MTB 2 CK - Surgery Flashcards
What ejection fraction cut off is associated with an increased risk for non cardiovascular surgery?
less than 35%
Patient recently experienced a myocardial infarction 5 months ago and wants to schedule a cholecystectomy next week. Management and why?
Defer surgery for another month and stress test that patient prior to surgery. Current guidelines recommend deferring surgery for at least 6 months after an MI followed by stress testing.
Patient needs a total knee replacement and has signs of JVD and lower extremity edema. What is needed in this patient’s surgical management?
Review of medications to ensure the patient is on the following drugs for his CHF. (all decrease mortality)
- ACE inhibitors.
- beta blockers.
- spironolactone.
What tests should be required for all patients with cardiac disease prior to surgery?
- EKG.
- Stress testing. (ischemic lesions)
- Echocardiogram. (structural disease and ejection fraction)
For men at what age are we at risk for cardiovascular complications?
45 years old
For patients with lung disease what is needed for management?
- Pulmonary function testing for vital capacity evaluation.
2. Smoking cessation for 6-8 weeks prior to surgery and use of nicotine patch.
For patients with renal disease what is necessary in management?
- Adequate hydration.
2. Dialysis 24 hours prior to surgery for those who need dialysis.
Patient with severe claudication needs a femoral-popliteal bypass. What testing needs to be done preoperatively?
- BMP.
- EKG.
- Thallium stress test.
Patient presents with severe facial trauma and is in need of an airway. What is contraindicated and what needs to be done?
Intubating with an orotracheal tube is contraindicated.
Perform a cricothyroidotomy.
Patient presents with a cervical spine injury and needs an airway. What do you do?
Intubate with orotracheal tube using a flexible bronchoscopy.
What is the oxygen saturation goal for a patient?
greater than 90%
What variables are a concert for airway compromise?
- altered mental status.
- facial trauma.
- apnea.
When evaluating whether or not to intubate a patient what variables guide your decision making?
- Is there a risk for a compromised airway such as AMS, facial trauma and apnea?
- Is there facial trauma?
- Is there a cervical spine injury?
What define SIRS?
Two of the following needs to be present.
- HR over 90
- Temp below 36 or above 38.
- RR over 20 or PCO2 of less than 32.
- WBC below 4 or above 12.
How does one define the following:
- Sepsis.
- Severe sepsis.
- septic shock.
- Sepsis is SIRS and an identified source of infection.
- Severe sepsis is sepsis with organ dysfunction.
- Septic shock is severe sepsis with hypotension.
What are signs f shock other than changes in vitals?
- Brain - confusion.
- Heart - chest pain and shortness of breath.
- Liver - elevated transaminases.
- Renal - elevated BUN/Cr ratio.
- Blood - increased lactate.
What variables are important when evaluating shock?
- signs and symptoms.
- CVP.
- CO.
- Wedge pressure.
- Response to fluids.
What is the treatment for hypovolemic shock and neurogenic shock?
Fluids and pressors.
Motor vehicle collision, abdominal pain that radiates to the back, and ecchymosis on the flank 2 days later. Diagnosis?
Hemorrhagic pancreatitis.
Elevated blood pressure and tearing midepigastric pain.
aortic dissection.
Brusing around the umbilicus. Name of finding? Causes?
Cullen sign
- hemorrhagic pancreatitis.
- abdominal aortic aneurysm.
Bruising in the flank Name of finding and cause?
Grey Turner sign.
Retroperitoneal hemorrhage.
What signs correlate with splenic rupture?
- Kehr sign - pain in the left shoulder.
2. Balance sign - dull percussion on the left and shifting dullness on the right.
With abdominal trauma if a bleeding is suspected, how does one evaluate such a problem?
- FAST scan first to evaluate for an intraabdominal bleed.
- CT scan to evaluate for a retroperitoneal bleed, especially if a splenic rupture is suspected despite a negative FAST scan.
Thoracotomy vs thoracostomy
Thoracotomy - making an incision to gain access to the thoracic organs
Patient undergoes a thoracotomy for CT surgery. What is a common complication of this procedure for the first few days?
Atelectasis and pneumonia because the pain from this procedure is unbearably difficult.
Free air under diaphragm.
Bowel perforation.
Air fluid levels.
Ileus.
Muffled heart sounds.
Pericardial tamponade.
What are common forms of trauma that lead to pericardial tamponade?
- broken ribs.
- gunshots.
- bullets.
Signs of pericardial tamponade?
- muffled heart sounds.
- electrical alternans.
- JVD.
- hypotension.
What defines tension pneumothorax when compared to regular pneumothorax?
tracheal deviation away from pathologic lung.
What is the best diagnostic test for pericardial tamponade?
Echocardiogram.
What is the management of tension pneumothorax vs regular pneumothorax?
Both require chest tube placement, but with a tension pneumothorax it is an urgent problem that needs immediate needle decompression prior to chest tube placement.
In a trauma setting what could lead to a blunting of the costophrenic angle on chest x-ray and CT scan.
Hemothorax.
75 year old man. Atrial fibrillation, coronary artery disease, and dyslipidemia. Severe abdominal tenderness. Pain worse with eating. Likely diagnosis? Next best step?
Acute mesenteric ischemia.
Angiography or possibly a surgical candidate.
What defines severe abdominal pain that is out of proportion to physical exam findings?
10/10 pain, with no guarding, soft abdomen and no rebound tenderness.
Patient has a history of abdominal pain after eating and bloody diarrhea. History of diabetes, hypertension and hypercholesterolemia. Likely diagnosis? Best initial test. Most accurate test? Treatment?
Ischemic bowel.
CT scan of the abdomen.
Colonoscopy with biopsy.
IV normal saline followed by surgical intervention.
Watershed areas of the GI tract include?
Splenic and hepatic flexures.
Air in bowel wall. Diagnosis? Treatment?
Mesenteric ischemia.
Emergent laparotomy with resection
Ear pain can be referred to what organ?
Pharynx.
Referred pain of the appendix (atypical part of the body)
Left lower abdominal quadrant.
Right upper quadrant abdominal pain, causes?
- cholecystitis.
- cholangitis.
- hepatitis.
- perforated duodenal ulcer.
- biliary colic.
Left upper quadrant abdominal pain, causes?
- splenic rupture.
2. IBS - splenic flexure syndrome.
Midepigastric pain, causes?
- pancreatitis.
- aortic dissection.
- peptic ulcer disease.
Right lower quadrant pain, causes?
- appendicitis.
- ovarian torsion.
- ectopic pregnancy.
- cecal diverticulitis.
Left lower quadrant pain, causes?
- sigmoid diverticulitis.
- sigmoid volvulus.
- ovarian torsion.
- ectopic pregnancy.
Crunching heard upon palpation of the thorax, pain radiating to left shoulder, odynophagia and severe and acute onset of excruciating retrosternal chest pain. Diagnosis? Test to confirm? Complications?
esophageal perforation.
Esophogram (Gastrografin) showing leaking of fluid outside of the esophagus.
Mediastinitis.
Where is the perforation in Boerhaave syndrome often located at?
Left posterolateral aspect.
What is the problem with concurrent alcohol and smoking use in a patient with peptic ulcer disease?
Prevents healing.
Other than peritonitis what other complications are associated with gastric perforation?
Pancreatitis (gastric juices fries the pancreas).
Medical management for perforated ulcer?
- NPO.
- NGT.
- IV fluids and antibiotics.
- Exploratory laparotomy.
Workup for a woman with abdominal pain. Beta-HCG is elevated and pelvic ultrasound shows ectopic pregnancy. What do you do?
Emergent surgery.
What should you never do in a patient with acute diverticulitis?
Barium enema.
What is the algorithm for right lower quadrant pain?
Is the person above or below 60?
male or female?
beta-HCG and pelvic ultrasound for a female patient?
What do you expect to find on ultrasound findings of someone with cholecystitis?
- pericholecystic fluid.
2. thickened gallbladder wall.
Pain that radiates to the back? Name 2 emergent conditions
- Pancreatitis.
2. Aortic dissection.
What results would be expected on a HIDA scan of someone with acute cholecystitis.
Delayed emptying of the gallbladder.
What signs special signs associated with acute appendicitis?
- Rovsing.
- Psoas.
- Obturator.
Is appendicitis a clinical diagnosis?
Usually you can treat appendicitis just from the history and physical. However, additional testing maybe required if the clinical picture is not obvious.
What is the treatment for appendicitis?
Laparoscopy
Complications of appendicitis?
- abscess.
2. gangrenous perforation.
For cholecystitis what is the most accurate test?
HIDA scan.
Failure to pass stool and flatus and hyperactive bowel sounds. Diagnosis?
Small bowel obstruction.
Mechanism of disease with bowel obstruction?
Occlusion of the lumen, gas and fluid build up, severely increasing pressure within the lumen. Decreased perfusion of the bowel and necrosis ensues.
Can someone have a bowel obstruction even though a small amount of GI contents is passing?
Yes, this is known as a partial small bowel obstruction.
What etiologies can cause a bowel obstruction?
- adhesions.
- hernias.
- Crohn disease.
- Neoplasms.
- Intussusception.
- Volvulus.
- Foreign bodies.
- Intestinal atresia.
- Carcinoid.
What is the best drug tot great obstructions from stool impaction in patients on chronic opioids?
Methylnaltrexone.
Multiple air-fluid levels with dilated loops of small bowel.
Small bowel obstruction
Fecal incontinence definition?
Continous or recurrent uncontrolled passage of fecal material greater than 10 mL for at least 1 month in an individual greater than 3 years of age.
Best initial test for fecal incontinence?
Most accurate test?
If there is a history of anatomic injury what would be the next best most accurate test?
sigmoidoscopy or anoscopy.
anorectal manometry.
endorectal manometry.
What is dextranomer/hyaluronic acid injections used for?
This substance is deposited in the submucosal layer of the GI walls to help bulk the tissue. 50% of patients with fecal incontinence will get better with this treatment.
What are some biofeedback measures to help with fecal incontinence?
Control exercises and muscle strengthening exercises.
What type of fractures are associated with comminuted fractures?
Crush injuries.
What causes a stress fracture?
Repeated insults to a bone.
When diagnosing a stress fracture does X-ray often show evidence of fracture? If not what next?
Usually stress fractures are not evident on X-ray.
Do a CT or MRI.
What is the management of a person with a stress fracture?
Conservative: rehabilitation, reduced physical activity and casting.
Surgery is indicated if symptoms are persistent.
What is the typical presentation for a pathologic fracture?
History of minimal trauma to bone causes a fracture.
Etiologies include the following:
1. Metastatic carcinoma (usually breast or colon).
2. multiple myeloma.
3. Paget disease.
70 year old female patient presents to the ER with right chest pain. Signs of ecchymosis on the right lateral thoracic wall and an indentation of rib 6. Patient stated this all started with a cough. Clinical problem?
Rib fracture likely pathologic.
Arm held to the side with externally rotated forearm with severe pain. Diagnosis? What other conditions need to be evaluated for?
Anterior shoulder dislocation.
Axillary artery or nerve injury needs to be ruled out.
Anterior shoulder dislocation presentation. Best initial test? Most accurate test? Treatment?
X-ray is the best initial test.
MRI.
Shoulder relocation and immobilization.
Causes of posterior shoulder dislocation?
- seizures.
2. electrical burns.
Arm is medially rotated and held to the side. On exam pulses and sensation is diminished. Diagnosis? Initial tests and most accurate test? Treatment?
Posterior shoulder dislocation.
X-ray followed by MRI.
Traction and surgery because pulses are diminished during physical exam.
With a clavicular fracture what needs to be ruled out? What is the treatment?
Subclavian artery and brachial plexus injury.
Simple arm sling.
Falling on an outstretched hand and persistent pain in anatomical snuffbox that occurred today. Diagnosis? X-ray findings? Treatment?
Scaphoid fracture.
X-ray won’t show results for 3 weeks.
Thumb spica cast.
Use a figure 8 sling or simple arm sling for a clavicular fracture
Simple arm sling.
Trigger finger is this a clinical diagnosis? How does it present? Treatment?
Yes.
Woman wakes up with severe pain in index finger which is flex while all other are extended. Pulling the finger causes a loud popping sound and pains subsides.
Steroid injections and surgery if steroids fail.
40 year old woman wakes up with severe pain in index finger which is flex while all other are extended. Pulling the finger causes a loud popping sound and pains subsides. Diagnosis? Mechanism of disease?
Trigger finger.
Thickening of tendon sheath restricts gliding motion of flexor tendons. Nodule may develop on the tendon and lock the finger in place.
Man over the age of 40 who complains of his hand not being able to extend. Diagnosis? Mechanism of disease? Treatment?
Dupuytren contracture.
Palmar fascia becomes constricted.
Surgery.
Define fat embolism syndrome.
- confusion.
- petechial rash, usually upper extremity and trunk.
- Dyspnea
19 year old breaks her femur 3 days ago during a soccer tryout. She is brought to the ER with confusion and shortness of breath. Splotchy magenta rash around base of neck and back. ABG shows PO2 under 60 mm Hg. Diagnosis?
Fat embolism syndrome.
What is the time frame of a fat embolism syndrome? Treatment?
Within 5 days of a fracture.
Oxygenation with goal of over 95%.
Mechanical ventilation if necessary.
What diagnostic tests would support a fat embolism syndrome diagnosis?
- PO2 under 60 mm Hg.
- Chest x-ray showing infiltrates.
- Urinalysis showing fat embolism.
60 year old man complains of bilateral leg pain of several moths. Pain is worse when walking several blocks and improves when sitting down. Leaning forward alleviates the pain. He is a nonsmoker. Likely diagnosis? Most appropriate diagnostic step?
Spinal stenosis.
Leg MRI.
What disease history is a dead give away to discern pseudoclaudication from claudication?
- Bilateral claudication-like symptoms.
2. relief of symptoms when leaning forward.
Treatment for spinal stenosis?
- NSAIDs.
2. surgery.
Spinal stenosis can present with pain in what parts of the body.
- neck pain.
- back pain.
- bilateral leg/buttock pain.
6 P’s of compartment syndrome?
pulselessness, poikilothermia, paresthesia, paralysis, pallor, and pain.
What are the early signs of compartment syndrome?
What are the late concerning signs of compartment syndrome?
- pain, paresthesia, and pallor.
2. paralysis, poikilothermia, and pulselessness.
With lateral and medial collateral ligament injury where is the direction of force that caused these injuries?
Opposite to the ligament because force causes a pivoting motion one one side causing the extension of the joint space on the opposite side, pathologically lengthening it.
What type of surgery is done for medial and lateral ligament repairs?
Surgery not arthroscopic repair.
Unhappy triad?
ACL, MCL, and medial or lateral meniscus.
Confusion in a 70 year old with 50 pack year smoking history. Mid abdominal pain. Pale in moderate distress. Pressure of 80 over 55, pulse of 120. Palpable pulsatile mass in abdomen. Diagnosis?
Ruptured AAA.
What are the management criteria of an asymptomatic abdominal aortic aneurysm?
3-4 cm: ultrasound q2-3 years.
4-5.4 cm: ultrasound or CT q6-12 mos.
> 5.5 cm: surgery.
Screening guidelines for abdominal aortic aneurysms?
over 65 in a smoker or former smoker need an abdominal ultrasound.
What do the following tests provide in the work up of an abdominal aortic aneurysm?
CT or MRI?
Ultrasound?
CT or MRI: information with regards to where the abdominal aortic aneurysm is in relation to the other arteries.
Ultrasound: information on size and a relatively inexpensive means of monitoring the AAA.
Risk factors for aortic dissection include what?
- hypertension.
- age over 40.
- Marfan syndrome.
How can aortic dissection present?
- Sudden onset of tearing chest pain that radiates to the back.
- Asymmetric blood pressure.
In an unstable patient with a clinical presentation of an aortic dissection what its the best next step? What other diagnostic options are there too? What would be the best diagnostic test of choice if the patient was stable?
TEE because of all the diagnostic tests this is the quickest.
CTA and MRA.
CTA.
What considerations need to be taken when managing an aortic dissection? How does this impact management?
Is this an ascending or descending dissection?
Ascending dissection: Emmergent surgery and blood pressure control.
Descending dissection: blood pressure control.
What is the best medications to initially treat an aortic dissection?
Beta-blockers to treat the hypertension followed by vasodilators such as sodium nitroprusside.
By what mechanism would giving vasodilators alone to treat an aortic dissection a bad idea?
Reflex tachycardia will increase the shearing forces of the pathology and worsen the patient’s outcome.
What are the 5 W’s of postoperative fever. State the timeline and meaning of the mnemonic.
POD 1-2: Wind - atelectasis or post-op pneumonia.
POD 3-5: Water - UTI.
POD 5-7: Walking - DVT, thrombophlebitis (IV lines), and PE.
POD 7: Wound - Wound infections & cellulitis.
POD 8-15: Drug fever or deep abscess.
Post-op day 2, patient experiences fever. Next best step?
Chest x-ray followed by sputum cultures to evaluate for atelectasis or pneumonia.
Post-op day 4, patient experiences fever. Next best step?
Urine analysis (look for positive nitrates and leukocyte esterase) followed by urine culture to evaluate for UTI.
Post-op day 6, patient experiences fever. Next best step?
Doppler ultrasound of extremities followed by changing of IV access lines and culture of IV tips to evaluate for DVT or thrombophlebitis.
Post-op day 7, patient experiences fever. What are the possibilities and what do you do?
DVT or thrombophlebitis - Doppler ultrasound of lower extremities and evaluate IV access lines and culture of IV tips.
Wound infection and cellulitis - exam the wound for erythema, purulent discharge and or swelling.
Post-op day 9, patient experiences fever. What are diagnostic causes and what do you do?
Drug fever - review medications.
Deep abscess - CT scan for examination of a deep fluid collection.
Patient experiences post-operative pneumonia on day 2. What could have prevented this outcome?
Incentive spirometry and vancomycin and tazobactam-pipercillin.
Patient has a DVT on post-operative day 6. What is the management for this patient?
Heparin for 5 days and bridge to warfarin
