Pestana Flashcards
Describe the significance of smoking as a pulmonary risk factor for surgery?
Smoking is the most common cause of increased pulmonary risk in surgery. The main issue is the compromised ventilation as opposed to oxygenation. Quality of ventilation can be measured with FEV1 and pCO2). There is a going to be a reduced FEV1 and increased pCO2 with compromised ventilation.
What to do in surgical patient with a recent MI?
This is the second worst predictor of cardiac risk. There is a very high risk of death in surgeries with 3 months of MI. Risk drops a ton if you wait until 6 months after the MI. So try to wait. If you can’t wait then try to send them to the ICU pre-op to optimize cardiac variables.
Who should you perform a pulmonary evaluation on pre-op and what are the components of this evaluation?
You should evaluate all patients with a smoking history and/or hx of COPD. First perform - FEV1 If FEV1 is abnormal evaluate blood gases.
What should be done to prepare a smoker or COPD patient for surgery?
They should undergo… 1) 8 weeks of smoking cessation 2) intensive resp therapy including: - physical therapy - expectorants - incentive spirometry - humidified air
Best predictors of hepatic risk and related operative mortality?
Serum bilirubin Serum albumin PT time Ascites Encephalopathy If one of these is abnormal, mortality goes up to about 40% If 3 are abnormal, or bilirubin alone is above 4; albumin below 2; or blood ammonia is 150 mg/dL mortality climbs to 80-85% If all 4 of above are abnormal there is about 100% operative mortality.
About how much fluid has been lost in a patient with a serum Na of 146 meq/L if there normal is 140 meq/L?
2 liters The general rule for estimation is 1L of fluid has been lost for every 3meq/L Na above 140 meq/L.
How hypernatremia develops and what the implications are for rapid vs slow development of hypernatremia?
In general the patient is losing water or some hypotonic fluid. If hypotonic fluid loss is slow, then the brain has the ability to adapt with various mechanisms and CNS manifestations will be limited. For slow hypotonic fluid loss and hypernatremia, the fluid depletion should be rapid, but the tonicity change should be slow–therefore give patients D5(1/2NS) rather than D5W. If the hypernatremia developed rapidly then the brain cannot adapt, and CNS symptoms are present. Treat rapidly with dilute fluids–D5(1/3NS) or D5W.
In general how does hyponatremia develop? Describe the 2 main clinical scenarios in which hyponatremia develops, and how each scenario would be managed?
Hyponatremia develops from retaining water. 1st Scenario: patient starts with normal fluid volume and adds to it due inappropriate ADH (post surgery aka water intoxication; or SIADH with tumors). - Water intoxication develops rapidly as ADH is released in cases of trauma and stress. Rapid development –> CNS Symptoms. Treat with hypertonic (3 or 5%) saline. - SIADH causes slow hyponatremia and should be treated with water restriction or ADH inhibitors. 2nd Scenario: patient losing large amounts of isotonic fluid from GI and volume depletion triggers ADH release and water retention. - patient is volume depleted –> give isotonic fluids –> kidneys will safely correct tonicity.
Wound Dehiscence Post Op Day it happens on Signature finding Treatment
Typically post op day 5 Salmon colored (peritoneal) fluid draining from the site. Reoperation early on to prevent a ventral hernia, or repair of the hernia later on–meaning this is not an emergency.
GI Fistulas How they present: How they harm the patient: Treatment Things preventing them from healing
Present with bowel contents draining through a drain or wound site. They can harm patients in a number of different ways: (1) drain into a cess-pool which is subsequently draining outside–the cess pool can cause sepsis; (2) drain directly to the outside and cause fluid / electrolyte / nutritional loss; (3) damage to abdominal wall. Electrolyte, fluid and nutritional losses aren’t very severe unless there is high volume output from an upper GI (esophagus, stomach, duodenum, upper jejunem). Treatment is usually supportive and making sure the belly wall stays healthy with drains and ostomy tubing. Fluids, electrolytes, and nutritional are delivered by tube distal to the fistula. Things preventing healing go under FETIDS mnemonic: foreign body, epithelialization, tumor, infections, distal obstruction, steroids.
Define “expectant management”
Same as watchful waiting
Base of skull fractures: Signs: How to assess fracture: Should avoid…
(1) battles sign; (2) raccoon eyes; (3) rhinorrea; (4) otorrhea CT scan to assess fracture and extend to neck to assess cervical spine integrity Should avoid intubation due to cervical spine risk.
3 causes of neurologic damage from head trauma and respective management of each:
Initial blow - no tx Hematoma - surgery Increased ICP - medical management
Epidural hematoma Presentation CT findings Treatment Full blown picture?
Trauma –> LOC –> lucid –> gradual fall back into coma. Patients will have dilated pupil on side of hematoma, contra lateral weakness, decerebrate posturing. CT reveals biconvex hematoma Treat with emergent craniotomy Full blown picture would be a blown pupil and contralateral hemi paresis, but that his rare.
Penetrating Trauma to the Neck
Management:
Gunshots to the middle zone of the neck:
Surgical exploration in all causes with: (1) expanding hematoma; (2) deteriorating vitals; (3)
Fat Embolism
Presentation
Diagnosis
Treatment
Respiratory distress in a multiple trauma patient with long bone fractures. Syndrome includes (1) drop in platelets, (2) patchy bilateral infiltrates on CXR, (3) petechial rashes, (4) fever, (5) tachycardia, (6) hypoxemia.
Diagnosis is not crucial, but can be confirmed with fat droplets in the urine.
Treatment is respiratory support alone.
GSW to the abdomen:
Management
Exceptions
Management is usually exploratory laparatomy.
Sometimes with low caliber gunshots to the RUQ can be treated conservatively if they are clinically and readiographically monitored.
Stab Wounds
Management
Perform ex-lap if there is (1) full penetration into the peritoneal space (usu. determined by evisceration); (2) hemodynamic instability; (3) peritoneal signs.
If the above are absent insert a gloved finger to assess damage. If you cannot assess the damage then move onto a CT scan.
Degree of trauma with epidural hematoma:
Small
Acute Subdural Hematoma
Presentation
Management
Patients usually have a relatively severe trauma and have more severe neurological deficits than in an epidural hematoma. The patients are often not fully awake.
Management depends on the clinical picture. If there is herniation, then a craniotomy should be done–but the prognosis is poor. If there is no herniation, then management is primarily to reduce ICP.
Methods used to reduce ICP:
Elevated head
Mannitol and furosemide
Hyperventilation to 35 mmHg
Sedation
Hypothermia
Diffuse axonal injury
Presentation
Management
Severe trauma. CT reveals blurring of the gray white interface and multiple punctate hemorrhages.
If there is no hematoma, then there is no surgery–instead tx is focused on limiting ICP elevation.
Chronic subdural hematoma
Presentation
Pathophys
Management
Elderly patients who somehow got head rattled around. There will be gradually deteriorating mental function.
Head getting rattled around causes tearing of the bridging veins and there is a subdural.
Craniotomy with drainage.
Penetrating neck wound management
Upper Neck: arteriographic diagnosis and management
Middle Neck: surgical exploration if there is (1) expanding hematoma; (2) Hemodynamic instability; (3) Clear signs of esophageal or tracheal injury.
Lower Neck: Arteriography; gastrograffin esophogram; esophagoscopy; bronchoscopy.
Asymptomatic wounds to the upper and middle zones can be treated with expectorant management.
Indications for cervical spine CT in blunt trauma:
Blunt trauma to the neck with neurological deficits
Blunt trauma to the neck with no neuro deficits but tenderness upon palpation.
CT is the best modality for assessing the cervical spine.
Brown-Sequard
Cause
Presentation
Clean cut knife injury to the back
Paralysis and loss of propioception distal to the injury on the contralateral side. Loss of pain perception distal to the injury on the ipsilateral side.
Anterior Cord Syndrome
Causes
Presentation
Caused by burst fractures of the vertebral bodies + anterior spinal artery occlusion.
Patients will present with paralysis and loss of pain perception distal to the lesion and typically maintenance of propioception. In occlusion of the Artery of Adamkiewicz there is often loss of urinary and fecal continence since it supplies much of the lumbo-sacral spinal cord.
Central Cord Syndrome
Causes
Presentation
Caused by forced hyperextension or cervical syringomyelia (cyst). Typically in the cervical region.
Patients will have cape like distribution of burning and paralysis in the upper extremities and completely normal functioning in the lower extremities.
Management of Spinal cord Syndromes:
Take MRI (or CT if you want to focus on the bone)
High dose corticosteroids immediately after the injury
Surgical therapy for hemothorax
When it is indicated
Which procedure
(1) Indicated if there is 1200 ml of blood when chest tube is placed. (2) If there is over 600 ml of blood over the course of 6 hours
Thoracotomy
Pulmonary contusion
How it happens:
Signs:
Happens with severe blunt trauma to the chest
Altered ABGs, finding on CXR
Management of flail chest:
Flail chest happens from big traumas and therefore you need to be on the look-out for other pathologies. For instance:
check ABGs and get CXR to assess for a pulmonary contusion. If contusion is suspected patient should be fluid restricted and diuresed.
If patient is in respiratory distress and needs mechanical ventilation, place bilateral chest tubes to prevent tension PTX from potential lung punctures by the fractured ribs.
Look for traumatic transection of the aorta.
Traumatic rupture of diaphragm
Clinical features
Management
Bowel found in the chest, both by phsyical exam and CXR
All suspicious cases eval by laparoscopy. Surgical repair through the abdomen.
Traumatic Rupture of the Aorta
Presentation / Clinical Features
Pathophysiology / Pathogenesis
Management / Treatment
Patients present following major deceleration injury or massive chest wall injury. *Also have fractures to bones very hard to break (sternum, scapula, first rib) **CXR will revealed a wide mediastinum
Caused by deceleration injuries or major trauma to the chest wall. Hematoma forms and contained by adventitia for some period of time and at some point bursts and kills patient.
Management: evaluate with transesophageal echo, CT angio, or MR angio. CT angio is the best.
DDx SubQ Emphysema
Traumatic rupture of trachea or bronchus
Esophageal perforation (iatrogenic)
Tension PTX (shock and resp failure are more of a concern)
Diagnosis and management of ongoing significant pelvic bleed.
Diagnosis: signs of hypovolemia with no evidence of abdominal bleeding (by DPL, FAST, or CT) and evidence of a large pelvic hematoma.
Management: Blood replacement first, followed by external fixation. Arterial embolization of both internal iliacs if there is arterial bleeding, and pelvic fixators
Urologic injuries assocated with lower rib fractures or pelvic fractures:
Lower rib: Kidney
Pelvic: Bladder or urethra
