Surg Flashcards
Airway
Open if pt can talk
Epidural hematoma
Unconscious period and then lucid and then unconscious
Subdural hematoma
Craniotomy if midline deviation. If not, monitor ICP. Head of bed up, sedation, hypervent
Linear skull fractures
Leave alone if closed and there is no overlying wound
Urethral injury
Blood at meatus and pelvic fracture. Do retrograde urethrogram (NOT Foley)
Penetrating injury of extremities
If no vessels, just do tetanus prophylaxis. If major vessels are near, do CT angio or doppler. If there is obvious vascular injury, do surg exploration and repair
Limited severe burn (<20%)
Do early excision and grafting
Developmental dysphasia of hip
Hereditary - uneven gluteal folds, can be dislocated with jerk and click. Don’t x-ray (hip is not calcified). Abduction splint with harness
Broken clavicle
Place arm in a sling
Hip fracture
Shortened leg and externally rotated
Posterior hip dislocation
Shortened leg and internally rotated
Femoral neck fracture
Replace femoral head with prosthesis
Intertrochanteric fracture
Open reduction and internal fixation
Gamekeepers Thumb
Torn ulnar collateral ligament so thumb hangs limp with collateral laxity
Trigger finger
Wake up with flexed finger and have to snap it back
Jersey finger
Can’t flex finger (ruptured flexor tendon). Splint
Mallet finger
Can’t extend finger (ruptured extensor tendon) and finger looks like mallet. Splint
Felon (finger)
Abscess in pulp of fingertip. Surg drainage
Marjolin Ulcer
SCC of skin developing in chronic leg ulcer. Biopsy edge and do wide local excision and graft
Fistula of GI tract
Bowel contents leak through a wound or drain site. Can cause sepsis, fluid/electrolyte loss, nutritional depletion, and erosion of belly wall. Worse high in GI tract bc you lose more fluid. Nature will heal if there is no FRIENDS (FB, Radiation, Infection, Epithelialization, Neoplasm, Distal obstruction, Steroids). Protect ab wall, give nutrients, and fluids
Met Alkalosis
Give NS and KCl
GERD
Long standing history - do endoscopy and biopsies to look for Barrett’s
Acute Edematous Pancreatitis
Alcoholic or pt w gallstones. Epigastric pain radiating to back with nausea and vomiting. Elevated amylase or lipase. ELEVATED HCT. Tx w NPO, Fluids, NG Suction
Acute hemorrhagic pancreatitis
LOWER HCT. BUN goes up, met acid and low PO2. Abscesses develop and must be drained.
Fibroadenomas
Firm, rubbery mass that moves with palpation. FNA or sonogram to dx.
Fibrocystic changes
Related to period. No malignant potential or risk. Do mammogram to confirm. If there is a persistent mass (probably a cyst, but maybe tumor, do aspiration
Pagets Disease
DCIS that spreads to nipple and causes redness and itching
Phyllodes
Develop in connective tissue of breast - can be malignant. Biopsy and remove
Breast cancer in pregnancy
Diagnose normally and do surgery as necessary. No chemo in first trimester. No radiation during pregnancy
Thyroid nodules
FNA to dx. If malignant, do lobectomy
Types of green vomiting
Duodenal atresia, annular panc, malrotation, intestinal atresia, meconium ileus
Duodenal atresia
One bubble in stomach, one in duodenum
Annular pancreas
One bubble in stomach, one in duodenum
Malrotation
One bubble in stomach, one in duodenum, little ones throughout intestines. Dx w contrast enema
Intestinal atresia
Green vomit and multiple air fluid levels. Caused by vascular accident in utero
Meconium ileus
Babies with CF (look for mom with it). Feeding intolerance and bilious vomit. Dilated loops of small bowel. Do gastrografin enema (therapeutic and diagnostic)
Tracheomalacia
Just respiratory sx present in newborn
Vascular rings
Aorta surrounds trach and esophagus causing sx in both. Bronch and barium swallow to dx.
Operability of lung cancer
Min 800 mL FEV1 is necessary after operation. Tx w chemo and radiation
Arterial embolization
Clot busters if partial. Embolectomy with Fogarty catheter for complete obstruction.
BCC
raised waxy lesion on upper part of face. Excise with negative margins
SCC
Lower lip and can metastasize. Excise with wider margins or do radiation.
Thyroglossal duct cyst
On midline at level of hyoid bone and connected to tongue. Remove cyst, part of hyoid bone, and track to the tongue
Branchial cleft cyst
Anterior edge of sternocleidomastoid muscle
Cystic hygroma
Large mushy mass at base of neck. Can extend into mediastinum. Do CT before removing.
Mitral stenosis
RF. Dyspnea on exertion, orthopnea, PND, cough, hemoptysis. Rumbling diastolic murmur. Develop A fib over time. MV repair (by doing surgical commissurotomy or balloon valvuloplasty and if that doesn’t work, do MV replacement
Amblyopia
Vision impairment from interference with processing images. Fix ASAP if in first 6 or 7 years of life. Brain suppresses one of the images if eyes can’t focus on same thing.
Acoustic Nerve neuroma
Sensory hearing loss in one ear with no explanation
Cavernous sinus thrombosis
Development of diplopia from paralysis of extrinsic eye muscles in pt with frontal or ethmoid sinusitis (infection spreads and causes thrombosis). Hospitalize, IV abx, CT, and drain.
Trigeminal neuralgia
Extremely sharp pain by touching specific area. MRI to rule out organic lesions. Tx w anticonvulsants. Radioablation if that fails
Ureteropelvic Jxn Obstructon
Normal Urinary output wo difficulty, but large diuresis –> pain
Testicular cancer
Take alpha fetoprotein and B-HCG before then biopsy w radical orchiectomy. Very radio and chemosensitive (platinum-based chemo
Transplant complications
Most common cause of issues is plumbing. With liver check biliary obstruction (US) and vascular thrombosis (doppler). W heart, do ventricular biopsy.
Acute rejection
Steroid bolus (after checking to make sure it isn’t plumbing issue)
Cricothyroidotomy
Done if airway can’t be secured and running out of time
Tracheostomy
Only done in controlled setting
Base of skull fracture
Look for CSF or raccoon eyes. Indicates that very serious head trauma was sustained. Get CT of neck in addition to head
Penetrating trauma to neck
Surg exploration if there is hematoma, deteriorating vital signs, or clear signs of esoph or trach injury (coughing or spitting up blood). If not, do arteriography before surgery to decide approach.
Air embolism
Sudden death in chest trauma pt who is intubated and on vent. Can happen anytime subclavian vein is opened to air (CV line, disconnecting CV line). Put pt in trendelenburg when putting in CV lines to prevent
Blunt trauma to abdomen w signs of peritoneal injury
Ex lap
Blunt trauma to abdomen wo signs of peritoneal irritation
FAST to see if there is bleeding
Hematuria
Always work up for cancer except for trauma pt who has mild hematuria (to be expected)
Ex lap reasons
Blunt trauma w peritonitis or penetrating trauma
Breast mass
Mammo or sono guided core biopsy is best way to biopsy
Fibroadenomas
Can be confirmed with FNA or US
Fluid after burn
Start w 1L/hr Ringers Lactate and adjust to get hourly UO of 1-2 mL/Kg/hr
Genu varum (bowlegs)
Normal to age 3. After that is probably Blount disease and surgery is needed
Genu valgus (knock knees)
Normal bt 4 and 8 yo
DeQuervain Tenosynovitis
Mothers who flex wrist and extend thumb to hold baby’s head. Pain on radial side of wrist and first dorsal compartment. Splint and steroids.
Dupuytren contracture
Men of Norwegian ancestry. Contracture of palm of hand and palmar fascial nodules cna be felt
Surgery contraindications
Bilirubin above 2, Albumin below 3, PT >16, or encephalopathy
Post op Fever (in sequential time order)
Atelectasis (day 1), pneumo (3) UTI (day3), DVT (5), wound (day7), drugs
SCC of anus
More common in HIV+ people. Fungating mass grows out of anus with metastatic infuinal nodes. Do Nigro chemo followed by surgery if there is residual tumor.
Pyogenic liver abscess
Complication of biliary tract disease, usually acute ascending cholangitis. Pts get fever, leukocytosis, and tender liver. Dx with sonogram or CT and do percutaneous drainage
Chronic constrictive pericarditis
Square root sigh, equalization of pressures, and signs of heart failure
Foul smelling sputum in child
Foreign body
Indomethacin
Prostaglandin antagonist used to tx PDA
SCC of mucosa
Old men who smoke and drink with rotten teeth and AIDS pts. Shows up as nodes in the jugular chain. Dx with triple endoscopy (panendoscopy). Establish dx w biopsies and CT. Tx with resection and radiotherapy/platinum based chemo
Meclizine
Antihistamine antiemetic
Dizziness
Inner ear (room spinning) - Phenergan, diazepam, or meclizine or cerebral disease (patient is spinning but room is still) - neuro workup
Cushing reflex
Sudden spike in Bradycardia and HTN done to maintain brain perfusion when a pt has a brain tumor. Visualize brain tumor with MRI or CT and tx ICP w high-dose steroids
Brain abscess
Space occupying lesion but comes 1-2 wks after infection like mastoiditis or otitis media. Dx with CT
Posterior urethral valves
Cause for newborn boy not to urinate. Voiding cystourethrogram to dx. Endoscopic fulguration (using electricity to remove tissue) or resection to tx.
Prostatic cancer dx
Transrectal needle biopsy. Tx w surg and radiation along w orchiectomy and androgen ablation.
Progression of getting a line
2 16s –> femoral or saphenous line –> intraosseous of prox tibia
Salmon-colored fluid
Wound dehiscence –> go to OR
Abdominal compartment syndrome
Fluids and blood that have been given during prolonged laparotomy cause swelling –> cant close incision –> put mesh over wound until it can be closed
Bladder injuries
Dx with retrograde cystogram including postvoid films. If there are extraperitoneal leaks, just put a foley. If there are intraperitoneal leaks, do surgical repair and suprapubic cystostomy.
Fractures involving growth plate
Closed reduction if epihyses and growth plate are in one piece. If growth plate is in two pieces, do open reduction and fixation to get precise alignment
Fractured femur
Can cause significant blood loss, orthopedic emergency. Can also cause fat embolism if there are multiple fracture sites
Fat emboli
Sx 2-3 days after injury. Look for petechiae, pulm, neuro sx. Multiple emboli get released so sx happen all over body
Morton neuroma
inflamm of common digital nerve at 3rd interspace. Analgesics and wider shoes. Surgery if severe
Malignant hyperthermia
Develops shortly after anesthesia. Ryanidine receptors activated by anesthesia –> release Ca2+ –> muscle contraction and use of ATP –> excessive heat and muscle death –> fever, Ca2+ release, acidosis, and myoglobinuria. Tx with IV dantrolene, 100% O2, correction of acidosis, and cooling blankets. Watch for myoglobinuria
Dantrolene
Works on ryanadine calcium receptor to abolish excitation-contraction coupling and cures malignant hyperthermia
Hypernatremia volume correction
Use D5W 1/2NS to rapidly correct volume without changing tonicity too much
GERD
Resection if there are severe dysplastic changes. For minor dysplastic changes, do Nissen fundoplication
Anal fissure
Examine under anesthesia and give diltiazem ointment (Ca channel blocker so it relaxes the sphincter)
Obstructive jaundice from tumor
Gallbladder will be dilated by distal obstruction. Then do CT scan. CT allows you to localize tumor and then can do perq biopsy.
Panc abscess
10 days after pancreatitis
Pan pseudocyst
5 weeks elapses. Dx w CT or sonogram. Drain large or symptomatic cysts
Cytosarcoma Phyllodes
Women in late 20s. Grow large and distort breast. Not fixed. Can become sarcomas. Core biopsy and remove.
Mammary dysplasia
Same as fibrocystic disease. Grows with period
Breast cancer
Should be suspected in any women with palpable breast mass. History of trauma does not rule out cancer. DX WITH CORE BIOPSY
Congenital diaphragmatic hernia
Causes hypoplastic lung that still has fetal type circulation. Intubate and ECMO and give baby 3 to 4 days for lung to mature before operating
Necrotizing enterocolitis
Feeding intolerance, abdominal distension, and dropping plt count in PREMATURE infants when first fed. Tx: stop all feedings and give ABx, IVF, and TPN. Surgery if there is abdominal erythema, air in portal vein, or air in intestines.
Bromocriptine
Dopamine agonist used to tx prolactinomas
Prolactinomas
Produce amenorrhea and galactorrhea in young women. Tx with bromocriptine and can do surgery transnasally
Tumors at base of frontal lobe
Cause papilledema on other side, optic nerve atrophy on same side, anosmia, and behavior changes
RCC
hematuria, flank pain, and flank mass. Hypercal, erythrocytosis, and elevated liver enzymes. Tx: surgery
Cytoscopy
Only reliable way to rule out bladder cancer
Perforation
Pain has sudden onset and is constant, generalized, and very severe. Free air under diaphragm in upright X-rays is found
Intraabdominal bleeding
Dx w CT scan if pt is hemodynamically stable (responds to fluid resuscitation)
Unstable intraabdominal bleeding
Doesnt respond to resuscitation fluid - FAST or DPL and then ex lap if blood is found
Causes for ex lap
Penetrating ab injury, blunt ab injury with signs of peritonitis, blunt ab injury with hemodynamic instability and blood found on FAST/DPL
Liver rejection
Usually technical problems, check biliary obstruction (US) and vascular thrombosis (doppler)
Kidney rejection
Steroid boluses. Can try antilymphocyte agents after that
Venous stasis ulcers
Chronically edematous, indurated, and hyperpigmented skin above medial malleolus. Ulcer forms. Dx with duplex scan and tx by keeping veins empty (support stockings, unna boots, etc.)
Ogilvie Syndrome
Paralytic ileus of colon in elderly, sedentary pts who have become further immobilized. Causes dilated colon. Rule out mech obstruction with imaging or endoscopy and then give neostigmine to restore colonic motility.
Neostigmine
Interferes with AChesterase –> increases ACh levels –> PS agonist
Intermittent claudication
Doppler studies to look for pressure gradient. If something is found, do CT or MRI angio to identify stenosis and look for graft vessel.
Primary peritonitis
Primary peritonitis (SBP) - child with nephrosis and ascites or adult with ascites who has mild acute abdomen. Culture of fluid will show single organism. Tx w abx!
Airway necessary when
patient is unconscious, expanding hematoma in neck, inhalation injury, needs a respirator, or breathing is noisy or gurgly
Cricothyroidotomy
if you can’t get intubation in the normal manner and running out of time
Breathing is okay if
Normal BS bilaterally and pulse ox is good
Trauma shock
Hemorrhagic, tamponade, or PTX (tamp and PTX due to blunt or penetrating trauma)
Hemorrhagic shock in urban setting
Do surgery to stop bleeding first and then give fluids
Hemorrhagic shock in non-urban setting
give 2 L LR and pRBC
Pericardial tamponade
Dx w sonogram and clinically. Promptly evacuate pericardial sac
Cardiogenic shock
High CVP (opposite of hypovolemic). DONT give fluids!
Penetrating head trauma
Do surgery
Skull fractures
If linear, leave alone. Tx in OR if not
Loss of consciousness and head trauma
Get a CT. Can go home if negative
Base of skull fracture
Get CT of cervical spine and no NG tubes
Epidural hematoma
Do surgery
Subdural hematoma
If no deviation, medically manage to keep ICP down. If deviated, do surgery
Ways to keep ICP down
Hypervent, hypothermia, sedatives, sit head of bed up, diuretics
Diffuse axonal injury
Severe trauma. Blurring of gray-white matter and small hemorrhages. Keep ICP down
Chronic subdural hematoma
Tx with surgical evacuation
Penetrating neck trauma
Surg exploration
Blunt trauma to neck
Get CT if there is any pain in the neck
Anterior cord syndrome
Burst fractures of vertebral bodies –> loss of motor and temp/pain on both sides below and preserved proprioception
Hemothorax
Usually can just place a chest tube low. If bleeding is excessive, do thoracotomy
Flail chest
Fluid restriction and diuretics to prevent pulm contusion. Look for traumatic transection of aorta. Put chest tubes in if you need to ventilate
“white out of lungs”
Pulmonary contusion
Sternal fractures
Watch for myocardial contusion
Diaphragmatic hernia
Only on left side. Abdominal surg to correct
Ruptured aorta
Look for it if there are hard to break broken bones (scapula, first rib) in deceleration injury and wide mediastinum
CT angio
CT with IV dye
Subq emphysema
Boerhaaves, ruptured trachea, or TPTX
Air embolism
sudden death in chest trauma pt who is intubated and on respirator or when subclavian is open to air (CV lines)
Below the nipple
Involves the abdomen
Where blood can collect
Thighs, abdomen, and pelvis (lungs also but will show up on CT)
Hemo stable
Do CT to look for blood
Hemo unstable
Do DPL or FAST to look for blood
Spleen injury
Try to repair it not remove it.
Immunizations in splenectomy
H. flu, meningococcus (neisseria meningitidis), and pneumococcus (strep pneumo)
Intraoperative development of coagulopathy
Give FFP and platelets. If there is also hypothermia and acidosis you have to terminate surgery
Abdominal compartment syndrome
Following long surgery, may be impossible to close. Place mesh over incision until it can be closed. Can also cause a closed incision to re-open
Pelvic hematoma
Interventional radiology has to embolize the internal iliacs
Penetrating urologic injuries
Surgically explore
Pelvic fractures
Can damage bladder and urethra
Urethral injury
Blood at meatus (anterior), inability to void, and high riding prostate (posterior injury). DON’T place foley. Do retrograde urethrogram to Dx
Bladder injury
Dx with retrograde cystogram with post-void films included
Renal injuries
Rib injury. Look for AV fistula –> CHF or HTN if renal artery is stenosed
Scrotal hematoma
Do US to look for ruptured testicle. If not ruptured, leave alone
Penetrating injury of extremities
If no nearby vasculature –> tetanus and clean. If nearby vasc –> doppler or CT angio. If obvious vascular damage –> surg
Combined bone, nerve, vessel injury
Bone first, then vessel (would be torn apart by fixing the bone if done first), then nerve
Crush injuries
Hyperkal, Hypercal, myoglobinemia, renal failure, compartment syndrome. Tx with IVF, diuretics, and fasciotomy
Chemical burns
Do intense irrigation. Alkali worse than acid
Electrical burns
Massive debridement and amputations may be necessary. Give fluids, diuretics, and alkalinize the urine to prevent myoglobinuria renal failure
CO poisoning
Give 100% O2
Burn fluid resuscitation
Start w 1 L LR and titrate to 1-2 mL/Kg/hr
Limited severe burns
Early excision and grafting
Surface burns
Silver sulfadiazine. Triple antibiotic around the eyes
Unprovoked animal bite
Rabies prophylaxis is mandatory
Snake bites
Give antivenin (CROFAB)
Black widow bite
IV Ca2+ gluconate
Human bites
Extensive irrigation and debridement
