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Surgery > Pestana Surgery > Flashcards

Pestana Surgery Flashcards

1
Q

What are 2 criteria that prove a patient’s airway is patent?

A
  1. Conscious

2. Speaking in normal tone of voice

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2
Q

What are 4 criteria in which a patient will need an airway placed?

A
  1. Unconscious (GCS <8)
  2. Noisy or gurgling breathing
  3. Severe inhalation injury
  4. Necessary to connect them to respirator
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3
Q

What is the most commonly used method of intubation?

A

Orotracheal intubation with laryngoscope

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4
Q

What type of intubation is necessary when there is subcutanous emphysema in the neck?

A

Nasotracheal intubation with fiberoptic bronchoscope

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5
Q

If a patient has severe maxillofacial injuries or an impacted foreign body, which type of intubation is preferred?

A

Cricothyroidotomy

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6
Q

Under what age is cricothyroidotomy avoided?

A

Under 12

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7
Q

What are the 2 criteria in establishing adequate breathing?

A
  1. Lung sounds on both sides of chest

2. Satisfactory pulse ox

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8
Q

What are 3 clinical signs of shock?

A
  1. SBP <90
  2. Fast, feeble pulse
  3. UO <0.5 mL/kg/hr
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9
Q

What is the urine output volume that defines shock?

A

Less than 0.5 mL/kg/hr

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10
Q

What are the 3 most common causes of shock in the trauma setting? How would you distinguish between the 3?

A
  1. Hemorrhage/hypovolemic (low CVP)
  2. Tamponade/cardiogenic (high CVP)
  3. Tension pneumothorax (high CVP + resp distress)
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11
Q

What are 5 features of tension pneumothorax?

A
  1. High CVP
  2. Resp distress
  3. No breath sounds on affected side
  4. Hyperressonance to percussion on affected side
  5. Mediastinum shifted to opposite side
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12
Q

What is the criteria for volume resuscitation in hemorrhagic shock from a trauma?

A

Start with 2 L LRs (without glucose), then pRBCs until urinary output is 0.5-2 mL/kg/hr and CVP doesn’t exceed 15 mmHg

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13
Q

What is the preferred method of IV access for fluid resuscitation in a trauma setting?

A

2 large-bore (16 gauge) peripheral lines

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14
Q

If peripheral IV access cannot be obtained in a trauma setting, what are 3 other options for access?

A
  1. Percutaneous femoral vein catheter
  2. Saphenous vein cut-down
  3. Intraosseus cannulation of prox tibia in kids <6
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15
Q

What is the preferred imaging modality to diagnosing pericardial tamponade?

A

Bedside US

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16
Q

What are the steps to managing pericardial tamponade?

A
  1. Clinical suspicion
  2. Confirm with bedside US
  3. Fluid and blood resuscitation
  4. Pericardiocentesis
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17
Q

What is the management of tension pneumothorax?

A
  1. Clinical suspicion
  2. DO NOT DO IMAGING or ABG
  3. Large needle or IV catheter into pleural space (anterior, high)
  4. Place chest tube connected to underwater seal
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18
Q

What are 5 causes of hypovolemic shock?

A
  1. Hemorrhage
  2. Burns
  3. Peritonitis
  4. Pancreatitis
  5. Massive diarrhea
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19
Q

What is the CVP in spinal cord shock?

A

Low

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20
Q

What is the CVP in hypovolemic shock? Spinal cord shock? Cardiogenic? Septic?

A

Hypovolemic - low
Spinal cord - low
Cardiogenic - high
Septic - low

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21
Q

What is the definitive treatment for spinal cord shock?

A

Vasopressors

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22
Q

Treatment of penetrating skull injury

A

Surgery

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23
Q

Treatment of penetrating head trauma

A

Surgery

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24
Q

Treatment of skull fractures

A

If closed, nothing
If open, close wound
If comminuted, surgery

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25
Q

Who gets a CT of the head in trauma?

A

Anyone who loses consciousness

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26
Q

Signs of skull base fracture

A

Periorbital ecchymoses
Rhinorrhea
Otorrhea
Ecchymoses behind the ear

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27
Q

What is the next step if skull base fracture suspected?

A

Assess C-spine with CT

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28
Q

What kind of head trauma results in LOC then a lucid interval and gradual lapsing into coma?

A

Acute epidural hematoma

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29
Q

What are the CT findings in acute epidural hematoma?

A

Biconvex, lens shaped (football)

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30
Q

What is the treatment of epidural hematoma?

A

Craniotomy

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31
Q

Which head bleed presents with loss of consciousness with no lucid interval?

A

Acute subdural hematoma

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32
Q

What are the CT findings of an acute subdural bleed?

A

Semilunar, crescent-shape

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33
Q

What is the treatment for acute subdural hematoma?

A

If midline deviation- craniotomy

If no midline deviation- prevent damage from inc ICP

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34
Q

What are 7 ways to manage increased ICP?

A
  1. Mannitol
  2. Furosemide
  3. Elevate head
  4. Hyperventilate to PCO2 35, if herniation
  5. Avoid fluid overload
  6. Sedation
  7. Hypothermia
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35
Q

When should hyperventilation be started in head bleeds?

A

In acute subdural bleeds when evidence of herniation

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36
Q

What are the CT findings of diffuse axonal injury?

A

Blurring of gray-white interface + multiple small punctate hemorrhages

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37
Q

Blurring of gray-white interface + multiple small punctate hemorrhages

A

Diffuse Axonal Injury

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38
Q

Treatment of DAI?

A

Preventing further damage from increased ICP

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39
Q

What is the diagnosis and treatment of chronic subdural bleeds?

A

Dx – non-con CT

Tx – surgery

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40
Q

What are the 3 cases in which a penetrating neck injury is treated with emergent surgical exploration?

A
  1. Expanding hematoma
  2. HD instability
  3. Esophageal or tracheal injury (coughing up blood)
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41
Q

What is the treatment for gunshot wound to upper zone of the neck?

A

Arteriogram

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42
Q

What is the treatment for gunshot wound to the base of the neck?

A

Arteriogram –> esophagogram –> esophagoscopy and bronchoscopy –> surgery

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43
Q

What is the treatment of uncomplicated stab wounds to the upper and middle zones of the neck?

A

Observation

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44
Q

What is the next best step in blunt trauma to the neck?

A

CT cervical spine

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45
Q

What are the findings associated with hemisection of the spinal cord leading to Brown-Sequard syndrome?

A

Loss of motor and propioception on SAME side as injury

Loss of pain on OPPOSITE side as injury

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46
Q

What is a consequence of burst fractures of vertebral bodies?

A

Anterior cord syndrome – loss of pain and motor BILATERALLY with preserved vibration/propioception (dorsal columns).

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47
Q

What injury is associated with central cord syndrome? What results?

A

Elderly with forced hyper extension of the neck (whiplash) causing paralysis and burning pain in BILATERAL upper extremities

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48
Q

What is the best way to diagnose spinal cord injuries?

A

MRI

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49
Q

What is the treatment of rib fractures in elderly?

A

Local nerve block + epidural catheter

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50
Q

What are the clinical signs of pneumothorax?

A
  1. Shortness of breath
  2. Decreased breath sounds on affected side
  3. Hyperresonant to percussion on affected side
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51
Q

Best way to dx and treat pneumothorax

A

Dx – CXR

Tx – chest tube (2nd IC space) connected to underwater seal

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52
Q

Clinical signs of hemothorax

A
  1. Shortness of breath
  2. Decreased breath sounds on affected side
  3. Dull to percussion on affected side
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53
Q

What is the best way to dx and treat a hemothorax?

A

Dx – CXR

Tx – chest tube (5th ICS) and rarely surgery

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54
Q

What are the indications for surgery in hemothorax?

A
  1. > 1500 mL output when chest tube inserted
  2. > 600 mL output over 6 hours
  3. When a systemic vessel is source of bleeding
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55
Q

Dx of pulmonary contusion

A

CXR, ABG

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56
Q

Dx of myocardial contusion

A

Troponins, EKG

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57
Q

What is the giveaway for a flail chest?

A

Paradoxical breathing – chest wall goes IN with inspiration and OUT with expiration

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58
Q

What is the treatment for pulmonary contusion?

A
  1. Fluid restriction
  2. Diuretics
  3. Monitor ABGs
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59
Q

How do you treat myocardial contusions

A

Treat complications like arrythmias

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60
Q

Tx of diaphragmatic rupture

A

Ex-lap

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61
Q

Where is the most common location of traumatic rupture of the aorta?

A

Junction of arch and descending aorta

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62
Q

Why is an aortic rupture injury the “hidden injury?”

A

Asymptomatic until hematoma in the adventitia blows up and patient dies

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63
Q

What signs may indicate aortic rupture?

A

Deceleration injury
Fractures in first rib, scapula, sternum
Widened mediastinum in CXR

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64
Q

What is the best test for traumatic aortic rupture?

A

CT angiogram

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65
Q

What injury occurred if there is subcutaneous emphysema in upper chest or lower neck?

A

Rupture of trachea or bronchus
Rupture of esophagus
Tension pneumothorax

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66
Q

What is the dx and treatment of trachea or bronchus rupture?

A

Dx – CXR and fiberoptic bronchoscopy

Tx – Intubation and surgery

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67
Q

What is the most likely cause of a sudden death in a patient with chest trauma who is intubated and on respiratory?

A

Air embolus

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68
Q

What are the risks of air embolism?

A
  1. Chest trauma
  2. Intubation and respirator
  3. Supraclavicular lymph node biopsies
  4. CV lines
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69
Q

What is the management of air embolus?

A

Immediate cardiac massage with left side down

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70
Q

What are the signs of a fat embolism?

A
  1. Long bone fractures
  2. Petechiae
  3. Thrombocytopenia
  4. Tachycardia
  5. Fever
  6. Resp distress
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71
Q

What is the treatment of fat embolism?

A

Respiratory support

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72
Q

Management of gunshot wound to abdomen

A

Ex-lap

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73
Q

What is the mgmt of stab wound to the abdomen?

A

If viscera seen, HD unstable, peritoneal = ex-lap
If none of above, digital exploration of wound and observation
If above fails, CT scan

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74
Q

What are some signs of internal bleeding?

A
  1. Drop in SBP
  2. Fast pulse
  3. Low CVP
  4. Low UO
  5. Cool extremities
  6. Pale, diaphoretic
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75
Q

What percent of blood loss must occur before shock sets in?

A

25-30% of total blood volume (about 1.5 L)

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76
Q

Where are the 3 locations that most commonly hide a massive amount of hemorrhage?

A
  1. Abdomen
  2. Pelvis
  3. Upper legs
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77
Q

What is the MOST accurate method of detecting intra-abdominal hemorrhage?

A

CT scan

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78
Q

Who needs urgent ex-lap for intra-abdominal bleeding?

A
  1. Peritoneal signs
  2. Major injuries seen on CT scan (done if HD stable)
  3. HD instability not improving with fluids
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79
Q

When do you do a CT abd in the setting of abd trauma?

A

If patient is hemodynamically stable

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80
Q

What is the workup of intra-abd bleeding?

A

If HD stable – CT abd

If HD unstable – FAST scan then ex-lap if FAST pos

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81
Q

What is the most likely source of clinically significant traumatic intra-abd bleeding?

A

Ruptured spleen

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82
Q

What is the treatment of ruptured spleen?

A

Repair > removal + post-op immunization for strep pneumo, HiB, meningococcus

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83
Q

What is the treatment of intraoperative development of a coagulopathy during abd surgery for trauma?

A

Platelet packs + FFP

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84
Q

What are 3 signs of abdominal compartment syndrome?

A
  1. Abd distension with sutures cutting tissue
  2. Hypoxia from difficulty breathing
  3. Acute renal failure from IVC compression
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85
Q

What is the treatment for a non-complicated pelvic hematoma?

A

Leave it alone

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86
Q

What is the management of expanding pelvic hematoma?

A

Pelvic fixation and to IR for angiographic embolization

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87
Q

Treatment of penetrating urologic injuries

A

Surgical exploration

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88
Q

What are 4 clinical signs of urethral injury in men?

A
  1. Blood at meatus
  2. High-riding prostate
  3. Feeling urge to void
  4. Scrotal hematoma
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89
Q

Next step in suspected urethral injury?

A

Retrograde urethrogram

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90
Q

What are urethral injuries commonly caused by?

A

Pelvic fractures

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91
Q

Best test to diagnose bladder injuries?

A

Retrograde cystogram

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92
Q

Treatment of bladder injuries

A

Extraperitoneal leak – Foley

Intraperitoneal leak – surgery and suprapubic cystostomy

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93
Q

How are renal injuries diagnosed and treated?

A

Dx – CT abd/pelvis

Tx – observation

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94
Q

What are 2 rare complications of kidney injury?

A

AV fistula leading to CHF

Renal stenosis causing HTN

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95
Q

Treatment of penetrating ext injuries

A
  1. Assess vascular status
  2. If no vas injuries, give tetanus and clean wound
  3. If vasc injuries but asx, CT angio or Doppler US
  4. If vasc injuries and pt is sx, surgery
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96
Q

What is the order of repair of vessels, nerves, bone?

A

Bone –> vessels –> nerves –> fasciotomy

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97
Q

What is the treatment of a crush injury?

A
  1. IVF + osmotic diuretics + alkalinize the urine to prevent hyperK, myoglobinuria and renal failure
  2. Fasciotomy to prevent compartment syndrome
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98
Q

Which is worse, alkaline or acid burns?

A

Alkaline

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99
Q

What is the treatment for chemical burns?

A

Irrigation with water

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100
Q

What is the biggest concern with high-voltage electrical burns? How is it treated?

A

Myoglobinemia –> myoglobinuria –> renal failure

Treat with IVF, osmotic diuretics, alkalinize urine

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101
Q

What are 5 complications of high-voltage electrical burns?

A
  1. Myoglobinuria causing acute renal failure
  2. Posterior dislocation of shoulder
  3. Compression fractures of vertebral bodies
  4. Cataracts
  5. Demyelinization syndromes
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102
Q

Treatment of inhalation injuries

A
  1. Assess need for intubation via ABGs
  2. Give O2 if carboxyhgb levels elevated
  3. Confirm with fiberoptic bronchoscopy
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103
Q

What is the risk of circumferential burns of the extremities and chest? What is the treatment?

A

Development of eschars that cut off blood supply

Treat with bedside escharotomies

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104
Q

What are the fluid resuscitation parameters for burn patients?

A

Resuscitate with 1 L LRs (no sugar) with pts >20% body surface burned to urine output of 1-2 cc/kg/hr while keeping CVP <15 mmHg

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105
Q

What are the fluid resuscitation parameters for babies with burns?

A

If burn >20% then start at 20 cc/kg/hr

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106
Q

Besides fluid resuscitation what are the steps in treating extensive burns (>20%)?

A
  1. IVF
  2. Tetanus ppx
  3. Clean burned area
  4. Silver sulfadiazine or mefenide acetate if cartilage involved
  5. NGT suction for 1-2 days then tube feeds with high calorie, high nitrogen diet
  6. After 2-3 weeks, skin grafts done
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107
Q

How are smaller burns (<20%) treated?

A

Early excision and grafting

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108
Q

How do you treat provoked dog bites?

A

Observe dog for signs of rabies

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109
Q

What is the treatment of snake bites?

A
  1. Draw blood for T&S
  2. Get coags, LFTs, BMP
  3. Administer antivenin
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110
Q

Treatment of bee stings

A
  1. Epinephrine

2. Remove stingers

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111
Q

Treatment of black widow spider bites

A

IV calcium gluconate

Muscle relaxants

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112
Q

Treatment for brown recluse spider bites

A

Dapsone and surgical excision

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113
Q

Treatment of human bites

A

Surgical I&D

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114
Q

What is the diagnosis of DDH in a newborn?

A
  1. Clinical – Ortolani/Barlow, uneven gluteal folds

2. Confirm with ultrasound (NOT x-rays)

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115
Q

Tx of DDH in newborn

A

Abduction splinting in Pavlik harness for 6months

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116
Q

Insidious limping, hip pain and decreased hip motion in a 6 yr old

A

Leg-Calve-Perthes (AVN of capital femoral epiphysis)

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117
Q

How do you dx Legg-Calves-Perthes?

A

AP and lateral x-rays show flattened femoral head

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118
Q

How do you treat Legg-Calves-Perthes?

A

Casting and crutches to contain femoral head in acetabulum

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119
Q

Chubby young boy with groin pain, limp, decreased ROM at the hip

A

SCFE

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120
Q

Dx of SCFE

A

X-rays

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121
Q

Tx of SCFE

A

Orthopedic emergency – pin the femoral head back in place

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122
Q

What is the classic picture of a pediatric septic hip?

A

Toddler with febrile illness who holds hip flexed, abducted and externally rotated

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123
Q

What is the diagnosis of septic hip?

A

Aspirate hip

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124
Q

What is the dx of a septic hip?

A

I&D + abx

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125
Q

For how long is varus normal in a child?

A

Normal until 3

Blount disease if persists after 3 (surgery needed)

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126
Q

For which ages is valgus normal for kids?

A

Between 4-8

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127
Q

Features of Osgood-Schlatter’s Disease

A
  1. Teenagers
  2. Persistent pain over tibial tubercle
  3. Pain worse with activation of quads
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128
Q

What is the treatment of Osgood-Schlatter’s Disease?

A
  1. RICE

2. If refractory, extension or cylinder cast for 4-6 weeks

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129
Q

What is the treatment for clubfoot in newborns?

A
  1. Serial plaster casts

2. If refractory by 9-12mo, Achilles tenotomy and long-term braces

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130
Q

Treatment of scoliosis

A
  1. Bracing to prevent progression

2. If refractory, surgery

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131
Q

Which fractures in children are most concerning and may require surgical intervention instead of reduction and casting?

A

Supracondylar fractures of humerus

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132
Q

Child falls onto hand with hyperextended elbow

A

Supracondylar fracture of humerus

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133
Q

What is the most important complication of supracondylar fractures of humerus in kids?

A

Volkmann Contracture

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134
Q

How are growth plate fractures treated?

A

If epiphyses and growth plate displaced but in one piece, closed reduction

If epiphyses and growth place in two pieces, ORIF

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135
Q

What are features of primary malignant bone tumors?

A

Persistent achy pain for months
Invasion of soft tissues
Sunburst appearance
Periosteal onion-skinning

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136
Q

What is the MC primary malignant bone tumor? Where is it usually located?

A

Osteogenic sarcoma, around knee, sunburst pattern

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137
Q

What bone tumor in children is common? Where is it located?

A

Ewing sarcoma, diaphysis of long bones

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138
Q

What is the most common bone tumor in adults?

A

Mets (breast, prostate)

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139
Q

Bone x-rays with multiple punched-out lytic lesions

A

Multiple myeloma

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140
Q

Treatment for multiple myeloma

A
  1. Chemo

2. Thalidomide

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141
Q

Most common location for sarcoma mets?

A

Lungs

NEVER lymph nodes

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142
Q

Best diagnosis of sarcoma

A

Incisional biopsy

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143
Q

Treatment of sarcomas

A

Very wide local excision –> XRT and chemo

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144
Q

Treatment of clavicle fractures

A

Figure of Eight sling

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145
Q

What nerve is potentially damaged from anterior shoulder dislocations?

A

Axillary

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146
Q

Colles fracture

A

Dorsally displaced fracture of distal radius in elderly women who fall on outstretched hand

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147
Q

Tx of Colles fracture

A

Closed reduction, long-arm cast

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148
Q

Monteggia fracture

A

Diaphyseal fracture of proximal ulna and anterior dislocation of radial head due to blow to ulna

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149
Q

Galeazzi fracture

A

Distal radius fracture with dorsal dislocation of distal radioulnar joint

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150
Q

Tx of Monteggia fracture

A

ORIF for broken bone

Closed reduction of dislocation

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151
Q

Tx of Galeazzi fracture

A

Closed reduction of dislocation

ORIF of broken bone

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152
Q

Young adult falls on outstretched hand

A

Scaphoid fracture

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153
Q

Dx of scaphoid fractures

A

Initially – clinical (wrist pain, TTP of snuffbox)

Later – X-rays

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154
Q

Treatment of scaphoid fractures

A

If undisplaced – thumb spica cast

If displaced – ORIF due to non-union rates

155
Q

Closed fist hits a hard surface

A

Metacarpal neck fractures

156
Q

Position of patient during hip fracture

A

Shortened and ext rotated limb

157
Q

Tx of femoral neck fractures

A

Replace femoral head with prosthesis

158
Q

Tx of intertronchanteric fractures

A

ORIF + post-op anticoagulation

159
Q

Tx of femoral shaft fractures

A

If HD unstable, ex-fix and then IM nailing when stable
If open, orthopedic emergency - I&D and closure in 6 hrs
If closed and stable - IM nailing

160
Q

Treatment of tibial stres fractures

A

Cast and crutches, repeat x-ray in 2 weeks

161
Q

MC locations of compartment syndrome

A

Forearm

Lower leg

162
Q

Patient position with a posterior hip dislocation

A

Leg shortened, adducted, internally rotated

163
Q

Tx of gas gangrene

A

IV penicillin
Emergent I&D
Hyperbaric oxygen

164
Q

Tx of necrotizing fasciitis

A

Repeated, massive excisions of necrotic tissue

Broad spectrum abx

165
Q

What nerve is injured in mid-shaft humerus fractures? Deficits?

A

Radial nerve

Loss of extension of wrist

166
Q

What is injured in posterior dislocations of the knee?

A

Popliteal artery

167
Q

Fractures with fall from height

A

Feet, leg

Lumbar or thoracic spine

168
Q

Fractures with head-on MVC

A

Face, head

Femoral head/neck if knees hit dashboard

169
Q

Tx of carpal tunnel

A

Splints, NSAIDs, EMGs and then surgery

170
Q

Tx of trigger finger

A

Steroid injection and then surgery

171
Q

What is a felon and what is the treatment?

A

Abscess in the pulp of a fingertip

I&D

172
Q

Gamekeeper thumb

A

Injury of ulnar collateral ligament from forced hyperextension of the thumb, requires casting to prevent arthritis

173
Q

Jersey vs Mallet finger

A

Jersey– injury to flexor tendon when flexed finger forcefully extended
Mallet– injury to extensor tendon when extended finger forcefully flexed

174
Q

How can you differentiate between herniated disc and spinal stenosis pain?

A

Herniated disc pain is exacerbated by coughing, sneezing or defecating (from increased pressure)

175
Q

Cauda equina syndrome

A

Distended bladder
Flaccid rectal sphincter
Perineal saddle anesthesia

176
Q

Ulcers located on pressure points

A

Diabetic ulcers

177
Q

Location of arterial ulcers

A

Tips of toes

178
Q

Dx of arterial ulcers

A

Clinical, Doppler

179
Q

Tx of arterial ulcers

A

Fix PVD – angioplasty and stents

180
Q

Location of venous stasis ulcers

A

Medial malleolus

181
Q

What kinds of people get venous stasis ulcers

A

Pts with chronic lower ext edema, varicose veins

182
Q

Dx of venous ulcers

A

Duplex

183
Q

Tx of venous ulcers

A

Support stockings then surgery

184
Q

Marjolin ulcers

A

SCC of skin in chronic ulcers, wounds, burns, chronic draining sinuses from osteomyelitis

185
Q

Dx of marjolin ulcers

A

Biopsy

186
Q

Tx of marjolin ulcers

A

Wide local excision and skin grafts

187
Q

Plantar fasciitis

A

Sharp heel pain on every foot strike that is worse in AM and may be caused by a bone spur

188
Q

Tx of plantar fasciitis

A

Should resolve in 12-18 months, surgery to remove bone spur may help

189
Q

Morton neuroma

A

Inflammation of common digital nerve at the 3rd interspace between 3rd and 4th toes caused by toes that get squished in shoes

190
Q

Acute tx of gout

A

Indomethacin + colchicine

191
Q

Chronic control of gout

A

Allopurinol + probenecid

192
Q

At what EF are non-cardiac surgeries contraindicated?

A

EF <35%

193
Q

What are risk factors for intra-op cardiac events used in preop assessment?

A 
JVD
Recent MI
PVCs or arrhythmia
Age >70
Emergency surgery 
Aortic stenosis
Poor health
Chest or abd surgery
194
Q

What is the WORST single finding predicting high cardiac risk?

A

JVD

195
Q

4 drugs used to pre-treat someone with elevated JVP from CHF prior to surgery

A
  1. Beta blockers
  2. Digitalis
  3. ACEIs
  4. Diuretics
196
Q

How should a patient with COPD or smoking history be evaluated preoperatively?

A

Obtain FEV1 then ABGs

197
Q

When should smoking cessation occur prior to surgery?

A

8 weeks

198
Q

What are 5 parameters used to predict risk in patients with liver disease?

A
  1. Encephalopathy
  2. Ascites
  3. Serum albumin
  4. INR
  5. Bilirubin
199
Q

What are the 4 parameters of severe nutritional depletion?

A
  1. Loss of >20% body weight in few months
  2. Albumin <3
  3. Anergy to skin antigens
  4. Transferrin <200
200
Q

What should you do preoperatively for someone with severe nutritional deficiencies?

A

At least 4-5 (7-10 better) of enteric feeds

201
Q

Intra-op fever

A

Malignant hyperthermia

202
Q

What are 2 metabolic derangements that occur with malignant hyperthermia?

A
  1. Metabolic acidosis

2. Hypercalcemia

203
Q

Treatment of malignant hyperthermia

A
  1. IV dantrolene
  2. 100% O2
  3. Correct acidosis
  4. Cooling blankets
204
Q

Fever within 30-45 minutes of invasive procedures

A

Bacteremia with chills, fever

Get blood cx and start empiric abx

205
Q

Causes of post-op fever temporally

A

Atelectasis –> pneumonia –> UTI –> DVT/PE –> wound –>abscesses

206
Q

Fever on post-op day 1

A

Atelectasis

207
Q

Dx and tx of atelectasis

A
  1. CXR

2. Incentive spirometry and if refractory, bronchoscopy

208
Q

What is the sequelae of untreated atelectasis?

A

Pneumonia

209
Q

Fever on POD3

A

Pneumonia or UTI

210
Q

Dx and tx of post-op pneumonia

A
  1. CXR and sputum culture

2. Abx 1

211
Q

Dx and Tx of post-op UTI

A

Dx – UA with culture

Tx – abx

212
Q

Fever on POD5

A

DVT

213
Q

Dx and Tx of DVT

A

Dx – Doppler

Tx – heparin drip

214
Q

Fever on POD7

A

Wound infection

215
Q

Dx and Tx of wound infection

A

Dx – clinical

Tx – IV abx if cellulitis, I&D if abscess

216
Q

Fever on POD10-15

A

Deep abscess

217
Q

Dx and Tx of post-op abscess

A

Dx – CT scan

Tx – percutaneous IR guided drainage

218
Q

What causes an MI intraoperatively?

A

Hypotension

219
Q

When does post-op MI typically occur?

A

POD2-3

220
Q

Treatment of post-op MI

A

Stents

NOT tPA

221
Q

When do PEs typically occur post-operatively?

A

POD7

222
Q

Physical exam findings of PE

A
  1. Pleuritic chest pain
  2. SOB
  3. Anxious, diaphoretic patient
  4. Tachycardia
  5. Elevated JVP
  6. Hypoxia and hypocapnia
223
Q

Dx and Tx of PE

A

Dx – spiral CT/CT angio

Tx – IV heparin drip or IVC filter if anticoagulation contraindicated or PEs recur while on heparin

224
Q

Risk factors for DVT/PE

A
  1. Patients >40
  2. Immobilization
  3. Pelvis or leg fractures
  4. Venous injury
  5. Femoral venous catheter
225
Q

What are the signs of intraoperative tension pneumo?

A

Hypotensive with elevated CVP and more difficult to bag

226
Q

How is an intraoperative tension pneumo treated?

A

If abdominal surgery, can needle decompress via diaphragm

If non-abdominal surgery, can needle decompress via 2nd IC space

227
Q

What is the FIRST thing to be suspected in a post-op patient who is confused and disoriented?

A

Hypoxia

228
Q

Tx of ARDS

A

PEEP at low volumes

229
Q

When is the onset of DTs?

A

2-3 days post-op

230
Q

What is the treatment for DTs?

A

IV benzos or IV alcohol (5% in D5)

231
Q

Cause of rapid, acute post-op hyponatremia

A

Giving Na-free IVF (like D5) in post-op patients who already have high ADH

232
Q

When should a patient be straight cath’d post-op if no urine output? When does a Foley go in?

A

After 6 hours of not voiding

After 2-3 repeated straight cath without spontaneous void

233
Q

What is the MCC of Anuria?

A

Plugged or kinked Foley

234
Q

What are the 2 causes of post-op oliguria in someone with normal perfusion (not in shock)? How can they be distinguished?

A
  1. Fluid deficit
  2. Acute renal failure
    500cc fluid bolus challenge – after 20 min, dehydrated patients will have temporary increase in UO and patients with ARF won’t
235
Q

When is the differentiation between post-op ileus vs SBO?

A

Ileus is painless and normal with first few days, but if it doesn’t resolve after 5-7 days it is most likely an early SBO

236
Q

Dx and tx of post-op SBO

A
  1. KUB – dilated SB and air-fluid levels
  2. Confirm with CT abd to find transition point

Tx – surgery

237
Q

Ogilivie Syndrome

A

Paralytic ileus of the colon that happens in elderly, sedentary patients who have had surgery anywhere OTHER THAN the abdomen

238
Q

Tx of Ogilvie syndrome

A
  1. Fluid and electrolyte correction

2. Colonoscopy with rectal tube

239
Q

When does wound dehiscence typically occur?

A

POD5

240
Q

What is the sign of wound dehiscence?

A

Pink, “salmon-colored” fluid (peritoneal fluid) leaking out of wound

241
Q

Tx of wound dehiscence

A
  1. Securely tape and bind wound

2. Prompt reoperation to prevent evisceration and hernia

242
Q

What is the tx of wound evisceration

A
  1. Keep pt immobilized
  2. Cover bowel with warm, sterile, saline-soaked dressing
  3. Emergency closure
243
Q

What are the 2 ways in which fluid leaks out of post-op fistulas?

A
  1. Leaks into cesspool that sits and slowly leaks out – sepsis
  2. Leaks directly out
244
Q

3 problems with post-op fistulas

A
  1. Fluid, electrolyte imbalance
  2. Nutritional depletion
  3. Erosion of abdominal wall
245
Q

Tx of post-op fistulas

A
  1. IVF and electrolytes
  2. Elemental nutrition PAST fistula
  3. Suction tubes and ostomy bags to protect abd wall
246
Q

What are factors that prevent natural healing of post-op fistulas?

A

FETIDS – foreign body, epithelialization, tumor, infection/irradiated tissue/IBD, distal obstruction, steroids

247
Q

How does a post-op patient become hypernatremia?

A

Patient losing free water – every 3 mEq of Na above 140 = 1 L of H20 lost

248
Q

Tx of hypernatremia

A

D5 1/2NS to volume replete but SLOWLY replete tonicity

249
Q

What are the 2 causes of hyponatremia in post-op patients?

A
  1. SIADH (may be normal state or malignancy)
  2. If pt is losing large amts of isotonic fluid via GI tract, they will retain water if not replaced with isotonic fluids
250
Q

Tx of hyponatremia

A

Acute hyponatremia w/sx – hypertonic 3 or 5% NS slowly
Chronic hyponatremia – fluid restrict
Acute dehydrated pt losing GI fluids – isotonic fluids to correct hypovolemia (NS if alkalotic, LR if acidotic or normal pH)

251
Q

3 causes of post-op hypokalemia

A
  1. GI losses
  2. Loop diuretics
  3. Increased Aldo from stress response
252
Q

Causes of hyperkalemia postop

A
  1. Renal failure
  2. Aldosterone antagonists
  3. Crush injuries
  4. Tissue ischemia
  5. Acidosis
253
Q

Treatment of hyperkalemia

A
  1. IV calcium
  2. D50 + insulin
  3. NGT suction or resins (kayexalate)
  4. Dialysis
254
Q

Causes of post-op acidosis

A
  1. Excess production – DKA, lactic, low-flow states
  2. Loss of buffers – loss of bicarb in GI tract
  3. Inability to excrete acid – kidney failure
255
Q

When do we order X-rays?

A

Broken or dislocated bones
CXR
KUB

256
Q

Dx of carcinoid

A

Urinary 5HIAA

257
Q

Right-sided colon cancer presents how?

A

Iron-deficiency anemia and occult blood loss

258
Q

How is right-sided colon cancer diagnosed?

A

Colonoscopy with biopsy

259
Q

How does left-sided colon cancer present?

A

Decreased stool caliber
Bloody stool
Constipation

260
Q

Dx of left-sided colon cancer

A

Flexible sigmoidoscopy and then colonoscopy prior to resection

261
Q

What are 5 indications for colectomy in UC?

A
  1. Disease >20 yrs
  2. Nutritional depletion
  3. Multiple hospitalizations
  4. Need for steroids or immunosuppressants
  5. Toxic megacolon
262
Q

Best dx test for C.diff

A

Stool C.diff toxin assay

263
Q

Best tx for C.diff

A

Metronidazole

264
Q

When does C.diff infection require colectomy?

A
  1. Refractory to treatment
  2. WBC >50
  3. Lactate >5
265
Q

Which hemorrhoids hurt?

A

External

266
Q

Which hemorrhoids bleed?

A

Internal

267
Q

How are internal hemorrhoids treated?

A

rubber band ligation

268
Q

Where are anal fissures most commonly located?

A

Posterior midline

269
Q

What is the cause of anal fissures?

A

Tight sphincter

270
Q

What are 6 methods of treating anal fissures?

A
  1. Stool softeners
  2. Topical nitroglycerin
  3. Topical calcium channel blockers
  4. Botox
  5. Forceful dilatation
  6. Lateral internal sphincterotomy
271
Q

Exquisitely painful defection with blood-streaked stool and avoidance of bowel movements leading to constipation

A

Anal fissure

272
Q

Exquisite peri-rectal pain, fever, difficult to sit or have bowel movement

A

Perirectal abscess

273
Q

Tx of perirectal abscess

A

I&D

274
Q

What is a serious complication of perirectal abscess?

A

Necrotizing fasciitis esp in diabetics

275
Q

Fecal soiling and perineal discomfort after having peri-rectal abscess drained

A

Fistula-in-ano

276
Q

Treatment of fistula-in-ano

A

Fistulotomy

277
Q

Fungating mass growing out of anus +/- inguinal lymphadenopathy

A

SCC of anus

278
Q

Dx of SCC of anus

A

Biopsy

279
Q

Tx of SCC of anus

A

Nigro chemo/XRT + surgery IF there is residual tumor

280
Q

4 causes of colonic GI bleed

A
  1. Diverticulitis
  2. Malignancy
  3. Angiodysplasia
  4. Polyps
281
Q

Best next diagnostic step in upper GI bleeds

A

EGD

282
Q

Diagnostic test for melena

A

EGD

283
Q

First step in work-up of bright red blood per rectum

A

NG tube and aspiration to rule out upper GI cause
If blood, upper GI
If no blood or bile, could be duodenum
If no blood but bile, lower GI

284
Q

After Upper GI bleed has been ruled out, what is the next step in work-up of BRBPR?

A

Rule out hemorrhoids with anoscopy

285
Q

What are the diagnostic steps to determining location of lower GI bleed?

A

Colonoscopy (if <0.5 cc/min) or tagged RBC study (if 0.5-2cc/min) or angiogram (if >2cc/min)

286
Q

Blood per rectum in a young adult is from where?

A

Upper GI source

287
Q

Blood per rectum in an older patient is from where?

A

Upper or lower GI

288
Q

Blood per rectum in a child is from where?

A

Meckel’s diverticulum

289
Q

Tx of massive upper GI bleed from stress ulcers

A

Angiographic embolization

290
Q

What are the 4 categories of acute abdominal pain?

A

Obstruction
Ischemia
Inflammation
Perforation

291
Q

Free air under diaphragm

A

Likely perforated peptic ulcer, need emergency surgery P

292
Q

Sudden onset, constant, generalized, severe abdominal pain with peritoneal signs

A

Perforation of peptic ulcer

293
Q

Acute onset, colicky abdominal pain with patient moving constantly to find painless position

A

Obstruction – ureter, cystic or CBD, SBO

294
Q

Gradual onset of increasing intensity abdominal pain that is diffuse and becomes focal later and is associated with fever and leukocytosis

A

Inflammatory process causing abd pain

295
Q

Acute onset severe, constant epigastric pain radiating to the back with nausea and vomiting

A

Acute pancreatitis

296
Q

Dx of acute pancreatitis

A

Amylase and lipase and confirm with CT scan

297
Q

Tx of acute pancreatitis

A

NPO, NG tube, IVF, pain control

298
Q

What would show in the UA in a patient with kidney stones?

A

Microscopic hematuria

299
Q

Best diagnostic test for kidney stones

A

CT scan

300
Q

Acute LLQ abdominal pain, fever, leukocytosis

A

Diverticulitis

301
Q

Dx of diverticulitis

A

CT scan

302
Q

Tx of diverticulitis

A 
NPO
IVF
Pain control
Abx -- cipro/flagyl 
IR guided drainage if abscess
Elective resection if >2 attacks
303
Q

Dx of sigmoid volvulus

A

KUB – small bowel air-fluid levels, distended colon that tapers toward LLQ

304
Q

Tx of sigmoid volvulus

A

Flexible sigmoidoscopy with rectal tube

Elective sigmoidoscopy if recurrent

305
Q

Tx of mesenteric ischemia

A

Early – arteriogram with embolectomy

Late – ex-lap and resection

306
Q

Blood marker of hepatocellular carcinoma

A

Alpha-fetoprotein

307
Q

Alpha-fetoprotein is a marker for what

A

HCC

308
Q

Dx of HCC

A

CT scan

309
Q

Tx of HCC

A

Resection if possible

310
Q

What is a potential consequence of hepatic adenomas?

A

Rupture and bleed massively

311
Q

Dx of hepatic adenomas

A

CT scan

312
Q

Tx of hepatic adenomas

A

Resection

313
Q

Fever, leukocytosis and tender liver on palpation

A

Pyogenic liver abscess secondary to acute ascending cholangitis

314
Q

What is a complication of acute ascending cholangitis?

A

Pyogenic liver abscess

315
Q

Tx of pyogenic liver abscess

A

Percutaneous drainage

316
Q

How do pyogenic liver abscesses form?

A

Result from ascending cholangitis

317
Q

3 categories of jaundice

A

Hemolytic
Obstructive
Intra-hepatic

318
Q

Slightly increased total bilirubin with indirect predominance and normal direct bilirubin

A

Hemolysis

319
Q

Elevated total bilirubin, with increased direct and indirect and high levels of AST/ALT and mildly elevated alk phos

A

Hepatitis

320
Q

Elevated total bilirubin with increased direct > indirect, mildly increased AST/ALT and very high alk phos

A

Obstructive jaundice

321
Q

What are the signs of a malignant gallbladder obstruction?

A

Large, thin-walled, distended gallbladder

322
Q

Pt with jaundice, RUQ pain, leukocytosis

A

Choledocholithiasis

323
Q

US findings of choledocholithiasis

A

Non-distended gallbladder filled with stones and dilated CBD

324
Q

Dx of choledocholithiasis

A

US and confirm with ERCP

325
Q

Tx of choledocholithiasis

A

ERCP with sphincterotomy then elective cholecystectomy

326
Q

What are 3 cancers that can cause obstructive jaundice?

A

Pancreatic adenocarcinoma of head
Adenocarcinoma of Ampulla of Vater
Cholangiocarcinoma of CBD

327
Q

Dx of pancreatic adenocarcinoma

A 
CT scan 
(If negative, then do MRCP)
328
Q

Dx of adenocarcinoma of ampulla of vater

A

MRCP

329
Q

Dx of cholangiocarcinoma of CBD

A

MRCP

330
Q

How are pancreatic adenocarcinoma biopsied?

A

CT-guided percutaneous biopsy

331
Q

How are ampulla of vater adenocarcinomas biopsied?

A

Endoscopic biopsy

332
Q

How are cholangiocarcinomas biopsied?

A

ERCP with brushings

333
Q

Obstructive jaundice + anemia + occult blood in stool

A

Ampulla of Vater adenocarcinoma

334
Q

Dx of biliary colic

A

US

335
Q

Tx of biliary colic

A

Elective cholecystectomy

336
Q

Constant RUQ pain + fever + leukocytosis

A

Acute cholecystitis

337
Q

Tx of acute cholecystitis

A 
NGT
NPO
IVF
Abx
Urgent cholecystectomy
338
Q

Constant RUQ pain, high fever, chills, prominent leukocytosis, extremely high alk phos

A

Ascending cholangitis

339
Q

Tx of ascending cholangitis

A

IV abx

ERCP

340
Q

Fever and leukocytosis about a week after diagnosis and treatment of acute pancreatitis

A

Pancreatic abscess (drain it)

341
Q

Early satiety, epigastric discomfort, deep palpable mass in a patient with history of acute pancreatitis or abdominal trauma

A

Pancreatic pseudocyst

342
Q

Tx of pancreatic pseudocysts

A

If <6cm or <6weeks, observation

If >6cm or >6weeks, drainage

343
Q

A patient with long-standing epigastric pain, steatorrhea, new-onset diabetes

A

Chronic pancreatitis

344
Q

All hernias should be electively repaired to prevent strangulation and obstruction EXCEPT in which 2 cases?

A
  1. Umbilical hernias in kids 2-5

2. Sliding hiatal hernias

345
Q

Breast cancer most commonly mets to which 2 locations?

A

Brain

Bone

346
Q

Where do sarcomas typically met to?

A

Lungs

347
Q

Screening guidelines for mammograms

A

Starting at 40 and every 2 years

348
Q

Best way to biopsy breast masses?

A

US guided core biopsies

349
Q

Firm, rubbery breast mass that moves with palpation in young women

A

Fibroadenoma

350
Q

Dx of fibroadenoma

A

US or FNA

351
Q

Tx of fibroadenoma

A

Resection is optional, more for cosmetics

352
Q

Very large, palpable breast masses that distort entire breast in women in their 20s

A

Cystosarcoma phyllodes – benign but can become malignant, core biopsy, resection

353
Q

Multiple lumps in bilateral breasts that relate to the menstrual cycle in women in 30s and 40s

A

Fibrocystic changes

354
Q

Dx of fibrocystic breast changes

A

Mammogram unless persistent mass, then aspiration (clear fluid= normal cyst, bloody = send for cytology)

355
Q

Bloody nipple discharge in 20s-40s

A

Intraductal papilloma

356
Q

Dx of intraductal papilloma

A

Mammogram to r/o other lesions

357
Q

Tx of intraductal papilloma

A

Galactogram and resection

358
Q

Tx of breast abscess

A

I&D + biopsy of abscess wall

359
Q

Features of malignant breast masses

A 
Ill-defined
Fixed, non-mobile
Skin retraction
Peau du orange 
Nipple retraction
Eczema of areola
Reddish orange skin
Palpable axillary lymph nodes
360
Q

How is breast cancer managed during pregnancy?

A

No XRT or hormones during pregnancy

No chemo during 1st trimester

361
Q

Radiological features of malignant breast cancer

A

Fine microcalcifications not present before
Irregular, spiculated mass
Asymmetric density

362
Q

For which types of breast cancers can lumpectomy be used?

A

Small lesions far from nipple and areola

363
Q

How is a small breast lesion far away from nipple and areola treated?

A

Lumpectomy + XRT

364
Q

How are large breast masses that lie close to nipple and areola managed?

A

Total mastectomy (with no XRT)

365
Q

Which sub-type of infiltrating ductal carcinoma has the worst prognosis?

A

Inflammatory

366
Q

Which subtype of infiltrating ductal carcinoma has a higher rate of bilaterality?

A

Lobular

367
Q

How is DCIS managed?

A

If lesions are in ONE quadrant of breast, lumpectomy + XRT

If multiple lesions scattered, total mastectomy + SNB

368
Q

What hormonal therapy can be used for pre and post menopausal women with breast cancer?

A

Premenopausal - tamoxifen

Postmenopausal - anastrazole

369
Q

Tx of brain mets from breast cancer

A

Resection or XRT

370
Q

Where do bony mets from breast cancer prefer?

A

Vertebral pedicles

371
Q

Which type of thyroid cancer is NOT easily diagnosed by FNA?

A

Follicular

372
Q

Tx of follicular thyroid cancer

A

Total thyroidectomy

373
Q

Which cells does medullary thyroid cancer come from?

A

C-cells (make calcitonin)

374
Q

Calcitonin is associated with what type of thyroid cancer?

A

Medullary

375
Q

Tx of hyperthyroidism due to hot nodules

A

Radioactive iodine

376
Q

What must be done prior to parathyroidectomy?

A

Sestamibi scan to locate gland prior to surgery

377
Q

First step in the work-up of Cushing

A

Low-dose dexamethasone suppression test

If suppresses cortisol, not Cushings

378
Q

If there is no suppression of cortisol with a low-dose dexamethasone test, what is the next test?

A

24 hr urine cortisol levels

If elevated, suspect Cushings and confirm location with high-dose dex suppression test

379
Q

Watery diarrhea and multiple ulcers extending past 1st part of duodenum

A

Zollinger-Ellison

380
Q

Dx of Zollinger Ellison

A

Gastrin levels and CT scan

381
Q

Tx of Zollinger Ellison

A

Resect mass

382
Q

Migratory necrolytic dermatitis

A

Glucagonoma

383
Q

Hypokalemia in a hypertensive patient not on diuretics

A

Primary hyperaldosteronism from adenoma or hyperplasia (differentiate by postural changes – in hyperplasia more Aldo when upright and less when lying down)

Surgery (1 decks)

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