Pestanas Flashcards
Anterior cord syndrome usu see in what type of fractures? WHat’s the loss
- burst fractures of the vertebral bodies
- loss of motor function and loss of pain and temp on both sides distal to the injury with preservation of vibratory and positional sense.
Central cord syndrome occurs when?
elderly with forced hyperextension of the neck (rear-end collision)
There is paralysis, and burning, pain in the upper extremities with preservation of most functions in the LE
What’s the best imaging to assess for spinal cord injury? Immediate therapy includes
MRI
high-dose corticosteroids
Why is rib fracture deadly in elderly? Treat with?
rib fracture –> pain –> hypoventilation –> atelectasis –> pneumonia
Treat with nerve block and epidural catheter
When will a hemothorax needs a thoracotomy
when initial drainage after chest tube placement is greater than 1500 mL or collected over 600 mL in tube over next 6 hrs
How to treat sucking chest wounds
you will see a flap that sucks air with inspiration and closes with expiration. Treat with occlusive dressing that allows air out but not in. If not, can lead to deadly tension pneumo
Flail chest can occur with multiple rib fractures that allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing). The real problem is pulm contusion (“white out of lungs”). How to manage
pulm contusion is very sensitive to fluid overload. Treatment includes fluid restriction and use of diuretics.
monitor with ABG. If a respiratory is needed, put in b/l chest tubes to prevent tension pneumo, Also r/o aortic dissection
In sternal fractures, suspect what type of contusion
myocardial contusion
get EKG, troponins.
Treatment is focused on arrhythmaia
When to suspect traumatic rupture of aorta? What’s the best imaging in trauma setting?
- big deceleration injury, presence of fractures in chest bones that are hard to break like first rib, scapula, sternum, or fracture of multiple ribs, presence of wide mediatstinum
- can use TEE, spiral CT aka CT angio or MRI angio, but in trauma setting, most practical is CT angio
How to secure airway in someone with subcut emphysema in neck
fiberoptic bronchoscope
pt with multiple trauma develops petechial rashes in axillae and neck, fever, tachycardia and low plt count with respiratory distress (b/l patchy infiltrates on chest x-ray). due to?
fat embolism from long bone fractures
While doing an exploratory laparotomy for an intraabdominal bleed, when do you abort operation with packing of bleeding surfaces and temporary closure?
coagulopathy with multiple tx, hypothermia, and acidosis
resume operation later when pt has been warmed and the coagulopathy treated
Pelvic hematomas are usu left alone if they are not expanding. What to do when someone has a pelvic fracture
- r/o associated injuries: rectum -rectal exam and proctoscopy, bladder, vagina -pelvic exam, urethra in men -retrograde urethrogram
- hard to do surgery on pelvic fracture b/c if you open, the pelvic hematoma can lose its tamponade effect.
- maybe do pelvic fixators and then IR for embolization of both internal iliac arteries
What to do with scrotal hematomas
typically do not need surgical intervention
What to do with fracture of penis
emergency surgical repair if not impotence will ensue as AV shunts will develop
In penetrating injuries of the extremities,
WHat to do if penetrated not near any major vessels are injured? What to do if penetration is near major vessels but pt is asymptomatic? What to do if there’s obvious vascular injury?
WHat to do if penetrated not near any major vessels are injured? tetanus ppx and cleaning of the wound
What to do if penetration is near major vessels but pt is asymptomatic? Doppler studies or CT angio
What to do if there’s obvious vascular injury? surgical exploration
If someone has combined injuries of arteries, nerves, and bone. What to repair first?
usual sequence is stabilize bone first, then do the delicate vascular repair and do the nerve last
should do fasciotomy b/c prolonged ischemia can lead to compartment syndrome
Injuries that lead to myoglobinemia-myoglobinuria renal failure (crush injury, high voltage electrical burns), how to manage?
fluids
osmotic diuretics like mannitol
alkalinize the urine
Formula such as 4 x body weight x % body surface covered with burns has been used to calculate how much LR pt needs in one day with half infused within first 8 hours. Now, it’s more common to use a predeterminated rate of fluid infusion. What is it? What to monitor
start at 1000 mL/h of LR on anyone whose burn exceeds 20% of body surface
adjust to maintain UO of 1-2 mL/kg/h while avoiding CVP > 15 mmHg
In addition to fluids resuscitation, what are other things impt in burn care?
tetanus ppx cleaning of burn areas use of topical agents (std is silver sulfadiazine, if deep penetration is desired, use mafenide assoc with acidosis, silver nitrate) iv pain meds NG suction TPN
T/F: tetanus ppx and wound care are required for all bites
True
How to treat black widow spider bites?
bitten pts get n/v, severe generalized muscle cramps
antidote is iv calcium gluconate. Muscle relaxants can help.
How to treat brown recluse spider bites?
often not recognized at the time wiht development of skin ulcer on the next day with necrotic center and a surrounding halo of erythema
Dapsone is helpful
6 yr old with limping, decreased hip motion and hip pain. He walks with an antalgic gait, and passive motion of hip is guarded. How to dx?
x-ray of hip will show legg-calve-perthes disease (avascular necrosis)
treatment via casting and crutches
Chubby boy around 13 with groin or knee pain and limping. When sitting with legs dangling, the sole of affected side points toward the other foot. Hip cannot be internally rotated. HOw to dx and treat
SCFE
x-rays
surgical treatment to pin the femoral head back in place
Imaging choice for acute hematogenous osteomyelitis
MRI bc x-rays won’t show anything for a couple of weeks.
Treat with abx
Bowlegs (genu varum) normal until? Persistence after that age is called?
normal until age 3
if persistent varus –> blount disease will need surgery.
Genu valgus (knock knee) is normal btw?
ages 4-8
no treatment
teenager with persistent pain right over tibial tubercle, aggravated by contraction of quads. PE shows localized pain right over tibial tubercle without knee swelling. What to do and what is it?
Osgood-Schlatter disease aka osteochondrosis of the tibial tubercle
conservative management with RICe. If no improvement then ortho for cast for 4-6 wks
Pain around knee in someone young. X-ray shows sunburst pattern.
Osteogenic sarcoma
tumor in someone from 5-15 affecting diaphysis. X-ray shows onion skinning.
Ewing sarcoma
Multiple myeloma presents with fatigue, anemia, bone pain. What will x-ray show? What will you find in urine? In blood?
- x-ray–> punched out lytic lesions
- urine –> bence jones protein
- blood -abnormal immunoglobulins
Soft tissue sarcomas appear as firm, fixed to surrounding structures. Most often metastasize to lungs. What to do to diagnose?
incisional biopsy. Treatment includes very wide local excision, radiation and chemo
what does closed reduction in ortho mean?
immobilized in a cast
Regular x-rays can miss posterior shoulder dislocation. What views are needed?
axillary or scapular lateral views are needed
What’s a monteggia fracture
direct blow to the ULNA such as on a raised protective arm hit by a nightstick. There is a diaphyseal fracture of the proximal ulna with anterior dislocation of the radial head.
What is a galeazzi fracture?
distal third of radius gets direct blow and fractures leading to dorsal dislocation of the distal radioulnar joint.
Fracture of scaphoid usu has negative x-ray results for 3 weeks. Treat with thumb spica. What if x-ray shows displaced and angulated fracture?
open reduction and internal fixation
Boxers fracture involves
metacarpal neck fractures typically 4th or 5th or both. Hand is swollen and tender. X-rays are diagnostic.
How to manage intertrochanteric fractures
open reduction and internal fixation and post-op anticoagulation.
femoral neck vs femoral shaft fracture
femoral neck –> replace femoral head with prosthesis
femoral shaft –> intramedullary rod fixation
Someone with protracted pain and swelling after a knee injury has a “catching and locking” that limit knee motion and a “click” when the knee is forcefully extended. What is it and how to manage
meniscal tears
repair is necessary
Unhappy triad
injuries to medial meniscus, medial collateral and the anterior cruciate
Someone has pain under a cast. What to do
always remove and examine the limb
open fractures with broken bone sticking out thru a wound require?
cleaning in the OR and suitable reduction within 6 hours from the time of injury
Pt in MVC lies in stretcher with the leg shortened, adducted, and internally rotated. What is it
posterior dislocation of the hip
vs in broken hip, the leg is shortened but leg is externally rotated.
manage with emergency reduction to avoid avascular necrosis
How to treat gas gangrene (tender, swollen, discolored, gas crepitation)?
copious IV penicillin, extensive emergency surgical debridement and hyperbaric oxygen
Carpal tunnel is usu treated conservatively with NSAIDs and wrist split. If you need surgery, what to do beforehand
electromyography of median nerve
What is a trigger finger? How to treat
usu waking up at night with a finger that is acutely flexed and unable to extend unless they pull it with the other hand. When they do so, there is a painful snap. Steroid injection is the first line therapy.
What is de quervain tenosynovitis? How to treat
young mothers who as they carry their babies force their hand into wrist flexion and thumb extension. pain along radial side of wrist and first dorsal compartment. PE, pain can be reproduced by asking her to hold her thumb inside her closed fist then forcing the wrist into ulnar deviation.
Splint and anti-inflammatory agents can help but steroid injections are best
What is a felon
an abscess in the pulp of a fingertip caused by a neglected penetrating injury. Throbbing pain, fever, can lead to tissue necrosis
must drain
What’s a gamekeeper thumb
injury of ulnar collateral ligament due to forced hyperextension of the thumb, Casting is usu done
What’s a mallet injury
extended finger is forcefully flexed (a common vb injury) and extensor tendon is ruptured. The tip of affected finger remains flexed when the hand is extended resembling a mallet. Splinting is first line
What to do with traumatically amputated digits?
surgically reattached whenever possible. amputated digit should be cleaned with sterile saline, wrapped in a saline-moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice.
Describe venous stasis ulcers vs ulcers from arterial insufficiency
Venous stasis ulcers: from chronically edematous indurated and hyperpigmented skin above the medial malleolus. Ulcer is painLESS with granulating bed. Duplex scan
Arterial ulcers: look dirty, at tip of toes, pale base devoid of granulation tissue. Also do doppler
How to manage marjolin skin ulcers (chronic ulcers from burns or sinus tracts that develop squamous cell carcinoma)?
biopsy is diagnostic
wide local excision and skin grafting are done
Plantar fasciitis is a very common problem affecting older overweight pts who complain of disabling sharp heel pain every time their foot strikes the ground, worse in the morning. How to manage
xray may show a bony spur matching location of pain and PE shows exquisite tenderness to palpation over the spur but the bone spur is not the cause of the problem.
manage conservatively bc will resolve on its own in 12-18 months.
GOldman’s index of cardiac risk is no longer the preferred method of assessing cardiac risk. Functional status is. But what is included in goldman’s index
in descending order of importance:
- JVD
- recent MI
- PVC or any rhythm other than sinus
- age > 70
- emergency surgery
- aortic valvular stenosis
- poor medical condition
- surgery within the chest or abdomen
What’s the worst single finding predicting high cardiac risk? What’s the second worst?
JVD/CHF -#1 worst
recent MI -#2 worst- impt to defer surgery for 6 months
Smoking poses an increased pulmonary risk. Problem with ventilation or oxygenation? What to advise before surgery?
- compromised ventilation with high pCO2, low FEV1 rather than compromised oxygen
- cessation of smoking for 8 weeks before surgery is recommended
List the 2 clinical and 3 lab values used to predict operative mortality in someone with liver disease
- encephalopathy
- ascites
- serum albumin
- INR
- bilirubin
Define severe nutritional depletion. How to manage before surgery?
1) loss of 20% of body weight over a couple of months
2) serum albumin below 3
3) anergy to skin antigens
4) serum transferrin level of less than 200 mg/dL
as few as 4-5d of preop nutritional support can make a huge difference; 7-10 d will be optimal
What’s an absolute contraindication to surgery
diabetic coma
what 2 meds given during anesthesia can cause malignant hyperthermia that can be treated with IV dantrolene, cooling blankts, 100% O2, correction of acidosis?
succinylcholine
halothane
Deep thrombophlebitis typically produces fever starting on POD5. How to manage?
doppler studies of deep leg and pelvic veins is teh best diagnostic modality.
anticoagulate with heparin
Wound infection happens usu on POD7. What to do if cellulitis vs abscess vs can’t tell
cellulitis -abx
abscess -open and drain the wound
when these 2 cannot be distinguished, US is diagnostic
Suspect deep abscesses (subphrenic, pelvic or subhepatic) if pt has fever around POD 10-15. How to diagnose and what to do?
diagnose with CT scan
Percutaneous IR-guided drainage
what is the most common cause of triggering perioperative MI
hypotension
What’s the centerpience of therapy in ARDS?
PEEP
How to treat Delirium tremens
IV benzo IV alcohol (5% in 5% dextrose) is still preferred in some surgical community
Zero urine output post-op, suspect mechanical obstruction so check for kinks in catheter. What about loe urinary output
either fluid deficit or AKI
low-tech test is do a fluid challenge -bolus of 500 mL of IV fluid infused over 10 or 20 minutes. in which fluid deficity pt will respond by increasing UO
can also check urine sodium or FeNa
paralytic ileus after post-op. What will you find on PE
no pain, mild distension, absent bowel sounds and no passage of glass
POD5 -salmon colored fluid is soaking the dressing of a wound after an open lap. What tis it
wound dehiscence
manage by taping securely, with wet gauze and be careful when pt coughs, moves around or strains bc can eviscerate
Whats the safe speed limit of giving IV potassium
10 mEq/h
Pt with dysphagia worse with liquid than solids with occasional regurg of food. Barium swallow shows birds beak. What is it? How to confirm? best treatment?
Achalasia
Confirm with manometry
Treat with balloon dilatation done by endoscopy
someone old with intestinal obstruction and severe abd distension with X-ray showing air-fluid levels in small bowel, very distended colon and a huge air-filled loop in the RUQ that tapers down toward the LLQ with the shape of a parrot’s beak. What’s next and what to do
sigmoid volvulus
do a proctosigmoidoscopic exam -that should resolve the problem. If recurrent consider sigmoid resection
What is courvoisier-terrier sign?
a large thin-waled distended gallbladder often a sign of malignant obstruction (head of the pancreas adenocarcinoma, adenomcarcinoma of the ampulla of vater, cholangiocarcinoma)
For suspected obstructive malignancy causing jaundice, start with CT to find tumor. If you can’t, do MRCP. how to biopsy these tumors?
- CT-guided percutaneous for a large pancreatic mass
- Endoscopic for ampullary (suspect when theres anemia and positive blood in the stools)
- ERCP and brushing for a ductal neoplasm
- endoscopic US for tiny tumors within the head of pancreas
Acute pancreatitis can be subdivided into edematous, hemorrhagic or suppurative.
edematous -alcoholics and gallstones, elevated HCT, treat with NPO, NG suction and IV fluids
hemorrhagic -starts out like edematous, but with LOW HCT, most likely require ICU care, can develop multiple pancreatic abscesses and to anticipate and drain them, may need daily CT scans.
suppurative -abscesses should be drained
When is a necosectomy ideal to do?
in necrotic pancreas when dead tissue is well delineated typically after 4 weeks. Material can be scooped out.
How to manage pancreatic pseudocyst based on size and duration?
- pseudocyst typically forms 5-6 wks after acute pancreatitis
1) if pseudocyst is 6 cm and/or duration is > 6 wks, more likely to rupture –> drainage of cyst, or cystogastrostomy
Steps involved in assessing for Cushings
1) overnight low dose dexamethasone suppression test (if suppression then rules out cushing disease). If no suppression, then
2) 24-hr urine free cortisol, if elevated, then
3) high-dose suppression test (if suppression at high dose –> pituitary cause; if no suppression –> ectopic ACTH production or adrenal adenoma)
If you suspect someone is self-injecting insulin to cause hypoglycemia, but c-peptide is normal. What other med can this person still be abusing?
sulfonylureas
What is nesidioblastosis
devastating hypersecretion of insulin in the newborn requiring 95% pancreatectomy
HOw to manage renovascular HTN in the young woman with fibromuscular dysplasia
balloon dilatation and stenting
Posterior urethral valves are the most common reason for a newborn boy not to urinate during the first day of life. What to do?
cath to empty bladder
voiding cystourethrogram is diagnostic test
endoscopic fulguration or resection will fix it
How to manage vesicoureteral reflux which often manifests as recurrent UTIs in young
- abx
- voiding cystourethrogram
- long-term abx until child grows out of the problem
low implantation of ureter is usu asymp in young boys, but leads to what fascinating clinical presentation in girls.
feels need to void and can void normally but is also wet with urine all the time bc urine drips into vagina from the low implanted ureter. evaluate with careful vaginoscopy
Ureteropelvic junction obstruction can normally allow for normal urinary output to flow without difficulty but if a large diuresis occurs, the narrow arrow can’t handle it. Classic presentation is?
adolescent who goes on a beer drinking binge for the first time and develops colicky flank pain
Workup of hematuria for cancer includes
CT and cystoscopy
Most testicular cancers are very chemo-sensitive and radio-sensitive. WHich chemo?
platinum based
Pneumaturia -suspect?
- air in urine 2/2 to colovesical fistula most likely formed due to diverticulitis (other causes can be cancer)
- will need to do CT to show diverticular mass
- sigmoidoscopy may be needed to r/o cancer
Esophageal atresia presents as excessive salivation noted shortly after birth or choking spells when first feeding is attempted. What to do to dx and to manage?
if you pass NG tube, it will coil in the upper chest when you take x-ray.
most common is tracheoesophageal fistula, so rule out VACTER (vertebral, anal, cardiac, tracheal, esophageal, renal and radial anomalies)
fix with primary surgical repair. If delayed, put in gastrostomy
How to manage congenital diaphragmatic hernia?
surgical repair but must wait 3-4 days to allow for lungs to mature. Babies in resp distress need ETT, low pressure ventilation, sedation and NG tube. Difficult cases may require ECMO.
When to suspect exstrophy of the urinary bladder? How to manage?
abdominal wall defect but over the pubis (which is not fused), with a medallion of red bladder mucosa, wet and shining with urine.
baby has to be transferred immediately to a specialized center where a repair can be done w/in first 1 or 2 d of life.
How to treat a baby (more commonly premature) with feeding intolerance, abd distension, rapidly dropping plt count. When do you need to do surgery?
Infant most likely has necrotizing enterocolitis. Should stop all feeds, and administer broad spectrum abx, IV fluids, IV nutrition.
Surgical intervention is required if infant develops abdominal wall erythema, air in the portal vein, intestinal pneumatosis or pneumoperitoneum
Pt with exertional claudication of arm with coldness, tingling, muscle pain and posterior neurologic signs of visual symptoms, equilibrium problems point to?
If without neurologic symptoms, can suspect what other ddx
subclavian steal syndrome is rare and occurs when theres a stenotic plaque at the origin of the subclavian allowing enough blood to reach arm but not enough when arm is exercised.
dx with duplex scanning and bypass surgery cures it.
without posterior neuro signs, can think about thoracic outlet syndrome
Arterial embolization from a distant source should be treated within 6 hours. How to manage
- doppler studies
- early incomplete occlusion may be treated with clot busters
- Embolectomy with fogarty catheter
- Fasciotomy should be added if several hrs have passed before revasc
When is surgical valvular replacement indicated in someone with aortic stenosis?
gradient of more than 50 mmHg
first indication of CHF, angina or syncope
BCC grows very slowly but can kill by relentless local invasion. Thus it needs to be removed completely. How to diagnose and how to treat
diagnose with full-thickness biopsy at EDGE of lesion.
remove completely with 1 mm of clear margin
SCC prefers lower lip and can metastasize to regional LNs. Excision with how wide of a margin is needed?
excision with 0.5 to 2 cm margins.
What is the current preferred adjuvant systemic therapy for metastatic melanoma
interferon
Before removing a thyroglossal duct cyst, what type of imaging should you do to confirm that the actual thyroid gland is present
radionuclide
What cysts can appear along the anterior edge of the SCM.
branchial cleft cysts
Why is CT scan before surgery to correct cystic hygroma a must
cystic hygroma is found at the base of the neck as a large, mushy, ill-defined mass that occupies the entire supraclavicular area and seems to extend deeper into the chest. CT is mandatory to rule out extension into mediastinum as it often does
parotid mass: pleomorphic adenoma vs cancer
pleomorphic adenoma make up most of parotid masses, are benign, but have potential to become malignant, no pain or CNVII paralysis –superfical parotidectomy sparign nerve
parotid cancer presents as a hard mass with pain and potential CNVII paralysis –parotidectomy and nerve is removed with graft
a kid with u/l ENT problems like u/l earache, u/l rhinorrhea, u/l wheezing, suspect and do what
foreign body
do endoscopy under anesthesia
What is a ludwig angina and what to worry about and do
ludwig angina -abscess of the floor of the mouth often due to bad tooth infection.
should do incision and drainage but what to worry about is threat to airway so may need to intubate
How to manage cavernous sinus thrombosis
emergency
hospitalization, IV abx, CT scan or MRI, drainage of affected sinuses
Meniere disease -vertigo, hearing loss, tinnitus is treated how
salt restriction
diuretics
