SCORE Flashcards
Stress dosing for steroids – when and how much
For major surgery with > 20 mg/d for ≥ 3weeks for sure, if >5 mg test adrenal axis. Stress doing is 50-100 mg q8hr for like 3 days
Most common early splenectomy complication?
Hemorrhage – from short gastrics or splenic artery
What is the respiratory quotient?
The respiratory quotient is the ratio of CO2 produced to that of O2 consumed. Carbs are = RQ of 1.00. Fats are the only one that’s > 1.
When to withhold therapeutic anticoagulation?
Most patients can be safely taken off their therapeutic anticoagulation meds prior to surgery. Protection of a cardiac valve is the most urgent indication, and they can be left without anticoag for at least 72 hr and even a week (especially in the aortic position). Put off elective surgery for at least 6 mo. after drug-eluting stent placed b/c need at least that duration of clopidogrel. If it’s necessary for pts to stay on anticoagulation, switch to heparin and turn off 4 hr preoperatively.
How do SCDs prevent thromboembolism?
Stimulate release of nitric oxide
What does pressing on the cricoid cartilage do?
The cricoid cartilage is the only “ring” of the trachea that continues posteriorly, so pressing on the cricoid during intubation causes it to press up against the esophagus to occlude it and prevent reflux of gastric contents.
Mechanism of action of anesthetic agents
Blockade of sodium channels in the nerve membrane preventing depolarization. Non-ionized portion penetrates the lipid membrane, and the ionized portion blocks the inner aspect of the sodium channel. The closer the pKa is to biological pKa (7.4), the less ionized the agent is allowing for greater penetration and faster onset of action.
What is the “lethal triad?”
Hypothermia, coagulopathy, and acidosis
Hemorrhagic shock’s effect on the intestinal tract
1) Angiotensin II and vasopressin are the principal hormones that cause vasoconstriction of the splanchnic vasculature in hemorrhagic shock (thyrotropic releasing hormone and thromboxane A2 also have some action)
2) Prostaglandin release causing small arteriole vasodilation and large arteriole vasoconstriction – preserving blood flow to the mucosa and less so to the muscularis propria
3)
Dosing of calcium gluconate for hyperkalemia and EKG changes
10 mL of 10% Ca gluconate and redone in 5-10 min if no effect or use of more potent calcium chloride
When is parenteral albumin administration appropriate?
Large SA burns after resuscitation with crystalloids
How is it best to evaluate penetrating cardiac injuries after thoracic trauma complicated by a hemothorax?
Subxiphoid exploration
Only clear indication for laparoscopy in trauma?
Rule out diaphragmatic injury and peritoneal entry in thoracoabdominal penetrating injuries
Ultimate anatomic blind spot for penetrating injuries
Diaphragm
Cushing reflex
Occurs with increased ICP (>20), CPP decreases and this reflex compensates for it by increasing the parasympathetic and sympathetic nervous system. This causes bradycardia, increased systolic bp, and slow irregular breathing.
Management of hemothorax by blood volume
If >1000 mL comes out, put in a second CT for better evacuation and hemostasis and to prevent clot/occlusion of the tube. Emergent thoracotomy if >1500 mL is evacuated upon CT placement of >200 mL for 2-4 hr or need for transfusion to maintain MAPs.
The most deleterious esophageal mucosal injury is caused by what during GERD?
Gastric acid and pepsin. Acid alone does minimal damage. The combo of pepsin and acid is highly deleterious.
What diagnostic test is used to determine the depth of invasion for esophageal cancer and therefore helps to determine staging and benefit of neoadjuvent therapy?
Endoscopic u/s. It is the most accurate test to determine local LN mets and depth of invasion
Contraindication for Nissen with Barrett’s
High grade dysplasia
Diagnosis of esophageal perforation
Gastrograffin swallow
Surgical approach to gastric perforation by location of perf
Cervical- left oblique neck dissection
Upper 2/3 Thoracic- right posterolateral thoracotomy in the 4th-5th intercostal space
Lower 1/3 Thoracic- left posterolateral thoracotomy in the 6th or 7th intercostal space
Abdominal- upper midline lapartomy
Post-operatively what is Afib likely due to due?
Fluid overload. Use metoprolol and lasix
What patients should succinylcholine not be used for paralysis? What is the mechanism? And for how long should you avoid?
Burn patients – up to one year
Prolonged immobilization
Upper or lower motor neuron disorder
Mech- up regulation of the nicotinic ACh receptors causing exaggerated K release w/succinylcholine
The benefits of using PCC (prothrombin complex concentrates)?
Typically stored at room temperature and can be infused rapidly and in a small volume. FFP needs to be thawed and is a larger volume
