MTB - Surgery Flashcards
How do you secure the airway in trauma pt with cervical spine injury
- Orotracheal intubation with manual cervical immobilization
- Best answer - flexible sigmoidoscopy
Best way to secure airway in pt with extensive facial trauma and bleeding into airway
Cricothyroidotomy
In a patient with hemorrhagic shock - what next steps should you take in management?
Prep for surgery
- 2 large bore IVs
- fluids, blood, type and screen
- insert Foley catheter
- administer IV abs
Initial bolus of fluids for children
20 ml/kg of Ringers lactate
Signs to make you think of vasomotor shock
Hypotension
Tachycardia
Warm and flushed skin
History of medication, spinal anesthesia or allergen exposure
First step in management of vasomotor shock
Vasoconstrictors and fluids
Asymptomatic head injury with closed skull fracture - management
No surgery is needed
Next step - clean any lacerations
Tx. Depressed or comminuted skull fractures
Surgery - repair or craniotomy
First step - head trauma and LOC
CT of the head and neck without contrast
What should be given to all patients with open skull fractures
Tetanus toxoid
Prophylactic antibiotics
Management of a CSF leak due to skull fracture
CT scan of head and neck
No treatment of CSF leak - it will stop on its own
Prophylactic antibiotics are not necessary
Management of all patients with epidural hematoma
Emergency craniotomy
Management of subdural hematoma
Emergency craniotomy only if there are lateralizing signs or midline displacement
Management of diffuse axonal injury
No surgery
Therapy aimed at preventing more damage from raised ICP
How does hyperventilation help with lowering ICP
Causes vasoconstriction and thus, decreased blood volume in the brain and therefore, lowers ICP
First line measures in elevated ICP
- Head elevation
- Hyperventilation
- Avoid fluid overload
Second line measures for lowering ICP
- mannitol - use very cautiously
2. Sedation and /or hypothermia (lower oxygen demand)
What causes of acute abdomen are treated with surgery? (4)
- Peritonitis
- Abdo pain plus signs of sepsis
- Acute intestinal ischemia
- Pneumoperitoneum
Primary peritonitis
Spontaneous inflammation in children with nephrosis
Adult with ascites and mild abdominal pain
Three things that can mimic acute abdomen
Lower lobe pneumonia
Myocardial ischemia
Pulmonary embolism
CF: GI perforation
Acute abdo pain that is sudden, severe, constant and generalized. It is excruciating with any form of movement
MCC of GI perforation
Diverticulitis
Perforated peptic ulcer
Crohn’s disease
Best dx test - GI perforation
Supine and erect CXR
- will show free air under the diaphragm or falciform ligament
Management - GI perforation
NPO and IVF
IV antibiotics
Emergency surgery
Preferred method of securing airway in trauma patient
Orotracheal intubation
Study of choice for suspected esophageal perforation
Gastrograffin contrast esophagogram
Baby is born and it is excessively salivating and has had multiple choking spells with feeding - dx?
esophageal atresia
first step - esophageal atresia?
NG tube - coils in upper chest on XR
Tx. esophageal atresia
primary surgical repair
- if delayed, do gastrostomy to prevent acid reflux into lungs
Tx. Anal Atresia
if a fistula is present - repair can be delayed until further growth; if no fistula - colostomy
VACTERL
Vertebral Anomalies Anal atresia Cardiovascular anomalies TE fistula Renal and/or radial anomalies Limb defects
Management - Congenital Diaphragmatic Hernia
- Endotracheal intubation
- Low pressure ventilation
- Sedation
- NG Suction
- Repair in 3-5 days
Management - Gastroschisis or Omphalocele
if large –> Silastic Silo and manual replacement of bowel daily
1. supplement with TPN
Tx. Exstrophy of the Bladder
Transfer to specialized center with repair in 1-2 days!
Conditions presenting with “double bubble” sign
Annular pancreas
Duodenal atresia
Intestinal Malrotation
XR - multiple air-fluid levels throughout the abdomen (dx?)
Intestinal Atresia
CF: Necrotizing Enterocolitis
Feeding intolerance in preemie
Abdominal distention
Dropping platelet count
Tx. Necrotizing Enterocolitis
- Stop feeds
- Broad spec. abx
- IVF and TPN
When do you do surgery for NEc?
Signs of necrosis or perforation
- abdominal wall erythema
- portal vein gas
- gas in bowel wall
Dx. Meconium Ileus
XR –> multiple dilated loops of bowel and ground glass appearance in lower abdomen
Management of Meconium Ileus
Gastrograffin enema
- both diagnostic and therapeutic
Management of Hypertrophic Pyloric Stenosis
- correct dehydration and electrolyte abnormalities
2. Ramstedt pyloromyotomy
CF: biliary atresia
progressive rise in bilirubin (CB) in a 6-8 week old baby
Dx. biliary atresia
Give baby 1 week of phenobarbital then do a HIDA scan; if no bile reaches duodenum –> will need surgical exploration
A patient presents with chronic constipation; A rectal exam causes explosive expulsion of stool and flatus w/ relief of distention - dx?
Hirschsprung dz
Dx. with full thickness biopsy of rectal mucosa
Management - Intussusception
Barium or Air enema
Dx. of Meckel Diverticulum
Radioisotope scan
Tx. Meckel Diverticulum
Surgical Resection
diagnostic testing for intestinal obstruction
CBC and lactate level (elevated)
supine/erect AXR
initial management of intestinal obstruction
NPO
IVF
NG suction
Tx. volvulus
proctosigmoidoscopy with rigid tube - leave rectal tube in place
What two hernia types do NOT require surgical repair?
umbilical hernias in children < 2 yo
esophageal sliding hiatal hernia
Diagnostic test for acute diverticulitis
CT w/ contrast
- fat stranding of inflamed bowel
Management of acute diverticulitis
No peritoneal signs? outpt abx
Peritoneal signs and abscess -> admission, IVF, NPO, IV abx
warning signs for acute hemorrhagic pancreatitis
dropping Hct
very high WBC, glucose and BUN
very low Ca
tx. pancreatic pseudocyst
if painless - do not drain
if painful and > 6 cm and > 6 weeks - percutaneous or endoscopic drainage
Dx of appendicitis
clinical picture and physical exam
- only do CT scan if those are not clear
What IV abx can be given in acute appendicitis
Cipro + Metro
Ampicillin/sulbactam
Levofloxacin + Clindamycin
Cefoxitin or Cefotetan
Abdominal pain that is out of proportion to exam - next step?
Surgery consult
Order angiography
Tx. of mesenteric ischemia if diagnosis is made in (1) surgery and (2) angiography
- Embolectomy and revascularization
2. Vasodilators and thrombolysis
Diagnostic testing for suspected intra abdominal abscess
CBC
Contrast CT of abdomen and pelvis
Tx. Intra abdominal abscess
drainage
Antibiotics
Diagnostic testing for obstructive jaundice
USG
Confirm with EUS or MRCO
Treatment of obstructive jaundice due to stones
ERCP with sphincterectomy
Cholecystectomy should follow
Dx. Obstructive jaundice due to tumor
USG
Ct scan
Treatment of acute Cholecystitis
NG suction, NPO, IVF, antibiotics
When do you do an emergency cholecystectomy for acute Cholecystitis
- Generalized peritonitis
2. Emphysematous Cholecystitis (perforation or gangrene)
Reynolds Pentad
Jaundice Fever Abdominal pain Altered mental status Shock
Clinical findings in acute ascending cholangitis
High fever Very high WBC count High ALP High total bilirubin and direct bilirubin Mild elevation of LFTS
Management of acute ascending cholangitis
- Blood cultures
- Antibiotics
- Emergency decompression with ERCP
Antibiotics used in acute ascending cholangitis
Amp + gent
Monotherapy with either imipinem or levofloxacin
Hepatic risk factors with increased morbidity and mortality for surgery
- Bilirubin > 2
- Albumin below 3
- Prothrombin time > 16
- Encephalopathy (altered mental status)
Can you operate on someone with EF < 35%?
No
When can you do surgery on a patient with recent myocardial infarction?
Defer surgery for 6 months
Preop assessment: patient with severe progressive angina
Perform cardiac cath to eval for possible revascularization
Pre op assessment of pt who smokes
Order PFTs to evaluate fev1: if high pco2 or fev1 < 1.5 (at increased risk of pneumonia) other smoker pts should stop smoking 8 weeks prior to surgery
Post op fever day 1
Atelectasis
- incentive spirometry
Post op fever day 3
Pneumonia
- CXR infiltrate
- sputum culture and antibiotics
Post op fever day 3
UTI
- urinalysis and urinary culture
- antibiotics
Post op fever day 5
DVT
- get Doppler of LE and pelvis
- give anti coagulation
Post op disorientation
Always consider hypoxia first and get an ABG
when is open reduction and internal fixation appropriate for fracture?
severely displaced or angulated fractures that cannot be aligned
tx. open fractures
cleaning in the OR and reduction w/in 6 hours
what test should you always order in anyone with facial fracture?
spinal XR
Tx. gas gangrene
IV penicillin and hyperbaric oxygen
what do you suspect in pt with shoulder pain and inability to move arm who recently had a seizure (or got an electrical burn)?
posterior shoulder dislocation
- arm held close to body, forearm internally rotated
Dx. posterior shoulder dislocation
axillary or scapular views of the spine
patient comes in with arm held close to the body, externally rotated forearm and numbness over the deltoid muscle
anterior shoulder dislocation
Tx. clavicular fracture
figure 8 sling
Monteggia vs. Galeazzi fracture
direct blow to either ulna (monteggia) or radius (galeazzi) –> diaphyseal fracture and displaced dislocation of nearby joint
Tx. monteggia/galeazzi fracture
ORIF - diaphyseal fracture
closed reduction - dislocation
tx. femoral neck fractures
femoral head replacement - high risk of avascular necrosis
tx. intertrochanteric femoral fractures
Open reduction and pinning
Tx. femoral shaft fractures
intramedullary rod fixation
best initial therapy: trigger finger
steroid injection
best initial therapy: deQuervain’s tenosynovitis
steroid injection
Dupuytren’s contracture - tx
surgery
how do you differentiate between a hip fracture and posterior dislocation of the hip?
posterior dislocation - internally rotated leg
hip fracture - externally rotated leg
tx. rupture of achilles tendon
casting in equinis position or surgical repair
first step in management of compartment syndrome
emergency fasciotomy
neurovascular complication of oblique distal humerus fracture
radial nerve damage –> unable to extend the wrist; function is usually regained after reduction, if not - surgery
neurovascular complication of posterior dislocation of the knee
popliteal artery injury –> decreased distal pulses; order doppler studies or arteriogram; prophylactic fasciotomy if reduction is delayed
characteristic feature of lumbar spinal stenosis
increased pain with extension of the spine that improves with sitting or bending forward`
dx. lumbar spinal stenosis
MRI of the spine
Tx. lumbar disc herniation (acute)
ibuprofen and bed rest
do not need to get an MRI at first
when do you need immediate surgical decompression in lumbar disc herniation?
cauda equina –> bowel bladder incontinence, flaccid anal sphincter and saddle anesthesia
Tx. ankylosing spondylitis
anti-inflammatory agents
physical therapy
which ca. cause blastic bone mets?
prostate ca and breast ca
first test to order in suspected metastatic bone malignancy
XR
heel pain that is worse in the morning, resolves with walking and is accompanied by tenderness to palpation of the heel
plantar fasciitis
- bony spur on heel
tx. plantar fasciitis
symptomatic - resolves w/in 12-18 months on its own
inflammation of common digital nerve at 3rd interspace between 3rd and 4th toes; very tender to palpation in that area
Morton’s neuroma
Tx. mortons neuroma
analgesics, appropriate footwear
male pt presents with severe, sudden onset testicular pain. on exam, cremasteric reflex is absent and testis is high riding. - dx? next step?
R/O testicular torsion
- order testicular USG
Tx. testicular torsion
immediate surgery with bilateral orchiopexy
- do not delay surgery for diagnostic tests
male pt comes in with acute scrotal pain, urinary symptoms and fever - dx? next step?
dx - acute epididymitis
next step - urinalysis and culture
Tx. epididymitis
- males < 35 yo: ceftriaxone and doxycycline
2. older males: tx. as UTI - levofloxacin
management of urologic obstruction + infection
- decompression of urinary tract above obstruction (ureteral stent or percutaneous nephrostomy)
- IV Abx
MCC for newborn boy not to urinate in first DOL
posterior urethral valves
management: posterior urethral valves
- catheterize bladder
2. voiding cystourethrogram
child with hematuria from trivial trauma
congenital anomaly until proven otherwise
child with UTI
undiagnosed congenital anomaly ex. vesicoureteral reflux
dx. vesicoureteral reflux
voiding cystogram
- give long term abx
young girl who voids appropriately but her underwear are constantly wet with urine
low implantation of ureter (into vagina)
ureteropelvic junction obstruction
only sx if diuresis occurs - ex. teenager who drinks large volumes of beer and develops colicky flank pain
48 year old man comes in c/o coldness and tingling in L hand as well as pain when he does strenuous work. These episodes are accompanied by dizziness and blurred vision. Dx?
Subclavian steal syndrome
Dx. subclavian steal syndrome
angiography
Tx. subclavian steal syndrome
bypass surgery
Tx. symptomatic AAA (abdominal pain, hypotension)
urgent surgery w/in the next day
Tx. asymptomatic AAA
ASA + Statins
4-5.4 cm: USG q6-12 mo
< 4cm: USG q2-3 years
most impt modifiable RF for AAA
smoking
Elective repair for AAA
- if > 5.5 cm
- rapidly enlarging (>0.5 cm in 6 mo)
- AAA assoc. with PAD or aneurysm
MC location of AAA
infrarenal aorta
most important intervention to prevent progression of thoracic aortic aneurysm
BP control
MC complication post AAA repair
spinal cord infarction - ASA occlusion
- get immediate neuro consult
management of intermittent claudication (if not interfering significantly with lifestyle)
cessation of smoking
cilastazol and ASA
dx. intermittent claudication
doppler studies - ABI <0.9
When do you consider surgery stenting or angioplasty for intermittent claudication?
disabling symptoms or impending ischemia to extremity
preferred intubation method in pt with multiple facial fractures
oral laryngoscopy
- blind nasal intubation is C/I
CF: patellar tendon rupture
excrucitating pain
joint swelling of anterior knee
difficulty bearing weight
unable to perform active extension of leg
unable to maintain passively extended knee against gravity
CF: ACL tear
lots of pain
inability to ambulate
popping sensation/sound at time time of injury
positive anterior drawer test
mechanism of meniscal injury
twisting force with the foot fixed on the ground
what test do you use to test meniscal injury
McMurray’s maneuver
- audible or palpable click or popping sensation during extension of involved knee
Tx. ruptured patellar tendon
early surgical repair
