, hoarse
dx
tx
indications for surgery
GERD
24Hr pH monitoring most sensitive
behavior mod, antacids, H2 blocker, PPI
surgery (EGD first) if bleeding, stricture, Barrett’s, incompetent LES, max dose PPI not resolving, or just patient preference to medications
hematemesis, subQ emphysema, pleural effusion, inc amylase
next best test?
test to avoid?
tx?
boerhaave’s (esophageal rupture)
-full thickness -subq emphysema
(mallory weiss partial thickness)
CXR, Gastrograffin (avoid barium because more irritating to mediastinum)
NO ENDOSCOPY
Surgical repair if full thickness
gross hematemesis unprovoked in cirrhotic with pulmonary hypertension
diagnosis
treatment
gastric varices
ABCs
NG lavage
octreotide
balloon tamponade only if need to stabilize for transport
-endoscopic sclerotherapy or banding
do you treat asymptomatic varices found incidentally on endoscopy?
No
give beta blockers
IF SYMPTOMATIC treatment is endoscopic sclerotherapy or banding… once stabilized with ABCs NG lavage octreotide balloon tamponade if necessary
when to balloon tamponade esophageal varices
if need to stabilize for transport
definitive treatment is endoscopic sclerotherapy or banding on endoscopy
progressive dysphagia and weight loss makes you think…
esophageal cancer
SCC or Adenocarcinoma
types of esophageal cancers and locations and presentations of each
SCC middle 1/3 smokers drinkers
Adenocarcinoma in distal 1/3 in long-standing GERD
both present with progressive dysphagia and weight loss
workup for esophageal cancer
barium swallow
endoscopy with biopsy
staging CT
other than GERD, what else should be on differential fir acid reflux pain after eating and lying down
hiatial hernia
hiatial hernia types, presentation, treatment
Type 1 hiatial hernia Sliding
- GE junction slides into thorax
- exacerbation of GERD sx (acid reflux pain after eating, lying down)
- tx GERD sx (antacid, H2 blockers, PPI)
Type 2 hiatial hernia ParaEsophageal
- abdominal pain, obstruction, strangulation
- surgery
what causes cough, wheeze, hoarse in GERD
atypical symptoms from reflux high enough to get back into airway
