SRGRY BLOCK II Flashcards
mainstay of evaluation of the mediastinum
Cervical mediastinoscopy
What is the procedure to sample nodes and biopsy tissue in anterior mediastinum
Anterior mediastinotomy - “Chamberlain Procedure “
most common evaluation of a solitary pulm nodule
Needle Bx
standard approach for open lung biopsy
Surgical Biopsy: thoracoscopy
PET vs CT in looking at mediastinal lympnodes
PET more accurate than CT scan in detection of cancer spread to mediastinal lymph nodes
PTX with loss of V/S in the ED or shortly after=
ED THORACOTOMY
Standard to Dx PTX
The posteroanterior (PA) and lateral chest radiograph
Exhalation accentuates the contrast & magnitude of collapse
How can you Dx a PTX from a Large Bullae
CT SCAN
Most common plueral problem
PTX
Are primary pleural tumors common
NO, involvement of the pleura with metastatic cancer is common
Pleural Effusion: Chylothorax
cloudy, milky fluid, numerous fat globules & few cells, mainly lymphocytes
Amount of fluid required to blunt the Costophrenic Angle on AP/PA films
300-500 mL fluid - blunting of the costophrenic angle
entire hemithorax opacified - 2000-2500 mL may be present
Imaging for complex, loculated, or recurrent collections of pleural effusions
CT
Threshold for Transudative Effusion
total protein content <3 g/dL,
an LDH level less than 200 units/dL,
and a specific gravity below 1.016
> 25% of all pleural effusions are secondary to
CANCER
Steps for Thoracocentesis in Pleural effusions
Identify needle insertion site
Anesthetize area
Sterile prep and drape
Insert needle under negative pressure
(9th or 10th Intercostal space, mid scapular line)
Collect/drain fluid
Withdraw needle and bandage
Send fluid to lab for analysis!!
Post procedure CXR!!
When chest tube output falls below 200 mL/day and reexpansion of the lung is verified
What is the next step
pleurodesis should be performed
Chest tube for malignant effusion
Chest tube (20-28F) & closed-tube drainage for 24-48 hours then Pleurodesis
Dx of Choice for Empyemas
Procedure of choice for diagnosis: Thoracentesis
Chest tube for hemothoraces
Large-bore (32-36F) closed chest tube drainage
Diet for Chylothorax
Low fat diet
Agents for pleurodesis
talc, or doxycycline
Tx for a lung abscess
First-line - aerobic and anaerobic coverage for 4-6 weeks
In patients who do not respond - Percutaneous drainage
Operative intervention :
failure of clinical or radiological improvement after 4-6 weeks of abx therapy or Empyema
MC agent of Empyema
Staph
a pleural fluid glucose level less than 40 mg/dL and a pH less than 7.0
Empyema of more than 7 days
D shape density on CXR
EMPYEMA!
Dx for a Empyema
CXR: D shaped density
Thoracentesis - procedure of choice for diagnosis of thoracic empyema
Then bronchoscopy: r/o obstruction and CT scan: DDX lung abscess
Thoracocentesis: pH <7.0 glucose <40 mg/dL LDH level >1000 units/L strongly suggest
Evolving Empyema
EMpyema Tx:
Initial treatment - closed tube thoracostomy
If question of therapeutic adequacy at 24-72 hours – CT scan
Candidates for open drainage
thoracoscopic or open lobectomy
MC central lung tumor
Small Cell
MC peripheral lung tumor
Adenocarcinoma
ipsilateral miosis, ptosis, and anhidrosis
Horners
ipsilateral shoulder and arm pain in the C8-T1 nerve root distribution, Horner syndrome, and a superior sulcus—usually squamous—lung cancer
Pancoast
Paraneoplastic syndromes of carcinoid and small cell CA
Carcinoid syndrome
Paraneoplastic Syndrome of Small cell Cancer
SAIDH
Paraneoplastic Syndrome of Squamous, Large cell and Adenocarcinoma
Hypertrophic Pulmonary Osteoarthopathy (clubbing, growth fxs)
A pt presents with SAIDH
(low serum Na), Hyper pigmentation, and Cushings Syndome/ gl intolerance
Think
Small Cell Lung Caner
What is the approach to Dx a Lung Neoplasm
CT Scan + Upper Abdomen Scan
(With contrast to eval Mediastinum)
Serum Alk Phosphatase
(If elevated: bone scan+ brain MRI/CT)
PET Scan for metz
Drain if there is a Pleural Effusion
Threshold size for benign vs malignant neoplasm in the lung
Less than 2 cm is likely benign
absolute contraindications to standard resection of a pulm neoplasm
Significant pulmonary hypertension and myocardial infarction within 3 months
3 types of Aneurysm
Saccular- discrete outpouching of vessel wall
Fusiform- diffuse
Mycotic- associated with infection
If a AAA is palpable as a pulsatile mass on US
What is the approx size
5 cm
Most appropriate initial test to eval AAA
US
Best for following size of AAA
Gold standard for pre op imaging for a AAA
CTA
Threshold for repair or a AAA
Asymptomatic- elective if >5.5cm
Symptomatic- emergent repair regardless of size
Rapid expansion >1cm/year
What type of complication should be strongly considered in a pt with recent abdominal aortic surgery
Communication with GI tract -> aorto-enteric fistula (GI bleed)
What is the most reliable test to eval a Aortic Transection
CT Angio
Stanford A vs B
Which is more likely to rupture
Stanford A
Standard imaging for a Aortic Dissection
CT
Abrupt onset of tearing, chest/back/abdominal pain
Pulse deficit or BP difference >20mmHg
Wide mediastinum on CXR
Think
Aortic Dissection
Difference in treating ascending vs descending Aortic Dissections
Ascending aortic dissections Surgical management (EMERGENT)
Descending aortic dissections
Medical management
Acute vs Chronic Mesenteric Ischemia
Acute:
- Severe/diffuse abdominal pain
- Pain out of proportion to physical exam findings
- Normally no signs of peritonitis
- May lead to peritonitis if bowel becomes necrotic
Chronic:
- Food fear- post prandial abdominal pain
- Weight loss
- Diarrhea, nausea, vomiting
Imaging study to Dx Mesenteric ischemia
CTA or arteriography > Ultrasound
Risk factors for ischemic colitis
cardiovascular insults, aortic bypass surgery, aneurysmal rupture, prolonged strenuous exercise, vasculitis, and hypercoagulable state.
Tx for colonic ischemia
Supportive care - IV fluids, bowel rest, and antibiotics
colonicinfarction - require surgical treatment
Threshold to define TIA vs CVA
If the neurologic deficit lasts no longer than 24 hours and has complete resolution, it is defined as a TIA.
Deficits lasting longer than 24 hours are classified as stroke.
What is often the 1st S/s of CAD
Amaurosis fugax
If you find hollenhorst plaques in the retina
What is the next step
The next study in this patient should be an ultrasound of the neck.
3 causes of carotid related CVA
- Embolization (Most Common)
- Platelet aggregation on plaque and breaks off
- Central plaque degradation and breaks off - Cardioembolism - from Atrial fibrillation
- Flow-related brain ischemia
- Narrow artery -> decreased brain perfusion
most useful test in Carotid Artery Dz
Duplex ultrasound- Most useful test
-assesses luminal diameter and blood flow
What is the gold standard eval for Carotid Artery Stenosis
Carotid/Cererbral arteriography - “Gold Standard” and usually only if surgery is anticipated
Tx for Carotid Artery Dz
STOP SMOKING
Daily 81 mg Aspirin
(Clopidogrel should not be initiated if pending surgery)
Serial Duplex Scans
If SRGRY: stenosis >50% within the ipsilateral internal carotid artery
- > Endarterectomy
- > stent (younger pt, need’s Clopidogrel for 6 weeks post op)
How long is Clopidogrel started post op for a carotid stent
6 weeks post op
A pt presents with Light headedness anytime they use their arm
Think of what vascular problem
Subclavian Steal Syndrome
Stenosis of the subclavian artery
What are the two most common sites for PVD
Superficial femoral and iliac arteries the most common
PVD with calf pain
What artery>?
Femoral
PVD with buttock/ Thigh pain
What artery
Iliac
PVD with impotence
What artery
Aortic disease
A pt with PVD that is Hang leg over edge to decrease pain or sleep in chair
Think
Impending limb loss (rest pain)
Pt presetns wtih decreased pedal pulses, with loss of hair over the legs and shinny skin
+dependent rubor
Think
PVD
Look for a decreased ABI
ABI - < 1.0 indicates
occlusive disease proximal to point of measurement
What is the main stay of vascular imaging in PVD
Duplex US
CTA if SRGRY is indicated
Single most important risk fx for PVD
Smoking!
Rx for PVD
Statins
Antiplatelet drugs (Aspirin &/ Clopidogrel)
Cilostazol
(phosphodiesterase inhibitor for vaso dilation)
Pentoxiphylline
(decrease blood viscosity)
6 Ps of acute arterial occlusion
Pain out of proportion Pallor Poikilothermia (cool) Paresthesia Pulseless Paralysis
Tx for a acute arterial occlusion
Anticoagulate with heparin
(in atraumatic patients)
Arteriogram (if light touch is intact)
Embolic- thrombolytics or embolectomy
Emergent if neurologic compromise= Immediate surgical intervention; ie. skip imaging
Trauma- repair/embolize artery, +fasciotomy to prevent compartment syndrome
A pt presents with ischemia with exercise and is AS/s at rest
Atherosclerotic changes are absent on US
Thinks
Popliteal Artery Entrapment
- Abnormal insertion of medial head of gastrocnemius
- Medial deviation of popliteal artery
Treat with SRGRY
What is the workup for Symptomatic Penetrating injuries to the extremities
CT angiogram
Arteriogram
Ultrasound
Functional unit of the breast
Lobes are the functional unit of the breast and produce milk
What is the most common Cancer of the breast
Ductal carcinoma is most common
Lobular carcinoma is rare
What is mondors dz
Trauma of chest wall vein after trauma/surgery
W/u for Mastalgia
Address specific complaint
Complete CBE +/- CXR
What should be used to evaluate a mass in the breast
Mammography and ultrasonography should be used to evaluate a mass in a patient with fibrocystic condition.
When do we cut out a fibroadenoma from the breast
(Young woman with decreased incidence approaching menopause
Smooth or slightly lobulated approx. 1-3cm in diameter)
Excise for >35YOA, >2.5 cm, interval growth, unclear on bx, or if patient desires
When do we refer for SRGRY with nipple DC
Refer to surgery if unilateral or positive findings during w/u
F/u for nipple DC
Most are intraductal papilloma or mammary duct ectasia (benign conditions)
<15% DCIS (ductal carcinoma in situ)
Reexamine every 3-4 months for a year
mammogram and an ultrasound !!
What is the W/u for Galactorrhea
Not associated with breast cancer
Check for hyperprolactinemia or hyperthyroidism
-bitemporal hemianopsia
Diagnostic MMG
Reexamine every 3-4 months for a year
mammogram and an ultrasound
What is the approach to acute mastitis
Antibiotics to cover staph and strep
(Culture dependent)
Localized moist heat
Continue to drain breast
(pump or continue to breast feed)
What is the treatment for a breast abscess
Usually starts as mastitis
+ Systemic symptoms- fever, chills, sweats, leukocytosis
TX: Stop nursing
- Admission and IV antibiotics
- Incision & drainage in the OR
- I&D and Bx can be done in OR
What is polythelia
Extra nipple with or without underlying breast tissue
Normally noticed during pregnancy
Can occur anywhere along milk line
Completely cosmetic/benign
Tx: elective SRGRY
Approach to Unilateral Gynecomastia
Normally in young men
-No nipple discharge
Usually cosmetic concern or can have tender mass behind nipple
Obtain MMG or US if warranted
Reassure that it is not likely malignant!!
Usually regress with time but teenagers are impatient
What is the approach to BILATERAL Gynecomastia
Associated with decreased androgen production as a man ages
Reassurance or routine consult to General Surgery
BIRADS categories
0- Additional imaging needed
1-Negative/Normal
2- Benign findings (vascular calcifications, stable lesions, etc…)
3- Probably benign (<2% risk of malignancy, repeat in 6 months or Bx)
4- Suspicious (consider Bx)
5- Highly suggestive of malignancy (definitely Bx)
6- Biopsy proven malignancy
If US useful in the screening of Breast Cancer or Masses
US not useful in screening
Used to guide needle for Bx or aspiration
What imaging modality is especially good for dense breast tissue or those with implants
MRI
RSK fxs for Breast CA
Females
Advanced age
Excessive estrogen exposure
First degree relative with Breast Cancer
Breast Bx with atypia
BRCA oncogenes
- BRCA 1- 50-70% lifetime risk of breast cancer
- BRCA 2- 20-40% lifetime risk of breast cancer
A pt finds a painless lump in the breast with irregular margins
Think
Breast cancer
May have: Skin dimpling Nipple retraction Fixation to chest wall Axillary lymphadenopathy Peau d’ orange
What is the approach to imaging breast Cancer
Diagnostic MMG with F/U US
Then Bx as needed
What is the Bx approach for a palpable mass
Open Bx
What is the use of finding the sentinel lymphnode in breast cancer
If the lymph node does not have cancer, then metx is unlikely
If sentinel node does have cancer,
surgeon will perform axillary lymph node dissection and may need mastectomy/modified radical mastectomy, with chemo and radiation
When looking at cancer bio markers
(ER, PR, and HER2)
A triple negative means what?
Triple negative breast cancer
- Most are BRCA 1 oncogene positive
- Negative for ER, PR and HER2
More aggressive than other breast cancers with no targeted Tx
-Worst prognosis
Mainstay Tx with Chemotherapy
What is the treatment for breast cancer and a postive HER2 bio marker
HER2- Human Epidermal Growth Factor Receptor
-Poor prognosis 2/2 rapid metastasis
Treatment with monoclonal antibodies
What is the approach to lobular and ductal carcinoma in Situ
Lobular Carcinoma In Situ
- Marker for cancer
- Still encapsulated in the lobe
30% chance of developing cancer
Ductal Carcinoma In Situ (80% of all BC)
- Cancerous lesion and must be removed
- After excision, XRT to remaining breast tissue
What kind of breast cancer is more likely to be bilateral
Lobular
What is the F/u for bilateral breast cancer
MMG
Define Pagets Carcinoma
Ductal carcinoma involving the nipple
May or may not have palpable mass
Usually associated with nipple itching/burning
Eczematoid/crusted lesion on the nipple or areola
Any lesion refractory to topical abx or steroids >1 week should be referred to surgery!!
Mastitis in non lactating women.. think
Inflammatory breasts cancer
Should be very high on differential in non-lactating woman!
-> biopsy - invasion of the subdermal lymphatics
Tx: neoadjuvant chemotherapy, surgery, and radiation
Risk factors for breast cancer in men
average age at occurrence is about 70 years
increased incidence in men with prostate cancer
First-degree relatives are considered to be at high risk
BRCA2 mutations are common
What is the most important prognostic variable for breast cancer
Most important prognostic variable
-whether the tumor has metastasized to the axillary lymph nodes
When can drains be pulled from the breast after SRGRY
Normally drains are left in to prevent
Seromas
Drains are emptied daily/PRN and output measured
Drains are pulled when drainage <30ml/24H
Winged scapula is damage to what nerve
Long thoracic nerve
Loss of function to the latissimus dorsi is from what nerve injury
Thoarcodorsal nerve
Duration of XRT for breast cancer
Usually 2-6 weeks after surgery 5X week for 6-8 weeks
What is the most common metx for breast cancer
commonly metastasizes to the liver, lungs, and bone
A pt with breast cancer that then presents with HA, imbalance, vertigo. Vision changes
Think
Metx to the brain \
Triple-negative and HER2-positive tumors have a higher rate of brain metastases
What is TRAM SRGRY
Think about Priscilla
TRAM
(Transverse Rectus Abdominus Muscle) -flap can be used to reproduce the breast mound after mastectomy
After mastectomy, tissue expanders are often placed under flap
Gradually increase saline content to expand tissue until optimum size
Once desired size is achieved, permanent implant is placed
What separates an inguinal vs femoral hernia
Inguinal hernia- originates above inguinal ligament
96% of groin hernias
Femoral hernia- originates below inguinal ligament
4% of groin hernias
Layers of excision to repair a hernia
Skin.
Campers and Scarpas fascia
External and internal oblique
Transverse muscle and Fascia
Preperitoneal fat
Peritoneum
What defines an indirect inguinal henria
Indirect inguinal hernias - develop at the internal inguinal ring and are lateral to the inferior epigastric artery.
What defines a direct inguinal hernia
Direct inguinal hernias - occur through Hesselbach’s triangle
formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus muscle medially.
Where do congenital hernias arise from
Congenital hernia from patent processus vaginalis
Same congenital defect which causes hydroceles
Intestinal contents travel down spermatic cord
Pass thorough the deep and superficial inguinal ring
Most common hernia in both sexes
Direct inguinal hernia risk factors
Obesity
Pregnancy
Heavy lifting
Chronic cough
Straining to void (BPH/prostate ca)
Constipation
Cirrhosis with ascites
W/u for an inguinal hernia
Finger in the scrotum
Testicular eval
+ DRE
Initial Dx modality for an inguinal hernia
US (groin)
+/- KUB
+/- CT for SRG repair
What are the indications for laparoscopic hernia repair
Recurrent
Bilateral
Or need for early return to play
What nerve can be prophylactic devision to reduce chronic pain in an inguinal hernia
Ilioinguinal nerve
Recovery time for inguinal hernia repair
Laparoscopic : about 15 days
Open: about 34 days
Who is more likely to have femoral hernias
Women
Where do epigastric hernias come from
Protrusion through the linea alba above the umbilicus
What is the approach to umbilical hernias in newborns
Most spontaneously close prior to school age
Repair at age 2 if it persists
Rare to incarcerate
What is the approach to umbilical hernias in adults
Risk factors: multiparity, obesity, ascites, intra-abdominal tumors
Slowly enlarge and may incarcerate
Refer for elective surgical repair
-Emergency repair is often necessary
What is the approach to wound dehiscence
S/S: Yellow-pink (salmon) colored fluid
-Peritoneal fluid
Must return to OR for fascial closure PRIOR to evisceration
Call surgeon ASAP to evaluate patient and prepare for OR
Acute fascial dehiscence= evisceration
-Emergent surgical evaluation
Delayed fascial dehiscence =incisional hernia
-Urgent surgical consult
What is a sports hernia
Not a true hernia
Series of micro tears of:
- Adductor
- Rectus
- Femoris
- Psoas
- Hip flexor
- Obliques
What is the Tx for a sports hernia
SRGRY if:
- Lifestyle limiting pain
- Failure of conservative Tx >8 weeks
- Exclusion of other Dx
Where do hydroceles come from
Results from patent processus vaginalis
Peritoneal fluid ->hydrocele
What is the treatment for epididymitis in a young vs old man
Young man
- STI panel
- NSAID
- Scrotal support
- ABX for STIs!
Older man -STI panel -Scrotal support -NSAID -ABX for Gm neg rods!! (E Coli)
What is the treatment for Spermatocele
Benign finding
Confirm with US
Surgical intervention
Varicocele on the R side of the pt
Think
If on right or later in life, evaluate for mass occluding spermatic vein
When should SRGRY be done for pts with Varicocele
Surgery reserved for infertility of spermatic vein occlusion
Solid Mass on a testicle is…
Cancer UPO
Urgent referral for US and surgery
W/u for testicular torsion
Urgent US with Doppler and surgical evaluation
If testis viable ->
re-profuse and perform orchiopexy
If ischemic/necrotic -> orchiectomy
Most common post surgical complications 0-48 hours
Respiratory and cardiovascular issues
- Failure to maintain ventilation
- Aspiration
- Sudden cardiac event
- Hypotension
Most common post operative complications 48hours -30 days
Localized
- UTI
- Pneumonia
Systemic
- SIRS- Systemic Inflammatory Response Syndrome
- MODS- Multi Organ System Failure
Most common complication following anesthesia
Atelectasis
```
Presentation:
-Low grade fever
usually post operative
-Decreased breath sounds
-Basilar rales
Seen on CXR
~~~
Tx for post surgical pneumonia
Antibiotics
Aggressive pulmonary toilet
Intubation/mechanical ventilation
- Maintain PCO2 35-45
- Maintain O2 sats >95%
What is the single greatest risk factor for VAP
Single greatest risk factor is the duration of mechanical ventilation
-peaks at day 5 plateaus at day 15, and then significantly declines
Tx for aspiration in SRGY
Suction immediately
-Bronchoscopy
Bronchial hygiene
Antibiotics
Mechanical ventilation
Pulmonary edema that does not responde to diuretics
(Is not 2/2 HF)
Think
ARDS
Treat with mechanical ventilation: -Increased PEEP
increases functional residual capacity
Tx for ARDS
Moderate PEEP settings 10-15cm (>15cm PEEP considered high)
Lower tidal volumes 5-7ml/kg IBW vs traditional 10-15ml/Kg IBW
Maintain FiO2 <60% to avoid O2 toxicity
Increase the expiration time (inspirational hold) ->more alveoli open
Prone ventilation
Airway Pressure Release Ventilation
Lower Vt
Shorter burst breaths with low amplitude but rapid frequency at Vt max
When should we remove central lines
removal when not necessary or <7 days
A pt presents with resp insufficiency, confusion or coma, with petechia
After a long bone fx
Think
Fat embolus
What is the tx for a fat embolus
Supportive care
- positive end-expiratory pressure ventilation
- diuretics
Monitor ABG
Rule out MI/PE
Early fracture management
-External fixation or ORIF
RSK factors for a DVT
Major trauma malignancy age > 40 pregnancy, post partum or OCP use prior DVT prolonged immobility (travel by air, bus, long car ride)
Surgery specific
- Post op bed rest
- Pelvic/lower extremity surgery
- Major general surgery
- Central lines
W/u for a DVT
Duplex US
Prevention and Tx for DVT
Prevention
- Elastic stockings for compression
- Early ambulation
- Sequential Compression Devices (SCD)
Treatment - Anticoagulation
-Heparin, LMWH
-Anti-Xa or Direct thrombin inhibitors
Dabigatran & edoxaban require IV anticoagulation prior to initiation
-Warfarin
Wells criteria
S/S of DVT (3 points)
No other Dx (3 points)
TachyHR (1.5 points)
Immobilized x 3 days (1.5 points)
(Or SRGY in past month)
Prior DVT (1.5 points)
Hemoptysis (1 point)
malignancy (1 point)
Score above 4= think PE
Less than 4= D dimer
Less than 2= PERC them out
PERC out criteria
Age <50
heart rate <100
O2 sat >95
No hemoptysis No Estrogen use No Prior DVT or PE No Edema No SRGRY in past 4 weeks
New onset a fib or a RBBB
In a post SRGRY pt
Think
possible PE
Test of choice for a PE
Spiral CT pa
VQ if pregnant or poor renal function
Tx for a PE
Supplemental O2 and IV access \+Anticoagulation -SQ low molecular weight heparin -IV unfractionated heparin (where bleeding is a concern)
Oral warfarin for 3-6 months
-Therapeutic INR 2-3
Oral Xa or direct thrombin inhibitors
- Rivaroxaban and apixaban
- Dabigatran and edoxaban – require parenteral anticoagulation
Inferior Vena Cava filter (IVC filter)
-Use with PE from distal DVT and contraindicated for oral anticoagulation
What Rx can be given pre op to mitigate ileus
Mitigate with pre-op Entereg (alvimopan) and minimizing bowel manipulation
What is the most common cause of C. Diff
Most common cause: antibiotic associated diarrhea
-Clindamycin, cephalosporins, floroquinolones
ABX disrupt gut flora
C. dif overgrowth (spore forming, anaerobic, gm postitive bacillus resistant to most abx)
Suspect in patient with > 3 loose stools in 24 hours
Tx for C. Diff
Oral Vanc or metro
How long should a pt have a catheter in place s/p SRGRY to the sacral plexus
4-5 days
Most common complication of bladder Cath
Most common complication- UTI
Use sterile technique to insert
Remove ASAP when no longer needed
What is the treatment for DIC
Fresh frozen plasma - indicated for the replacement of coagulation factors
What is the treatment for post surgical seroma/ hematoma
Small- resolve spontaneously
Large- aspirate or open to decompress
What is the tx for surgical site infections
Surgical Site Infection
Open, irrigate and pack
Avoid temptation to reclose
Tx of compartment syndrome
Prevention/treatment
-Incise from skin through fascia
Fasciotomy- allows muscle to swell without compressing vessels
(Can also result from vascular trauma and insertion of IO into fractured long bone)
What is the approach to abdominal compartment syndrome
If the abdomen is closed, evaluate frequently for acidosis, decreased urine out put and increased lactate.
Can be mitigated by:
- Abdomen not closed and covered with wound vac
- Allows for tissue expansion and minimizes tissue ischemia and dehiscence
What is the wind water wound for fever in a post SRGRY pt
Wind- Atelectasis, pneumonia
Water- UTI
Wound- SSI
What is the risk of using Vanc or Aminoglycosides
Ototoxicity
What is the ICU death spiral
Systemic Inflammatory Response Syndrome (SIRS) 2 or more of the following -Temp >38.5°C (101.5° F) -Tachycardia -Tachypnea -Leukocytosis
Sepsis
-SIRS with a source
Septic shock
-Sepsis with end organ failure or MODS
Death
Exposure to XRT increases the risk of what type of thyroid cancer
Papillary
TSH low with high T3, T4
Hyperthyroidism (functional nodule)
What are two thyroid abs
Antithyroglobulin and antimicrosomal
What is the 1st line Dx of a solitary thyroid nodule
FNA
When should you use RAI scan
In a pt with hyperthyroidism, and evaluation of a nodule
Hot vs cold nodules
(follicular neoplasm)
Most nodules are cold
If hot (hormonally active) likely benign T3-T4 high and TSH low
On RAI scan
A pt has Low TSH and increased RAI uptake
Hyperthyroidism
On RAI scan a pt has low TSH and decreased RAI uptake
Subacute thyroiditis
Indications for thyroidectomy
Suspected or proven cancer on FNA
Malignant (papillary or medullary)
Follicular neoplasms
-Can’t differentiate between adenoma (benign) and carcinoma (malignant)
Atypical cells
Hormonally active nodules
Cystic nodules which recur after 2+ aspirations
Functionally malignant
Cosmesis
benign tissue hyperplasia surrounded by fibrous capsule
May be cold or hot
Follicular adenoma
SRGICAL removal
A hyperfunctioning adenoma that is less than 4cm
Rads Iodine
hyper functional adenoma >4cm
SRGRY
3 Ms of medullary thyroid cancer
Multi focal
Multi lobular
Metx
Role or thyroxine in cancer treatment
replace hormone and suppress mets
Radioactive iodine post cancer treatment
after thyroidectomy, reduce recurrence and increase survival, treat recurrence and mets
When would XRT be used for thyroid cancer
XRT- local invasion, recurrent, metastatic or unresectable mass
Approach to a thyroglossal cyst
Ultrasound for evaluation
Check thyroid function tests
Treat with antibiotics prior to elective surgery (avoid I&D)
Most common neoplasm to the anterior mediastinum
Thymoma – most common neoplasm
Substernal thyroid – most common clinical presentation
Most common neoplasm to the middle mediastinum
Lymphoma
Bronchogenic cyst
Most common neoplasm to the posterior mediastinum
Neurogenic tumor
Bronchogenic cyst
If a goiter has localized areas of hardness or rapid growth
What should you do
Aspiration biopsy cytology
Most common causes of hyperthyroidism
Hypersecretory goiter (Graves disease)
Or
Toxic multinodular goiter (Plummer disease)
Two tests in the eval of Thyrotoxicosis
T3 suppression test - hyperthyroid patients fail to suppress the thyroidal uptake of radioiodine when given exogenous T3.
TRH test - serum TSH levels fail to rise in response to administration of TRH in hyperthyroid patients.
Tx for Thyrotoxicosis
Methimazole
usually used in preparation for surgery or RAI treatment but may be used as definitive treatment
Then Radiodine
- after the patient has been treated with antithyroid medications and has become euthyroid
- indicated if over 40 years or are poor risks for surgery & for patients with recurrent hyperthyroidism
What is the Treatment of hyperthyroid patients requiring an emergency operation or those in thyroid storm
prevent release of preformed thyroid hormone - Lugol iodine solution or with ipodate sodium
give β-adrenergic blocking agents to antagonize the peripheral manifestations of thyrotoxicosis
decrease thyroid hormone production and extrathyroidal conversion of T4 to T3 by giving propylthiouracil
A pt with a decreased serum Ca2+ and an elevated PTH
Think
Secondary hyperparathyroidism (decreased serum Ca +elevated PTH)
- Chronic renal failure
- Malabsorption
What are the lab findings in Primary Hyperparathyroidism
High serum calcium - most important
Low phosphate
Increased alkaline phosphatase
Elevated BUN and creatinine
Hyperchloremic metabolic acidosis
If a pt presents with High serum calcium and a low phosphate
Think
Cancer (breast)
What is the imaging to find Substernal parathyroid glands
Advanced imaging- sestamibi, CT, MRI
Differnce between primary and secondary hyperparathyroidism
Primary (benign)- parathyroid glands excrete excess PTH
- Parathyroid adenoma
- Parathyroid hyperplasia
Secondary (malignant)- tumors produce PTH mimicking hormone or other cancer has metastasized to the bone
What is the surgical critera to remove parathyroid glands
Significant symptoms
- Renal stones
- Osteoporosis
- Hypercalcemic crisis
Or if serum calcium is greater than 1 mg above NML
GFR less than 60
T score less than 2.5 or h/o Fx
Age less than 50
What is the threshold for suspicion in a incidentaloma
Greater than 5 cm
If <5cm and confirmed benign, repeat CT in 3-6 months
A pt presents with Hyponatremia, hyperkalemia (aldosterone deficiency)
Hyperpigmentation (increased ACTH and CRH-> melanocytes)
Think
Renal failure
Adisonian Crisis
What tumor should be suspected in part with neurofibramatosis
Pheo
