Shelf Flashcards
Tx of hemorrhagic shock in urban setting
Surgery THEN volume replacement
Subdural hematoma management
ICP monitor
Elevate head 30 degrees
Hyperventilate
Avoid fluid overload
Administer furosemide or mannitol
Rib fracture treatment
Local nerve block and epidural catheter
Pulmonary contusion
Pt with blunt thoracic trauma who presents with deteriorating blood gases and a white, patchy, alveolar infiltrate on CXR; also has decreased breath sounds
Can appear up to 2 days after injury but can also be on the day of
Tx: Fluid restriction; diuretics
⭐️Should also check for a comorbid aortic transection
Given to any patient with a penetrating injury of an extremity
Tetanus shot
Test to order on a patient who fell from a height and has a broken tibia or fibula
Lumbar or thoracic spine x ray
Marjorlin ulcer
SCC developed form a ️Chronic skin ulcer
Presents as a pt. With an ulcer of many years that continuously heals and breaks down
Tx of Breast cancer in a pregnant woman
Just go with surgical excision and chemo later
Thyroid nodules
Get an FNA
Lobectomy if follicular Cancer
Tx. Of meconium ileus
Gastrografin enema
- treats and diagnoses
- shows pellets of meconium in the terminal ileum
- works by drawing fluid in and dissolving the meconium
Tx for obstructive arterial embolization
Emboli tommy with a fogarty catheter
-Add fasciotomy if it’s been 6 hours
Strabismus Tx
Corrective glasses
Instantly correct deficit
Workup for SCC of the oral mucosa
Triple endoscopy
- Presents in alcoholics who have rotten teeth often as a metastatic node in the neck
- may also show hoarseness, painless ulcers in the mouth, unilateral earaches
Tx: Resection; chemotherapy
BCC biopsy
Must make sure to get the edge of the lesion
Where do Branchial cleft cysts occur?
Along the SCM
Suspected in a pt. With unilateral sensory hearing loss and no history of exposure to loud noises
Acoustic neuroma
Acute epididymis
Severe testicular pain of sudden onset with fever and pyuria
⭐️Cord will also be tender
-unlike in testicular torsion
Tx: Antibiotics and US (to rule out torsion)
Wound to the head, what management is required?
Angiogram to assess the Vasculature
Exploratory laparotomy is indicated in abdominal blunt trauma if what is present?
Peritoneal irritation
Pt. With a penetrating urologic injury
Requires surgical exploration
Chemical burn Tx
Irrigate asap
Even before they come to the ER
Day 5 of post op from laparotomy and salmon-colors fluid is weeping from the wound
Wound dehiscence
-Wound should be tape and re operated on to prevent evisceration of abdominal contents
Woman with a metastatic lesion to the bone needs what workup
MRI
Tx of ureteral stones larger than 7mm
Shockwave lithotripsy
Abdominal compartment syndrome
️Occurs when lots of fluids or blood have been administered during a prolonged laparotomy; the abdomen cannot be closed due to tension on the tissues
- Place a temporary mesh cover
- Can present at PoD 2
- May present as sutures cutting thru the tissue, hypoxia, or renal failure
Desired UOP for burn pt
1-2ml/kg/hr
Concern with bilateral, comminuted femoral shaft fractures
Shock
Pt with a fractured hip but also with a poorly controlled secondary condition
Can delay emergency surgery for 72 hrs
Conditions included COPD, a-fib, pulmonary edema, pneumonia
GCS
Eyes:
4- spontaneous
3- verbal command
2- respond to pain
1- no response
Verbal:
5- oriented
4- confused
3- inappropriate words
2- incomprehensible words
1- no speech
Motor;
6- obeys command
5- localized
4- Withdraws to pain
3- flexure
2- extension
1- none
Tx for prolonged pancreatic pseudo cyst
Endoscopic drainage
Pts with blunt, hemodynamically stable trauma should get what test
FAST
Uncal herniation
Cushing’s reflex
CN III palsy
Ipsilateral hemiparesis
Contralateral homonymous hemianopsia
Coma
CN III palsy
Mydriasis
Down and out gaze
Cushing’s reflex
HTN
Bradycardia
Respiratory depression
Blunt genitourinary traum
Usually a renal contusion ,laceration, or vascular injury; presents as CVA tenderness and hematuria
Workup: Urinalysis, CT with contrast
Pts with a lower sc injury need this
Urinary catheter
Pt with constant back pain, obstructive jaundice, and weight loss
Pancreatic tumor
- Get a CT
- If it’s negative, get a MRCP to rule out probs with the ampulla of vater or cholangiocarcinoma
Hypernatremia correction
Use 1/2 NS w/ D5W
-For every 3mEq/L above 149, there is 1 L of fluid loss
Cystosarcoma phyllodes
Firm, rubbery and movable mass presenting in a woman with lack of routine care in her 20s
- grow and distort the Breast but they do not invade
- malignant potential so they must be removed
Congenital diaphragmatic hernia Tx
Intubation, low-pressure ventilation, NG suction
⭐️If predicted to be severe at birth, treat with extra corporeal membrane oxygenation
Acute transplant rejection Tx
Steroid boluses
Antithymocyte agents
OKT3 (antilymphocyte agent)
Pt passing a ureteral stone who develops fevers, chill,vans flank pain
Obstruction progressing to an infection
⭐️EMERGENCY
Tx: Ureteral stent; percutaneous nephrostomy
Venous stasis ulcer
Develops in Pts with varicose veins
-Duplex scan for work up
Tx: Pressure stockings, debridement
Ogilvie Syndrome
Paralytic ileus of the colon in elderly, Alzheimer’s Pts who are sedentary following surgery or a broken hip
-Imaging shows a massively dilated colon
Tx: Fluid and electrolyte correction
Colonoscopy (sucks out air)
Recital tube
Test performed for PVD
Abi
- divides the higher ankle systolic pressure by the higher brachial artery pressure
- 1.30 indicates calcified vessels
Reason why you would not perform orotracheal intubation on an unstable pt
Severe facial trauma
- Ok if there is cervical trauma and the neck is stabilized
- if there is facial trauma, do a cricothyroidotomy
Posterior urethral injury
Most commonly ️Occurs at the bulbomembranous jnxn
Sx: Blood at the urethral meatus, inability to void, perineal or scrotal hematoma, high riding Prostate on DRE
Dx: Retrograde urethrogram
Gilbert Syndrome
Most common inherited disorder of bilirubin conjugation
-️Decreased UDP-glucuronsyltransferase activity
Sx: Intermittent episodes of jaundice provoked by stress like surgery, infxn, fasting, exercise
Benign in nature and requires no treatment
Tx of epidural hematoma
Emergent surgical hematoma Evacuation
Retroperitoneal hematoma
Presents in patients with a recent cardiac catheterization, Anticoagulation with heparin, sudden onset of hypotension, tachycardia, flat neck veins, and back pain
- ️Occurs due to ️Bleeding at the arterial puncture site at the femoral artery above the inguinal ligament
- ️Occurs within 12 hours of the procedure
Tx: Supportive
Timeline causes of post op fever
<2 hrs: Prior trauma, infection, blood product administration (febrile non hemolytic transfusion reaction), malignant hyperthermia
> 24 hours: Nosocomial infection, SSI, MI, DVT, PE
> One week: C. DIF, drug fever, PE, DVT
> One month: Viral infxn, rare infection
Leriche Syndrome
Arterial occlusion at the bifurcation of the aorta into the common Iliacus
Triad: Bilateral hip, thigh, and butt claudication, impotence, and atrophy of the bilateral lower extremities due to ️Chronic ischemia
Pilonidal disease
Edematous, infected hair follicle in the inter gluteal region becomes occluded and infxn spreads subcutaneously and forms an abscess that ruptures and causes a pilonidal sinus tract
Affects young,bourse males with sedentary lifestyles
Sx: Painful, fluctuant mass slightly above the anus in the intergluteal region, mucoid or purulent drainage
Tx: I&D
Treatment for variceal hemorrhage
- Place 2 large bore IV catheters
- Volume resuscitation, IV Octreotide, and antibiotics
- Urgent endoscopic therapy
Imaging test for penile fracture
Retrograde urethrogram
To evaluate suspected urethral injury
Primary spontaneous pneumothorax Tx
Small (<2 cm): Supplemental O2
Large: If hemodynamically stable ➡️ Needle aspiration or chest tube placed in the second or third intercostal space in the Midclavicular line
If unstable ➡️ Tube thoracostomy
Contraindications to surgery in general
DKA, Coma
Malnutrition (albumin <3, transferrin <200)
Smoking (stop 8 weeks before surgery)
Goldmans index
Tells you who is at the greatest risk for surgery
- CHF (if echo shows <35%)
- MI in the past 6 months
- Arrhythmias
- Age > 70
- Emergent surgery
- AOrtic stenosis
Assist control vent setting
Sets the tidal volume and and rate but if a patient takes a breath, the vent only Gives the volume
Pressure support on vent
Pts body controls the rate but a boost of pressure is given; used to wean Pts off ventilators
PEEP
Pressure given at the end of a breathing cycle to keep the alveoli open; used in ARDS and CHF
Causes of increased anion gap metabolic acidosis
Methanol Uremia Diabetic Ketoacidosis Polyethylene glycol Infection, iron, isoniazid, inborn error of metabolism Lactic acidosis Ethylene glycol Salicylate
Signs of Hypokalemia
Paralysis, ileus, ST depression, U waves
Maintenance IV levels
First 10 kgs ➡️ 100ml/Kg/day
Next 10 ➡️ 50ml/kg/day
All above 20 ➡️ 20 ml/kg/day
Risks of prolonged TPN
Acute acalculous cholecystitis
Zinc deficiency
1st workup with electrical burn
EKG
What should be done on a pt. With a GCS < 8
Intubation
Neck trauma zones
Zone III: Above the angle of the mandible
-get an arteriography and triple endoscopy
Zone II: at the angle of the mandible-cricoid
-get Doppler us and exploratory surgery
Zone I: below the cricoid
-get an aortography
Fractures that go to the OR
Depressed skull fractures
Femoral neck fractures
Interotrochanteric fractures
Open fractures
Severe displacement
Causes of fever on POD 1
Atelectasis: treat with mobilization and incentive spirometry, is usually low grade fever
Necrotizing fasciitis: ️Occurs along Scarpa’s fascia, give IV penicillin and debride in OR
Malignant hyperthermia: give Dantrolene
Fever on POD 3-5
Pneumonia: culture sputum, a give MOXIFLOXACIN until it returns
UTI: Urine culture and broad spectrum abx
Fever on POD >7
Central line infxn: pain and tenderness at IV site
-pull line, blood cultures, antibiotics to cover staph
Cellulitis: pain at incision site with induration and drainage
-blood culture, start antibiotics
Dehiscence: pain at incision site, seepage of salmon-colored fluid
-surgical ️EMERGENCY, go to OR, antibiotics, primary c,laure of fascia
Abdominal abscess: unexplained fever
-CT with contrast, diagnostic laparotomy, drain
Lights criteria
Pulmonary effusion is transudative if…
- LDH <200
- LDH effusion/serum <0.6
- protein effusion/serum <0.5
Benign lung nodules
Popcorn calcifications = hamartoma
Concentric calcification = old granuloma
Well circumscribed
MCC of lung cancer in nonsmokers
Adenocarcinoma
Lung cancer metastasis locations
Liver, bone, brain, adrenals
Patient with lung cancer, kidney stones, constipation
SCC with Paraneoplastic PTHrP
Patient with lung cancer, shoulder pain, Ptosis, constricted pupil, and facial edema
Superior sulcus syndrome from small cell carcinoma
Old smoker presenting with Hyponatremia, moist mucous membranes, and no JVD
SIADH from small cell carcinoma
ARDS Dx and Tx
PaO2/FiO2 <200
Bilateral alveolar infiltrates on CXR
PCWP <18
Tx: Mechanical ventilation with PEEP
Esophageal varices Tx
Endoscopic Sclerotherspy or banding
Do not do these prophylactic ally
Female athlete triad for stress fracuture
Low caloric intake
Hypomenorrhea/amenorrhea
Low bone density
Burn wound sepsis
Presents as fever, tachycardia, tachypnea, increased blood glucose and WBC, ️Decreased platelets, oliguria, and mental status changes
Tx: Broad spectrum abs
-Likely a gram neg org after 5 days
Anatomic snuffbox muscles
Medial- Extensor pollicis Longus
Lateral-Extensor pollicis brevis, abductor pollicis longus
Confirmation of a scaphoid fracture if the x ray is negative
MRI
Ileus
Functional defect in bowel motility without any associated obstruction; presents as N/V, distension, obstipation, and Hypoactive bowel sounds
-Common postoperative due to opiate administration, inflammatory mediator action,and hypokalemia
Prosthetic joint infection
Early onset (within 3 months): Presents as wound drainage, erythema, swelling, fever -Staph aureus, GNRs, anaerobes
Delayed: Presents as joint pain,implant loosening
-Staph epidermidis, Enterococci
Post op Atelectasis lab values
Slightly basic pH
️Decreased pO2
Slightly ️Decreased pCO2
Dumping syndrome
Rapid emptying of hypertonic gastric contents; is a post-gastrectomy syndrome that occurs in many Pts
-Caused by loss of the normal action of the pyloric sphincter due to injury or surgical bypass leading to the shifting of fluid into the SI from the vascular space
Sx: Abdominal pain, diarrhea, nausea, hypotension, tachycardia, dizziness, confusion, fatigue, diaphoresis
Tx: Small meals, high carb, fiber, and protein diet (avoid sugars)
Acute Mesenteric ischemia
Can occur due to embolism from cardiac valve vegetations during endocarditis or from Pts with AFib
Sx: Sudden onset of severe periumbilical pain that is out of proportion to the expected exam, hematochezia,
Lab: Leukocytosis, elevated amylase and phosphate, metabolic acidosis, elevated lactate
Dx: CT
Post op infection in dehydrated old patients
Acute bacterial parotitis
Prevent with adequate hydration and oral hygeine
Complicated of AAA repair
Bowel ischemia
-Loss of IMA during surgery and no collateral circulation causes
Sx: abdominal pain, bloody diarrhea, fever, Leukocytosis
Most common complication of appendectomy
Infections, intrabdominal abscess with laparoscopic procedure
Follow up after diagnosis of a broken clavicle
Angiogram
Ischemic colitis
Abdominal pain and bloody diarrhea following a vascular procedure
RFs: Old age, chronic renal Disease, atherosclerotic disease, vascular surgery, MI
Sx: Mild pain and tenderness, hematochezia, diarrhea, lactic acidosis
Dx: CT shows thickened bowel wall and double halo
Colonoscopy shows mucosal pallor, petechiae, and hemorrhage
Tx: Supportive, IV antibiotics, colon resection
Blow to the lower abdomen
Consider rupture of the dome of the bladder
Leads to chemical peritonitis
Reynolds pentad
RUQ pain
Jaundice
Fever
Hypotension
AMS
Describes cholangitis
Tx: Ciprofloxacin and metronidazole
Think of this with gastric varices
Splenic vein thrombosis
And this could possibly be caused by ️Chronic pancreatitis
Suspected if stomach ulcers don’t resolve
Zollinger Ellison
-Test with a secretin stimulation test which would normally decrease Gastrin levels
Whipples triad
Fasting hypoglycemia <50
Symptoms including sweat, tremors, hunger
Relief of symptoms after glucose administration
-If you see these, it’s an insulinoma
RUQ pain, night sweats, palpable liver
Consider entamoeba histolytica
-Tx with metronidazole
Large livers cysts and fevers in an immigrant
Echinococcus
Transmitted thru dog feces
Traumatic splenic rupture
Consider with left lower rib fracture and intrabdominal hemorrhage
May also have diaphragmatic irritation
Most common site of carcinoid tumor
Appendix
Symptoms only appear when there are liver mets
Look out for diarrhea, dementia, dehydration, dermatitis
Volvulus Tx
Decompression from below if not strangulated; surgery if it doesn’t work or is strangulated
Most commonly ️Occurs in the secum or sigmoid
Signs of PE
Right heart strain
️Decreased vascular markings
Sinus tachycardia
Low co2 and O2
Varicocele
Soft scrotal mass with a bag of worms appearance
⭐️Decreases in size when laying down, increases when standing or with Valsalva
US: Retrograde venous flow, tortuous tubules, dilation of the Pampiniform plexus
⭐️More common on the left due to nutcracker syndrome
Tx: Gonadal vein ligation, scrotal support and NSAIDS if you don’t care about kids
Meningioma
Benign primary brain tumor that is usually well-circumscribed and a homogenously enhancing mass on MRI; can be calcified or appear hyper dense
Tx: Resection
Suspected diaphragmatic rupture
Check CXR for loops of bowel in the chest and shifting of the mediastinum
Will not always have bowel tho, sometimes it’s just an elevation of he left hemi diaphragm
Also follow up with a CT scan
Hematuria in a AAA
️Occurs due to the formation of an aorta Caval fistula to the IVC causing venous congestion to Retroperitoneal structures like the bladder
➡️hematuria
Paralytic ileus
Presents as abdominal pain following a traumatic injury, surgery, ischemia, and Hypokalemia
Sx: N/V, abdominal distention,constipation, obstipation, absent bowel sounds
Dangers of Retropharyngeal abscess
Thrombosis to the internal jugular and deficits in CN IX, X, XI, XII after spread to the carotid sheath
Acute necrotizing mediastinitis because the Retropharyngeal space drains here
⭐️LIFE THREATENING ️EMERGENCY
Tx of septic shock
IV fluids
- important to restore adequate tissue perfusion
- given as boluses
Identify underlying infxn and treat
Sx: Fever, tachycardia, hypotension, poor UOP, lactic acidosis, ️Decreased albumin
Compartment syndrome signs and symptoms
Pain out of proportion
Pain on passive stretch
Increase swelling
Parasthesia
Uncommon: ️Decreased sensation, motor weakness, paralysis, ️Decreased distal pulses
Mediastinal widening with a big aorta and history of blunt thoracic trauma
Think aortic rupture
Sx: Anxiety, tachycardia, HTN
Possible deviation of the trachea or nasogastric tube
Acute mediastinitis
Possible complication of cardiac surgery that is due to intra operative wound contamination
Sx: Fever, tachycardia, chest pain, Leukocytosis, sternal purulent wound drainage, widened mediastinum
Tx: Surgical debridement, antibiotics
Emphysematous cholecystitis
Form of acute cholecystitis where there is infection with gas producing bacteria like Clostridium
RFs: Vascular compromise, Immunosuppresion, gallstone
⭐️may detect crepitus in the RUQ
Torus palatinus
Benign bony growth located on the midline suture of the hard palate
Due to genetic and environmental factors
Usually present for a long time, is nontender, and feels bony
Can easily ulcerate with trauma and have trouble healing
Anal fissure Tx
High fiber diet
Adequate fluid intake
Stool softeners
⭐️Sitz bath
⭐️Topical anesthetics and vasodilators (nifedipine, nitroglycerin)
Lateral sphincterotomy if all else fails
Hint for abnormal neck masses
7 days= inflammation
7 months= Cancer
7 years= congenital
MCCo malignant tumor of the parotid
Mucoepidermoid carcinoma
Causes pain and CN VII palsy
Newborn with scaphoid abdomen and respiratory distress
Diaphragmatic hernia
Why give epinephrine with lidocaine?
Prevent possible systemic absorption which may cause
Tongue numbness
Seizure
Hypotension
Bradycardia
Arrhythmia
⭐️ DO NOT PUT EPI IN FINGERS TOES OR PENIS
Person who has trouble breathing after epidural or is bradycardia
“High block”