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Surgery > IPE > Flashcards

IPE Flashcards

1
Q

What routes of anesthetics should be avoided in those that are on anticoagulants?

A

Spinal, epidural and local nerve blocks

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2
Q

What is important about B blockers?

A

Should be continued on the day of surgery to prevent a labile response during surgery

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3
Q

What is important about digoxin pre surgery?

A

Continue up to and including morning of surgery
check for toxicity levels and do plasma K and Ca
Suxemethionium can lead to increased K and therefore ventricular arrhythmias

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4
Q

When can a patient last eat and drink before surgery?

A

Eat 6 hours and clear fluids 2 hours

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5
Q

When are compression stocking contraindicated?

A

PVD

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6
Q

What is the dose of heparin for prophylaxis for the average patient?

A

5000u

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7
Q

When is a CXR indicated before surgery?

A

known Cv disease, pathology or symptom

>65year old

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8
Q

When is an ECG indicated before surgery?

A

> 55y/o
poor exercise tolerance
history of MI, hypertension, rheumatic fever or other heart disease

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9
Q

when should a lateral cervical spine XR be done?

A

history of RA, ankylosising spondylitis or downs in preparation for a difficult intubation

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10
Q

What are the different types of surgery in terms of risk of infection?

A

Clean
Clean -contaminated
Contaminated
Dirty

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11
Q

What is meant by a clean surgery?

A

Incising infected skin without breaking any viscera

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12
Q

What is meant by clean contaminated surgery?

A

Intraoperative breach of viscera but not the colon

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13
Q

What is meant by contaminated surgery?

A

Breach of viscus and spillage/ opening of the colon

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14
Q

What is meant by dirty surgery?

A

Site is already contaminated by pus or faeces or exogenous sourrce

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15
Q

What are the different types of suture material?

A

Absorbable and non absorbable
synthetic or natural
monofilament, twisted or braided

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16
Q

What determines when sutures can be removed?

A

The site and the health of a patient - need longer in the elderly and smokers due to poorer healing

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17
Q

What is the function of premedication before surgery and anasethetics?

A

Allay anxiety and make anaesthesia easier to conduct

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18
Q

Explain a typical pre medication before surgery

A

Anxiolytic- given 2 hours pre surgery - Midazolam preferrred in children
Analgesia - aims to dampen down pain before starts
Antiemetic- ondansetron known to be the most effective
Antacid - reduce the aspiration risk
Antiobiotics may be considered depending on the surgery

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19
Q

What are the side effects of hyoscine and atropine?

A

Antimuscarinic and therefore tachycardia, urinary rentention, glaucoma and sedation

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20
Q

What are the side effects of propofol?

A

Respiratory and cardiac depression

pain on injection

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21
Q

What are the complications of anaesthetics?

A

Pain sensation- pressure necrosis, retention, local nerve damage
Consciousness - cannot inform if something is wrong
Muscle power - corneal abrasion, no cough which can lead to impaired gas exchange

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22
Q

What are the advantages of local nerve blocks?

A

Allow patients to have surgery when a local anaesthetic is contraindicated

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23
Q

What is malignant hypertension?

A

Autosomal D condition
Rapid rise in temperature leading to hypoxaemia, hypercabia, hyperkalaemia, metabolic acidosis and arrhythymias
Prompt treatment with Dantrolene, active cooling and ITU

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24
Q

What antibiotic prophylaxis can be given before an appendicectomy, colorectal resections and open biliary surgery?

A

Single dose of IV tazobactam
Gentamicin + metrondiazole
Co Amoiclav

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25
Q

What antibiotic prophylaxis can be given for oesophogeal or gastric surgery?

A

IV gent
Piperacillin/ tazobactam
Co Amox

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26
Q

What antibiotic prophylaxis given before vascular surgery?

A

IV Piperacillin/ tazobactam

Or flucloxacillin +metrondiazole if anaerobes

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27
Q

What prophylaxis is done for patients with MRSA?

A

high risk add teicoplanin or vanc to protocol

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28
Q

What is the maximum dose of lidocaine that can be given to a 70kg man at different strengths?

A

0.25% - 80ml
0.5% - 40ml
1- 20ml
2-10ml

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29
Q

What is the approach to pain?

A

Identify the cause and treat if possible
Give regular doses rather than as required
Chose the best route
Explaination and reassurance is helpful to reducing pain
Allow patient to be in charge and liase with acute pain service

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30
Q

When should NSAIDs be prescribed with caution?

A

Asthma, renal and hepatic impairment
heart failure
IHD
pregnancy and the elderly

Aspirin is contraindicated in the young at risk of Reye’s syndrome

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31
Q

What is given to reverse an over dose of opioids?

A

Naloxone

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32
Q

Explain the WHO pain ladder

A

Google

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33
Q

What is usually the cause of pyrexia within the first 48 hours post op?

A

Basal acelectasis

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34
Q

What are the causes of HTN post op?

A

Pain, urinary retention, idopathic hypertension or iontropic drugs

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35
Q

What might be causes of oligouria post op?

A

blocked or mal sited catheter
increased fluids given
check for a palpable bladder as may be in rentention

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36
Q

Why is metaclompramide not indicated in patients with post op nausea and vomitting?

A

Pro kinetic features which may make

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37
Q

How can post op complications be classified?

A

From anaesthetic
From surgery in general
From specific procedure

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38
Q

What are the risk factors for DVT?

A

increased age, pregnancy, synthetic oestrogen, trauma, surgery, past DVT, cancer, obesity

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39
Q

When is D dimer raised?

A

infection, post surgery, malignancy, thrombosis and pregnancy

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40
Q

What are differentials for a DVT?

A

cellulitis and ruptured bakers cyst

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41
Q

What are the differentials for bilateral swollen legs?

A

systemic disease with increased venous pressure or decreased intravascular oncotic pressure

  • RHF
  • decreased albumin in renal or liver failure
  • Venous insufficiency
  • Vasodilators - Ca channel blockers
  • pelvis mass
  • pregnancy (pre-eclampsia)
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42
Q

What is meant by wound dehiscence? How is it managed?

A

Break down of a wound after lapratomy which may lead to bowel outside the abdomen
Management includes calling a senior, pushing the bowel back in, covering with a sterile dressing and give IV Abx and return to theatre.

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43
Q

What are the risk factors for wound dehiscence?

A

elderly, malnourished, if infection, uraemia, or haematoma present

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44
Q

What are the early complications of biliary surgery?

A 
Iatrogenic bile duct injury
Cholangitis 
bile leakage 
bleeding
Pancreatitis
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45
Q

What are the late complications of biliary surgery?

A

Bile duct stricture

post cholecystectomy syndrome - symptoms arising from the alterations in bile flow due to loss of reservoir

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46
Q

What are the early complications of thyroid surgery?

A

Recurrent and superior laryngeal nerve
thyroid storm
tracheal obstruction due to haematoma - needs immediate removal of the sutures
hypoparathyroidism

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47
Q

What are the late complications of thyroid surgery??

A

Hypothyroidism

recurrent hyperthyroidism

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48
Q

What are the complications of aortic surgery?

A

Gut ischaemia
Renal failure
respiratory distress
trauma to ureters or anterior spinal artery
ischaemic events from distal emboli from dislodged thrombus
Bowel aortic fistula

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49
Q

What are the early complications of stomas?

A 
Haemorhage at stoma site
Stoma ishaemia
High output - consider loperamide and codeine to thicken
Obstruction secondary to adhesions 
Stoma retraction
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50
Q

What are the late complications of stomas?

A 
obstruction
dermatitis at stoma site
stoma prolapse
stoma intussusception
stenosis
paratomal hernia 
fistulae 
psychological problems
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51
Q

How do we assess if a patient is malnourished?

A

MUST score

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52
Q

What must be done before feeding through a nasogastric tube?

A

CXR - check in the right location before feeding or feed may go into the lungs if tube is malsited

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53
Q

How is TPN given?

A

via a dedicated central venous line or PICC line or via a dedicated lumen of a multi-lumen catheter

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54
Q

What are the complications of TPN?

A

Sepsis - staph aureus, Staph epidermis, candidia)- line must be taken out
Thrombosis - may result in PE or SVC obstruction
Metabolic imbalance - refeeding syndrome and deranged LFTs
Mechanical - pneumothorax on line insertion

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55
Q

Explain the pathophysiology behind refeeding syndrome

A

After a long period of starvation, insulin levels fall to low levels and then on carbohydrates been taken in increased insulin leads to increased phosphate and low serum levels.
Features include rhabdomylitis, red and white cell dysfunction, respiratory insufficiency, arrhythymias, cardiogenic shock and seizures

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56
Q

What HbA1c should be aimed for in a diabetic before surgery?

A

<69mmol/mol

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57
Q

What should be done for an IDDM patient before they have surgery?

A

Place first on the list to reduce the fasting time
Give all usual insulin the day before surgery
Long acting insulin is usually normally continued at normal time even when patients are on variable insulin infusion
If on the morning list - ensure no subcutanous insulin is given in the morning. If afternoon list give the morning dose.
If not eating normally and high levels a variable rate insulin infusion will be needed.

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58
Q

What should be done for an NIDDM patient before they have surgery?

A

If diabetes is poorly controlled treat as patients on insulin
Give all usual medication night before surgery except long acting sulphonylureas which can cause hypoglycaemia on fasting
If on morning list - omit morning dose and give with lunch and if on afternoon list normal morning dose and take any missed doses with late lunch.

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59
Q

Explain what must be considered when prescribing metformin and contrast

A

Metformin can be continued after IV contrast as long as GFR >60ml/L and normal serum creatinine.
To minimise the risk of nephrotoxicity if serum creatinine is raised or GFR <60 - omit metformin for 48hours and check renal function

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60
Q

What should diabetic patients have pre surgery?

A

Screen for asymptomatic cardiac and renal disease

be aware of silent MIs post op

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61
Q

How do you write up variable rate insulin infusion on a prescription?

A

Prescribe 50u of short acting insulin in 50mL of 0.9% saline to infuse at the rate dependent on BM
Fluid should also be prescribed to run through with the VRII.

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62
Q

What needs to be taken into account in patients under going surgery with jaundice?

A

Dont operate on a patient who is obstructively jaundice - do ERCP first
Coagulopathy - Vit K decreased in obstruction- if no history of liver disease give parentral vit K
Increased risk of sepsis due to increased bacterial translocation, bacterial colonisation of the biliary tree and decreased neutrophil function
increased risk of renal failure- ensure adequate fluids and monitor renal output

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63
Q

When are antibiotic indicated post ERCP?

A 
biliary tree decompression fails
history of biliary disorders
liver transplant 
presence of pancreatic psuedocyst
neutropenia
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64
Q

When should warfarin be before surgery?

A

5 days before

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65
Q

What is important to remember in those on steriods undergoing surgery?

A

Patients who are adrenal suppressed through the use of steroids may not be able to increase steroids needed post op
May need a bolus and increase in dose post op for a short time frame

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66
Q

What are some cautions to day surgery?

A 
Severe dementia
Severe LD
Living alone
Children if supervision difficult 
BMI >32
ASA greater than 3
infection at the site of operation
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67
Q

What are the differentials for an intra dermal lump?

A

Sebaccous cyst
Abscess
dermoid cyst
Granuloma

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68
Q

What are the differentials for a subcutaneous lump?

A

Lipoma
Ganglion
Neuroma
Lymph node

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69
Q

What are the causes of a distended abdomen?

A 
Fat
Faeces
Flatus 
Fetus 
Fluid
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70
Q

What are some differentials for RIF mass?

A 
Appendix mass or abscess
caecal carcinoma 
Crohns disease
Pelvis mass
TB mass
Transplanted kidney
undescended kidney
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71
Q

What are the different type of hepatomegaly?

A

Smooth- hepatitis, CCF, sarcoidosis, early hepatitis in alcoholics
Craggy- secondaries or primary hepatocellular carcinoma
Pulsating - tricuspid regurg

72
Q

How do you know a mass is in the pelvis?

A

Cannot get below it

73
Q

What signs are seen with someone who is peritonitic?

A 
Lying still 
positive cough test
rebound tenderness
Board like abdo rigidity 
guarding
74
Q

What is colic pain?

A

Regular waxing and waning pain caused by muscular spasm in a hollow viscus. causes restlessness

75
Q

Explain the presentation of an appenditicitis

A

Periumbilical pain that moves to the RIF

Tachycardia, fever, peritonism with guarding and rebound tenderness and percussion tenderness in RIF

76
Q

What signs can be used to help with the diagnosis of an appendicitis?

A

Rovsings sign- pain is greater in the RIF when palpating the LIF
Psoas sign - pain on extending the hip if retroceacal appendix
Cope sign- pain on flexion and internal rotation of the right hip if appendix is in close proximity to the obturator internus

77
Q

What tests can be done for appendicitis?

A

Blood tests will reveal neutrophil leukocyosis and elevated CRP
CT high diagnostic accuracy and is useful if diagnosis is unclear - reduced negative removal rate

78
Q

What are the complications of appendicitis?

A

perforation - more common with faecolith
appendix mass
abscess

79
Q

Explain the nerve and blood supply to the gut

A

For - to proximal 2nd part of the duodenum - epigastrium pain and coeliac trunk
Mid - above to 2/3 transverse colon - periumbilical- superior mesenteric
hind - distal to above- suprapubic - inferior mesenteric

80
Q

What are the differentials of appendicitis?

A 
Ectopic 
UTI
mesenteric adenitis 
cystitis 
Crohns disease
perforated ulcer
Cholecystitis
81
Q

What are the cardinal features of bowel obstruction?

A

Vomiting, nausea and anorexia
colic occurs early and can be complete constipation
abdo distention

82
Q

What is the difference between ileus and mechanical obstruction?

A

Ileus is a functional obstruction from decreased motility whereas mechanical obstruction is a blockage of the actual tube

83
Q

What is the immediate management of small bowel obstruction?

A

Drip and suck - NGT and IV fluids to rehydrate and correct any electrolyte imbalances

84
Q

What imaging can be done for patient with BO?

A

CT establish the cause

Oral gastrografin prior to CT to identify the level of the obstruction

85
Q

When is emergancy surgery indicated in BO?

A

strangulated

86
Q

What is a sigmoid volvulus?

A

Where the bowel twists around its mesentary which can produce severe rapid strangulate obstruction

87
Q

How is a sigmoid volvulus managed?

A

Flatus tube or sigmoidoscopy

rarely sigmoid colectomy requried

88
Q

What is the management for a umbilical and a indirect inguinal hernia in a child?

A

Umbilical can be monitored as very few require surgery

Indirect inguinal hernia - surgical repair required

89
Q

What are the cause of acute mesenteric ischaemia?

A

Superior mesenteric artery thrombosis or embolism
Mesenteric vein thrombosis
non occulsive disease states such as low output states - shock
trauma, vasculitis, radiotherapy and strangulation

90
Q

What is the presentation of acute mesenteric ischaemia?

A

Acute severe abdominal pain, no abdo signs and hypovolaemia

pain tends to be constant and around the RIF

91
Q

What will investigations show in a patient with acute mesenteric ischaemia?

A 
increased Hb due to plasma loss
increased WCC
increased amylase
persistent metabolic acidosis - increased lactate
CT/ MRI signs of ischaemia
92
Q

What is the treatment of mesenteric ischaemia?

A

surgery to remove necrotic bowel

need LMWH, fluid, Abx

93
Q

What are the complications of mesenteric ischaemia?

A

septic peritonitis

Sepsis and multi organ failure

94
Q

What is chronic mesenteric ischaemia?

A

severe colicky post prandial abdo pain, decreased weight and upper abdo bruit may be heard with PR bleeding

95
Q

What is a common cause for chronic mesenteric ischaemia?

A

Atherosclerosis

96
Q

What is the treatment for chronic mesenteric ischaemia?

A

once diagnosed should consider surgery due to ongoing infarct
percutaneous transluminal angioplasty and stent insertion

97
Q

What are the physical complications of a gastrectomy?

A

Abdominal fullness - feeling early satiety and improving with time
Afferent loop syndrome - afferent loop may fill with bile causing pain and bilious vomiting
Diarrhoea - codeine phosphate may help
Gastric tumour

98
Q

What are the metabolic complications of gastrectomy?

A 
Dumping syndrome - fainting and sweating after eating due to food of high osmotic potiental being dumped in the jejunum and late dumping cause hypoglycaemia 
weight loss from poor calorie intake 
bacterial overgrowth and malabsorption
anaemia - lack of iron and B12
osteomalacia
99
Q

When is surgery done for GORD?

A

Severe symptoms that are refractory to medical treatment and severe reflux is confirmed on mametry

100
Q

What are the causes of oesophageal rupture?

A 
Iatrogenic - OGD
Trauma - penetrating injury or indigestion of something sharp
Carcinoma
Boerhaave syndrome- violent vomitting
Corrosive indigestion
101
Q

What are the signs and symptoms of oesophageal rupture?

A

Odynophagia, tachypnoea, dyspnoea, fever, shock, surgical emphysema

102
Q

What is the management of oesophgeal rupture?

A

Iatrogenic - PPI, NG tube and antibiotics

Surgery may be required for others

103
Q

What are the indications for bariatric surgery?

A 
BMI >40
failure of non surgical management to achieve and maintain clinical beneficial WL for 6 months 
Fit for surgery and anaesthetics
Intensive management in tier 3 services 
Patient well informed and motivated

If BMI >50 or in newly diagnosed T2DM with BMI >30 surgery is recommended as first line

104
Q

What bariatric surgery can be done?

A

Laprascopic adjustable gastric banding
Sleeve gastrectomy
Roux- En - Y gastric bypass

105
Q

What is the difference between diverticulum, diverticulosis, diverticular disease and diverticulitis?

A

diverticulum- out pouching of the gut wall usually at sites of entering arteries
diverticulosis- means diverticulae are present
diverticular disease- implies symptoms are present
diverticulitis- inflammation of a diverticulum

106
Q

What is the best investigation to confirm acute diveriticulitis?

A

CT abdomen - also allows complications to be viewed

107
Q

What are the complications of diverticular disease?

A

Perforation - laprascopic hartman’s procedure performed
haemorhage - can cause large PR bleeds
Fistulae - Colovesical can present with pneumaturia and intractable UTIs
Abscesses - swinging fever, leucocytosis and localising signs
Post infective strictures

108
Q

What is the management of an acute GI bleed?

A

A to E
Blood tests - FBC, U&Es, LFT, clotting, amylase, CRP and G&S
Imaging - only need a AXR but if signs of peritionitis erect CXR
fluid management - Fluid in and monitor output
Clotting - with hold anticoags and think about reversal
Abx - if signs of sepsis
Keep bedbound
start stool chart- send culture for MC&S
consider surgery in unremitting bleeding

109
Q

What is pruritis ani? What causes it?

A

Itching of the anal region

Caused by fissures, incontinence, tight pants, worm infections and lichen sclerosis, anxiety

110
Q

What is a fissure in ano?

A

Painful tear in the squamous lining of the lower anal canal

111
Q

What are the causes of a fissure?

A

most due to hard faeces
spasm may constrict the inferior rectal artery causing ischaemia and affecting healing
rare causes include syphilis, herpes, crohns, trauma, anal cancer

112
Q

What is the management of a fissure?

A

Lidocaine and GTN onitment or topical diltazem
increase diet fibres and stool softeners
If all else fails can do a lacteral partial internal sphincterectomy

113
Q

What is a fistula in ano?

A

Track communicates between the skin and anal canal- blockage of a deep intramuscular gland duct is thought to predispose to the formation of abscesses which discharge to form the fistula

114
Q

Who’s law dictates the path of a fistula?

A

Goodsalls’ rule

115
Q

What are the causes of a fistula?

A 
Perianal sepsis and abscessess
Crohns 
TB
Diverticular disease
Rectal cancer
116
Q

What is the treatment for a fistula?

A

Fistulotomy and exicison

117
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions - occur at 3,7, and 11 oclock where the three main vessels enter the anal canal

118
Q

Why arent haemorrhoid painful?

A

Above the dentate line where there are no sensory fibres. When they thrombose become painful

119
Q

What are the causes of haemorhoids?

A

Constipation with prolonged straining

may have pelvic mass, pregnancy , CCF, or portal hypertension

120
Q

What are the symptoms of haemorrhoids?

A

Bright red bleeding often coating the stools, on the tissues or dripping into the pan after pooing.
PR examination prolapsing piles are obvious, internal haemorhoids not palpable

121
Q

What is the treatment of haemorrhoids?

A

1) Medical - increase fluid and fibre
2) non op - rubber band ligation, sclerosants
3) surgery - excisional haemorrhoidectomy and stapled haemorrhoidopexy

122
Q

What is the management for thrombosed piles?

A

Analgesia, ice packed, and stool softeners, pain usually resolves in 2-3 weeks

123
Q

What is the classification of haemorhoids?

A

1 st - remain in the rectum
2nd - prolapse through the anus on defaecation but spontaneously reduce
3 - require digital reduction
4- remain persistently prolapsed

124
Q

What are the types of gallstones?

A

Pigment stones
Cholesterol stones
Mixed stones

125
Q

What is Mirizzi syndrome?

A

A stone in the gallbladder pressures on the bile duct causing jaundice

126
Q

What are the complications for pancreatitis?

A

Pancreatic necrosis and psuedocyst - fluid in lesser sac with a fever, mass and persistent increased amylase
Bleeding - from elastase eroding into a major vessel such as the splenic A
Abscess
Thrombosis
Fistulae

127
Q

What are the most common sites for kidney stones?

A

Pelviureteric junction
pelvic brim
entry into the bladder

128
Q

What types of renal stones are there?

A

Calcuim oxalate
Struvite
urate
cysteine

129
Q

How do kidney stones present?

A 
Pain - renal colic -loin to groin with nausea and vomitting 
infection 
haematuria 
proteinuria 
sterile pyuria 
anuria
130
Q

What is the gold standard of imaging for kidney stones?

A

Non contrast CT- used to see stones and rule out DDs

131
Q

What is the management of kidney stones?

A

Analgesia - diclofenac and IV fluids and ABx if infection
<5mm in lower ureter- pass spontaneously with increased fluid
>5mm or pain not resolving - CCB or A blockers and most pass within 48 hours

132
Q

What are the indications for urgent intervention?

A

Present infection and obstruction- percutaneous nephrectomy may be needed to relieve obstruction, urosepsis, intractable pain or vomitting, impending AKI, obstruction in solitary kidney and bilateral obstructing stones

133
Q

What can be done in Calcium/ urate kidney stone management?

A

Thiazide duiretic- increase Ca reabsorption

Urate stones - give allopurinol

134
Q

What type of kidney stones are not seen on XR?

A

Urate

135
Q

What are some predisposing factors for kidney stones?

A

Recurrent UTIs
Hypercalcuria, hyperparathyroidism, neoplasia, sarcoidosis, addisions, cushings, lithium, cystinuria, gout, renal tubular acidosis
any urinary tract abnormalities

136
Q

What are the causes of retroperitoneal fibrosis?

A

Inflammatory aneurysms of the AAA
idopathic
malgnancy - typically lymphoma

137
Q

What are the implications of retroperitoneal fibrosis?

A

Ureters get embedded in a dense fibrosis tissue resulting in progressive bilateral ureteric obstruction and dilation.

138
Q

What is the typical patient for retroperitoneal fibrosis?

A

middle aged man with vague loin or back pain and increased BP

139
Q

What will investigations typically show in a patient with retroperitoneal fibrosis?

A

increased urea and creatinine
increased ESR and CRP anaemia
USS - dilated ureters and hydronephrosis
CT/MRI - periaortic mass

140
Q

What is the management of retroperitoneal fibrosis?

A

retrograde stent to relieve obstruction and uterolysis to dissect ureters out
may require immunosuppresion after procedure

141
Q

What is the definition of an aneurysm?

A

Dilation of an artery greater than 1.5 times its normal diameter

142
Q

What is the difference between a true and a pseudoaneurysm?

A

True involve all layers of the artery wall

False involve a collection of blood in the outer layer only which communicates with the lumen

143
Q

What are the causes of aneurysms?

A 
Atheroma
Trauma
infection
connective tissue disorders
vasculitis - takaysukis
144
Q

What are the complications of aneurysms?

A 
Rupture
thrombosis
embolism
fistulae
pressure on other structures
145
Q

What is the process of AAA screening?

A

All >65 year old males are invited for one off USS screening

146
Q

What are the signs and symptoms of a ruptured AAA?

A

Intermittent or continuous abdo pain which can radiate to the back, iliac fossa or groin
collapse
expansile mass

147
Q

When is elective surgery done in a AAA?

A

> =5.5cm or expanding at >1cm/year or symptomatic

148
Q

What should we aim for the BP to be in a ruptured AAA and why?

A

SBP <100mmHg

Permissive hypotension to avoid excess blood loss

149
Q

What is dissection of the aorta?

A

Blood separates the aortic media

150
Q

What are the signs and symptoms of a dissection?

A

Sudden shearing back chest and back pain

As dissection progresses can result in hemiplegia, unequal arm pulses, BP or acute limb ischaemia, paraplegia and anuria

151
Q

What are the classification for dissection and what does this mean for treatment?

A

De Backey and Stanford
A- surgery - involving the ascending aorta
B- non surgical management - doesnt involve the ascending aorta

152
Q

What is the management for dissection?

A

Crossmatch 10 u
ECG and CXR
TOE
ITU and remain hypotensive

153
Q

What is the pathophysiology behind PAD?

A

Atherosclerosis causing stenosis of the arteries

154
Q

What are the symptoms of PAD?

A

Cramping pain in the calf, thigh or buttock after walking for a given distance and relieved by rest.
Ulceration, gangrene and foot pain at night are a sign of critical ischaemia

155
Q

What is leriche syndrome?

A

Buttock claudication, wasting of the quads and impotence

156
Q

What is fontaines classification?

A

1 - asymptomatic
2- intermittent claudication
3- ischaemic rest pain
4- ulceration and gangrene

157
Q

What are the signs of PAD?

A 
Absent pulses
cold white legs
atrophic skin
punched out painful ulcers
postural dependent colour changes 
Buergers ankle - angle leg is raised to until it changes colour
158
Q

What investigations should be done in a patient with PAD?

A 
HbA1c
FBC- anaemia or polycythemia 
U&amp;Es - renal distress
lipids 
ECG
ABPI
159
Q

How should ABPI be interpretted?

A

Normal 1-1.2
PAD 0.5-0.9
critical ischaemia <0.5
may be falsely elevated in calcified vessels

160
Q

What imaging should be done in those with PAD?

A

Colour duplex is first line

if considering intervention - CT or MRI

161
Q

Explain the treatment of PAD

A

Management of risk factors - prescribe an antiplatelet unless contraindicated
Management of claudication - supervised exercise programmes and vasoactive drugs
When conservative management fails
- percutaneous transluminal angioplasty- ballon inflation
- surgical reconstruction includes bypass surgery
- amputation

162
Q

What is acute limb ischaemia?

A

May be due to thrombus, embolus, graft/angioplasty occulsion or trauma
surgical emergancy- 4-6 hours to save the limb

163
Q

What are the signs and symptoms of acute limb ischaemia?

A 
Pale
Pulseless
Painful
Perishingly cold
paraylsed 
paraesthetic

mottled indicates that the change irreversible

164
Q

What is the management of acute limb ischaemia?

A

Open surgery or angioplasty
if in doubt about the diagnosis do arteriography
embolus - fogarty catheter
Thrombus - thrombolysis
Anticoagulate with heparin after
monitor for signs of compartment syndrome

165
Q

What are varicose veins?

A

tourtous, dilated long veins that are visible to the naked eye

166
Q

What is the pathophysiology behind varicose veins?

A

blood from the superficial system passes to the deep venous system via perforators and at the saphenofemoral and saphenopopliteal junctions. Valves usually prevent back flow but if these become incompetent we see back flow and therefore venous hypertension and dilation of the superficial veins

167
Q

What are the risk factors for varicose veins?

A

Prolonged standing, obesity, pregnancy, family history, COCP

168
Q

what are the symptoms of the varicose veins?

A

Pain, cramp tingling, heaviness and restless legs

169
Q

What are the signs of varicose veins?

A

Haemosiderin deposition
Atrophie blanchie- white scarring at the site of previous ulcers
Swelling
Lipodermosclerosis - skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis
Ezcema
Gaiter ulcers
Scars

170
Q

What are the treatments for varicose veins?

A

Treat any underlying cause
Education - avoid prolonged standing and elevate legs whenever posssible
Endovascular treatment - radiofrequency abalation, endovenous abalation, injection sclerotherapy,
surgery - ligation, stripping

171
Q

What is a saphena varix?

A

Dilation of the saphenous vein at its confluence with the femoral vein- may be mistaken for a femoral/inguinal hernia but on examination will have blue tinge

172
Q

What is gangrene?

A

death of tissue from poor vascular supply and sign of critical ischaemia
Dry gangrene - no infection - will have line of demarkation
wet gangrene - tissue death and infection
Gas gangrene - subset of necrozing myositis caused by clostridium species

173
Q

What are the different types of ulcers?>

A

Arterial
Venous
Mixed
neuropathic

174
Q

What determines whether compression bandage can be used?

A

ABPI >.8

175
Q

What is a Marjolin ulcer?

A

Long standing ulcer that develops a SCC in the center

176
Q

What is granulation tissue in an ulcer and what does it signify?

A

Deep pink gel -like matrix contained within a fibrinous network and evidence of healing

Surgery (1 decks)

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