Management Flashcards
Treatment for Varicose Veins
Conservative - Stockings, Avoid prolonged standing, weight loss
Interventional-
Multiple Stab Avulsion
Radiofrequency Ablation
Endothermal Ablation
Foam sclerotherapy
Perforator Avulsion
Ligation
Trendelenburg Procedure
Treatment for foot drop
Conservative - Anlagaesia for neuropathic Pain
Physiotherapy - strengthening anterior and lateral leg compartment
Splints and braces - focus on preventing contractures
Orthotics
Surgery - within 3-6 months
Nerve repair - either direct or using a nerve graft/conduit
Reduced compression on nerve (aetiology dependent)
Nerve/tendon transfer
i) Monopolar vs bipolar
ii) cutting vs coagulation
i) Monopolar -single electrode. Tissue effects very localised to electrode. current needs to leave the body so chooses path of least resistance –> need a dispersion pad on the patient.
Bipolar - two electrodes. Current confined between two electrodes
If you must use unipolar diathermy with a programmable in-situ electrical device the pad should be placed as far as possible from the device
ii)Cutting - Low voltage continuous current which is concentrated over a small area. Electrode not in contact with tissue.
Coagulation - High voltage interrupted dispersed over a large area.
Other- dessication, fulguration and vaporisation
Causes of intraoperative hypotension:
1) Generally
2) Particular in pregnancy
1) Drugs - Most anaesthetic agents, being administered anti-hypertensive agents on same day as surgery
Hypovolaemia/Haemorrhage
Anaphylaxis
LA Toxicity
Tension pneumo
LV Outflow obstruction
Then typical causes: Infection/Systemic inflammatory response/ cardiogenic/ arrhythmia
2) Pregnancy (if complications arise you may want an obstetrician) :
Being supine - Compresses the IVC
Placental Abrution
PE
Nutrition in Head and Neck Cancer patients:
1) Advanced cancer receiving multi-modal treatment
2) Post operative dysphagia
1) Factors to consider are:
i) Benefit of enteral feed - reduction in weight loss, reduction in treatment toxicity, ?improved QOL, ?higher chance of return to pre-morbid ADL
ii) Method of delivery - due to long term nature of feeding PEG/PEJ are preferred. Long term NG/NJ –> Erosions in the nose and poor cosmesis
2) Post operative dysphagia:
i) Ideally encourage oral intake if safe
ii) If unsafe –> try to ascertain how long alternative feeding method will be required.
<1 month - consider NG
>1 month - Consider PEG
Methods of shoulder reduction
1) Milch - Supine. Abduct - external rotate - thumb pressure to humeral head
2) Kocher - Adduct arm. Flex elbow. Traction on humerus. External rotation and then forward flexion+internal rotation
3) Stimson - prone on bed. gentle traction with weight over 15-20 minutes
4) Hippocratic - Countertraction in axilla. Humerul traction with in/ext rotation
Describe X Ray - what else might be associated on x ray?
Management
i) Anterior dislocation of humerus (Adducted and externally rotated)
Hill - Sachs lesion - Fracture of humeral head as it is impacted against glenoid
Bankart lesion - Fracture of the glenoid labrum as humerus presses against labrum
ii) Management:
History + Examine NV Status
Consent
Analgaesia (Gas/Sedative)
Inline downward traction + Countertraction (with/without internal or external rotation)
Polysling for 2-4 weeks
Carpal Tunnel Surgery Steps
Check, Mark and SIte appropriately. WHO checklist.
LA to incision site and down to median nerve.
Scrub. Apply tourniquet to 200mmHg.
Incision: i) Draw line from between 2nd + 3rd web space to palmaris longus tendon
ii) A line from first web space to the hook of hamate
iii) Then from the intersect line to the distal wrist crease
Careful dissection avoiding palmar nerves.
Divide the palmar fascia –> Identify the carpal ligaments –> incise ligament
Protect the median nerve
Close
Subclavian Line Insertion
Structures at risk
Subclavian Vein - Just deep to middle third clavicle.
Patient Supine, head down, with head facing the opposite way from site of insertion.
Point needle and syringe medially, posteriorly and cephalad at junction 1cm between lateral/medial third of clavicle.
Pull back on syringe as inserting needle.
When inside vein insert catheter using selldinger technique
CXR to check position - Tip should be in SVC
Risk - pleura, Subclavian artery, thoracic duct (left), phrenic nerve
Nerves that can be damaged in inguinal hernia repair?
Ilioinguinal Nerve - Runs from deep ring to superficial ring.
innervates the anterior scrotum, base of penis, upper + medial thigh
Iliohypogastric Nerve - Runs beneath external oblique piercing it near the superficial ring. innervates skin above pubis
Genitofemoral nerve - Travels through the inguinal canal to innerate cremasteric muscle.
motor - cremaster sensory - scrotum
Management - Hip Fracture:
i) Intertrochanteric
ii) Subtrochanteric
iii) Intracapsular
Basics to talk about - pain management, neurovascular compromise of distal limb, procedures would be performed under fluroscopic guidance in theatre to ensure adequate reduction
i) Intertrochanteric/Subtrochanteric - Extracapsular so a dynanamic hip screw/ IM Nailing
ii) Intracapsular :
I,II - Fix with a cannulated screw (preserve the femoral head)
III, IV - Hemiarthroplasty
Garden Classification of HIp Fractures
Radiological Classification System for Intracapsular hip fractures.
I - Stable fracture/ Valgus Impaction
II - Non Displaced - Complete Fracture
III - Displaced but maintenance of end to end contact between fragments
IV - Completely displaced fracture
III + IV associated with AVN
What neurovascular structures are at risk in anteromedial approach to the knee?
Geniculate Arteries
Saphenous Nerve
Great Saphenous Vein
Achalasia
1) Grossly the pathophysiology
2) Classic radiological sign
3) Classic manometry findings
1) achalasia is caused by loss of myenteric plexus resulting in the discoordinated persitaltic movements observed and the non relaxation of the lower oesophageal sphincter
2) Classically seen on barium swallow as a “birds beak appearance”
3) Manometry
- Non-relaxing hypertensive oesophagea sphincter
- Aperistaltic smooth muscle
Lumbar Puncture:
i) Anatomical Landmarks
ii) Which layers do you go through?
i) Supracrestal line - line between the iliac crests that corresponds to L4/L5
L3/L4 - L4/L5 Best places to go
ii) Skin, Fat, Fascia, Supraspinous Lig, Interspinous Lig, Ligamental Flavum, Epidural Space, Dura, Arachnoid Space (The CSF is here in the subarachnoid space)
