SURG CARDS 1 Flashcards
1
Q
What is the most likely issue in a popliteal or femoral aneurysm?
A
The risk of embolizing (blue toe syndrome) rather than rupture
1
Q
What is the classic “syndrome” associated with aortoiliac occlusive disease?
A
Leriche syndrome (gluteal wasting, impotence, and claudication (calfs))
1
Q
What is the best way to measure intra-abdominal pressure?
A
Foley catheter (be sure to clamp)
1
Q
What % of a pts intravascular volume has been lost if the pt is a supine hypotensive?
A
At least 30%
1
Q
What is Becks triad?
A
JVD, hypotension, muffled heart sounds
1
Q
What are the most common causes of post-splenectomy bleeding?
A
Unligated short gastric vessel or slippage of a surgical knot
1
Q
What is a Richter’s hernia? How does it present?
A
When only a portion of bowel strangulates leading to partial SBO
1
Q
Where is venous drainage from esophagus
A
Superiorly into inferior thyroid vein, in middle into azygous and hemiazygous, distally L gastric vein (coronary vein)
1
Q
What is the operative mgmt of cervical esophageal injury vs. thoracic?
A
Cervical = debridement and drainage of posterior mediastinum; debridement with 2 layer muscle repair with reinforcement with intercostal muscle flap
1
Q
A Swan Ganz catheter uses thermodilution techniques to measure what parameter?
A
Cardiac output
1
Q
How is potassium cardioplegia introduced into the heart (2 ways)
A
1) Down the aortic root into the coronary arteries (sinuses of Valsalva) or it can be put into the coronary sinus (retrograde cardioplegia) since the venous system lacks valves
1
Q
What is indicated if inotropic support does not reverse the flow state of myocardial failure?
A
An intraaortic balloon pump should be placed (it is synchronized to the EKG = inflates in diastole to fill the coronary arteries; deflates in systole to vacuum blood and decrease afterload
1
Q
How do you differentiate complete colonic obstruction from partial? How do you manage?
A
Complete will be obstipated and incomplete will have have some flatus or stool; Partial = Admit, NGT, NPO, IVF; Complete = emergent surgery
1
Q
What STD increases the risk of colon CA?
A
Lymphogranuloma venereum (C. trachomatis)
1
Q
How are the lymph nodes procured in cancer surgeries of colectomies?
A
The mesentery is taken down all the way at the base of the supplying blood vessel, i.e. IMA ligated and taken at its base. This gets the max number of LNs since they follow the arterial supply
1
Q
What are the 3 hemorrhoidal beds?
A
L anterior, R anterior, and R posterior
1
Q
How does a rectal abscess begin?
A
Obstruction of the perianal glands between the internal and external sphincters (intersphincteric space)
1
Q
CCKb receptors in the stomach respond to what hormone?
A
These are actually gastrin receptors
1
Q
Palpable ridge on DRE in gastric CA
A
Blumers shelf = peritoneal seeding
2
Q
What ABI is associated with ischemic rest pain? What historically points you towards a pt having IRP?
A
0.4; dangling the foot over the bed at night to get rid of pain (caused by nerve hypoxia)/ dependent rubor
2
Q
What is the parasthesia of the anteromedial thigh called when caused by an obturator hernia?
A
Howship-Romberg sign
2
Q
What is the mgmt of cervical esophageal CA?
A
H/P and plain film then surgical debridement and drainage of posterior mediastinum. Place gastrostomy tube if anticipating NPO for awhile. Primary repair usually not necessary
2
Q
What are the major complications of cross-clamping of the aorta?
A
Spinal ischemia and renal ischemia
3
Q
What is required anatomically for flail chest?
A
2 or more adjacent ribs fractured segmentally in 2 or more places
3
What is the mgmt of an incarcerated hernia that is reduced? Not reduced?
Observation with urgent surgery (at minimum 12-24 hr obs with set up for elective surgery); emergent surgery
4
What are 2 distal complications of GERD in the esophagus?
Schatzki ring; Barret's esophagus (and poss. CA)
5
What are some complications of placing an arterial catheter?
Infxn, pseudoaneurysm formation, AVM (poss. Subsequent high output CHF)
6
What is the best esophageal substitute and why?
Stomach (rather than colon or jejunum) because requires 2 less anastomoses
7
When do you do surgery for spontaneous ptx?
If it is leaking greater than 7-10 d, recurrent ptx, and simulatneous bl ptx
7
In addition to the workup that goes into gastric adenocarcinoma, what should be included if it is found to be gastric lymphoma?
Bone marrow Bx
8
How do you treat HITT?
DC heparin and if still need anticoagulation put on direct thrombin inh
9
What is the initial step in Tx of acute mesenteric venous occlusion?
IV heparin with ex lap removal of necrotic bowel and 2nd look ex lap
9
What are the goal FiO2 and PEEP settings to wean a person off of the ventilator?
FiO2 \< 50%; PEEP \< 5 cm H20
9
What is the number one cause of adrenal insufficiency?
Previous steroid use
9
What is elevated TSH, extremely low T4, hyponatremia and low blood glucose in a critical care setting?
Myxedema coma
9
What is the usual mechanism for blunt aortic injury?
High speed decelerations (fall from great heights, MVA); leads to shearing of the mobile aortic arch in relation to the retropleural descending aorta)
9
What % of pts with inguinal hernia repair will develop chronic pain?
6-13%
9
What is a diverticular direct hernia?
A hernia of preperitoneal fat (through hesselbachs triangle)
9
What carries a worse prognosis, a Boerhaave tear or a tear of the esophagus d/t pneumatic dilation?
Boerhaave tear because releases stomach acid etc. into mediastinum
9
What is the gold standard for dx of hiatal hernia?
Contrast Upper GI series; CT would provide further info about anatomy i.e. if surgical mgmt planned
9
Which valves is most amenable to valvuloplasty?
Mitral; aortic dz would recur so should be txd with replacement
9
What usually precipitates diverticulitis?
obstruction of the neck of the diverticulum with a fecalith, like in appendicitis
9
What is the immediate mgmt for suspected diverticular bleeding
H/P, volume expanders or blood transfusion (order type and cross), NGT until bile return to rule out UGIB
9
Where are the G cells of the stomach found?
In the antrum
9
What is the best prognostic indicator for gastric CA?
pathologic staging (mets also impt as their presence excludes resection of stomach)
11
What is the number one precipitating event of hepatic encephalopathy?
GI bleed in a person with liver failure
11
What is the inguinal ligament made of? What are its attachments?
It is where the external abdominal oblique rolls itself over; ASIS and pubic tubercle
11
AT what size of cecal dilatation do you become concerned about perforation?
12 cm (That emergent case I saw at forbes was 13!)
12
How do you Tx acute variceal bleeds?
Often need FFP and platelets with BB (BB such as nadolol to decrease CO which leads to less splanchnic flow); octreotide decreases portal HTN and definitive control is with sclerosis and banding; if refractory to that then TIPS
12
What if a person become hypotensive in exercise stress testing?
Ominous sign, often signifies triple vessel dz or left main dz (both indications for cabg)
13
Where to the hemorrhoidal arteries come from?
Superior hemorrhoidal is from IMA, middle hemorrhoidal is from internal iliac a, and inferior hemorrhoidal is from internal pudendal
14
What is the best way to Dx rib Fx? Tx?
Point tenderness, may or may not show up on CXR/AXR? Analgesia, avoid splinting from pain
14
What is the triad of MEN I?
Pituitary adenomas, hyperparathyroidism (parathyroid adenoma), and gastrinoma
15
Sometimes the R vagus (posterior vagal trunk) can give off a small posterior branch to the stomach called \_\_\_\_\_\_. Surgical significance?
Criminal nerve of Grassi; if not cut it can lead to recurrent PUD
16
What is the acute tx of diverticulitis
Admit to hospital, make NPO, IV abx 5-7 d (small abscesses can be txd with bowel rest and abx but large abscesses should have IR drainage)
17
Why is it important to drain a hemothorax?
Blood is a nidus for infection bc bugs love the iron
17
What is the idea behind doing an ED thoracotomy?
You can do a pericardiotomy and open cardiac massage which is superior to CPR for hypovolemia; aortic cross-clamping allows more blood to heart and brain and decreases abdominal loss
17
What is the Tx of rectal prolapse (procidentia)
Sigmoid resection with rectopexy (suture rectum to presacral fascia)
17
how do you manage bleeding ulcers?
2 L crystalloids or whole blood, NGT to decompress stomach, PPI's, determine PT/aPTT and reverse coagulopathies, Tx with upper endoscopy
17
How do you manage gastric outlet obstruction?
NGT and IVF, NPO and often get some nutrition with TPN, then operate (since d/t fibrosis) = antrectomy (B1 or B2) with truncal vagotomy
18
What is the goal of neoadjuvant therapy in esophagectomy. What is used?
To downstage the CA prior surgery; 5-FU + Cisplatinum and 45 Gy radiation over 6-7 weeks
18
Name 6 extraintestinal s/s of UC
Ankylosing spondylitis, arthritis, uveitis, pyoderma gangrenosum, PSC, and pericarditis
19
Where do most umbilical hernias form in relation to the umbilicus?
Superior (weakest points)
20
What are 4 modalities you could use to workup GERD?
Esophagram (barium swallow); Esophageal manometry (weak LES pressure); Upper endoscopy; 24 hr pH study (mainly to determine if need surgery)
21
What is the most common cause of esophageal perforation?
Instrumentation of the esophagus esp. dilatation procedures for strictures, webs, or palliation of obstructive CA
22
What is an important step after splenectomy in trauma to decrease post-op infxn?
vaccinate against meningococcus and pneumococcus
23
What should be considered in the workup when you find gastric polyps?
Polyposis syndromes i.e. Puetz Jehgers and FAP
24
What are some "anginal equivalents"
DOE, jaw pain, throat pain, arm pain
25
What is a type IV endoleak?
due to diffusion of blood or serum through the graft that tends to reverse when anticoagulation is reversed
26
What drug is famous for causing acute mesenteric ischemia?
Digitalis
27
What is the cause of respiratory failure in flail chest?
The underlying pulmonary contusion; the fact that the fractured ribs are out of phase with the respiratory cycle doesnt matter. It is the fact that there is underlying lung trauma bc to fracture ribs you need a serious trauma, this level of trauma would cause pulmonary contusion
27
What drug can be given to decrease hiccups from gastric distention?
Thorazine
29
What is SCIWORA? What is the best dx test and why?
Spinal Cord Injury without radiographic abnormality; MRI because most commonly due to soft tissue injury such as ligaments (ligamentum flavum)
29
How does the intestinal type gastric CA spread? How does the diffuse type spread?
Hematogenous; Lymphatic
29
What is the number one risk of a rebleed after treating a bleeding duodenal ulcer?
Visible blood vessel in the ulcer crater (Dieulefoy ulcer)
29
Differentiate Truncal vagotomy, selective vagotomy, and parietal cell (highly selective) vagotomy
Truncal vagotomy cuts the vagal trunks and cuts out parasympathetics to stomach and most abdominal viscera; Selective vagotomy spares abdominal viscera but still knocks out stomach and pylorus; highly selective vagotomy knocks out the parietal cell mass only (Crow's foot preserved)
30
What electrolyte abnormalities would be present in gastric outlet obstruction?
Hypokalemic, hypochloremic, metabolic alkalosis
31
What is the best kind of airway to put in an awake pt?
Nasal airway tolerated better than oral airway
32
Infliximab is the mainstay of Tx more so in which IBD?
Crohns dz
34
A low PCWP is a sign of what? A high PCWP is a sign of what?
shock; heart failure
35
What are the 2 named branches of L1
Ilioinguinal and iliohypogastric
36
What should you start thinking in a critical care pt with a fever \> 105-106?
Thyroid storm (precipitated by high stress events, also high output cardiac failure and MS changes)
37
What is the most common cause of aortofemoral graft limb occlusion?
Distal outflow disease
37
What forms the ligamentum teres hepatis in the falciform ligament?
L umbilical vein
38
What is the initial Tx of marginal ulcer?
PPI and dc tobacco; possibly make NPO with TPN and surgically revise if not heal
40
What is the lethal physiologic triad that occurs with long OR time in trauma?
lactic acidosis, hyponatremia, and coagulopathy
41
Where does the venous blood going to the cardiopulmonary bypass machine come from?
single incision in RA or dual cannulation of SVC and IVC
42
What is systemic ischemia reperfusion syndrome?
Most common in pts with rest pain 2ndry to PAD that are revascularized and develop: hyperkalemia, COMPARTMENT SYNDROME, metabolic acidosis, myoglobinuria, and renal and pulmonary insufficiency
42
What is the immediate tx of open ptx?
Place a dressing taped on 3 sides so that there is outflow but no inflow; definitively you should place a chest tube and re-expand the lung
42
What operation is done for transverse colon CA to the left of the middle colic? To the right?
If to the right = extended right hemicolectomy; If to the left the middle colic = partial L colectomy (if all the way at splenic flexure = L hemicolectomy
42
What is blind loop syndrome? What are the s/s?
Bacterial overgrowth in the afferent loop of a B2; can lead to megaloblastic anemia by malabsorption of folate/B12 and steatorrhea from deconjugation of bile salts
43
What is the definition of massive hemothorax?
EITHER a rapid loss of 1500 ml into the thoracic cavity or ongoing thoracic blood loss \>200 ml/hr over 4-6 hrs
44
What is the basic workup for an unprovoked DVT?
Protein C/S levels, ATIII, Factor V leiden, Prothrombin gene mutation, anticardiolipin antibodies, (lupus anticoagulant?)
45
What valvular disease will affect the measurment of PCWP using a Swan Ganz?
Mitral disease esp. stenosis
47
How many clinicians must examine a person to call them clinically brain dead?
2
48
When should you suspect strangulation of a hernia? (3)
Erythema of the skin, tachycardia, WBC ct or fever (so basically erythema and SIRS)
49
What is the operative mgmt of a perforated duodenal ulcer?
Oversew with omental (Graham) patch placement; f/u endoscopy
50
What is permissive hypotension in ruptured AAA
Allow bp to be around 70-80 systolic to prevent further exsanguination into the peritoneum
51
Explain the fulminant presentation of UC
Toxic megacolon = there is transmural progression of the disease that destroys auerbach's plexus leading to massive dilation (basically an acquired hirschsprungs)
52
Why is low dose dopamine sometimes used during severe inflammatory states?
it increases LV EDV so has a similar effect to giving fluids
52
What are 3 restrictive bariatric procedures
Sleeve gastrectomy, adjustable gastric banding (AGB) and vertical banded gastrectomy (VBG)
53
What is the best approach for treating a recurrent inguinal hernia?
usually a laparascopic approach (TAPP or TEP)
53
What is a low anterior resection?
For an upper rectal CA takes out distal sigmoid and anastomoses the proximal sigmoid to the distal rectum
53
What is the treatment of Hypertrophic Gastritis?
Menetrier's dz: PPI + high protein diet (bc assoc. with protein losing gastropathy)
55
How do you treat superficial vein thrombosis?
NSAIDs and warm compress
55
What are the 3 zones of the neck?
Zone I = sternal notch to inf. Border cricoid; Zone 2 = cricoid cartilage to angle of mandible; zone 3 = angle of mandible to base of skull
55
What is a surgical indication for GERD in pediatric population?
Aspiration pneumonitis
57
How do you tx flail chest?
Aggressive pain control (bc splinting can lead to atelectasis), aggressive pulmonary toilet, with chest tube; judicious IVF bc can third space into injured parenchyma
58
What is an avulsion of the small intestine?
When it is separated from its mesenteric blood supply
59
What kind of arterial cather has highest infection rate?
Femoral (it?s a gross area)
60
If there is a blood pressure difference in the arms of a trauma pt what should be considered?
TRA (traumatic rupture of the aorta)
61
What is a loop colostomy
Take a loop of bowel out place a red rubber catheter underneath and open it
62
What is the Tx of a perirectal abscess?
I/D, Abx play no role unless immune compromised
64
Where do most indirect hernias pass in relation to the spermatic cord?
Pass WITHIN the cord but anteromedial to the cord structures (passes lateral to the epigastric vessels)
66
What are the 2 primary modes of ventilation?
Pressure control and Volume control
67
If you insert a Swan Ganz catheter and the pt has massive hemoptysis what happened?
Rupture of pulmonary artery
69
How do you follow someone with Barret's?
Endoscopy q 6-12 months with 4 quadrant bx every 1-2 cm of involved esophagus
69
Which malignant chest wall tumor is not primarily treated with resection
Plasmacytoma; it is txd like a systemic myeloma
70
How do you diagnose liver injury? Splenic injury?
CT for both
71
What is the main complication after drainage of a perirectal abscess?
Development of fistula in ano
73
What esophageal diverticulae are associated with reactive lymph nodes from histoplasmosis or tuberculosis?
Traction
75
What is the risk of contralateral disease in a person with popliteal aneurysm? What is the risk of AAA if a person has a popliteal aneurysm?
50% for both
76
What is the lowest safe EF you can revascularize a pt with?
20%
77
What should be suspected in anyone with an air fluid level on cxr? Next test?
Empyema or lung abscess; CT scan will differentiate the 2, lung abscess usually from aspiration
77
Where doe the IMV drain into
Splenic vein which then joins the SMV to form the portal v
78
Why could femoropopliteal disease only, theoretically be asympomatic unless exercising?
Profunda femoris can provide enough flow at rest
78
What position should a central venous catheter be done in and why?
Trendelenburg to engorge the vessels and reduce the risk of air embolus
79
What is dependent rubor called in PAD?
Buerger's sign
80
How do you calculate Cerebral Perfusion Pressure?
MAP-ICP (i.e. how much is actually getting to the brain)
81
Differentiate the TAPP and TEP approaches to hernia repair
TAPP = transabdominal preperitoneal repair = enter peritoneum and fix from inside; TEP = totally extraperitoneal repair whereby blow up preperitoneal space with balloon and gas and enter laparoscopically
83
What are the boundaries of the femoral triangle?
Inguinal ligament superiorly, adductor longus medially, and sartorious laterally
84
Why should you perform surgery for BAI with cardiopulmonary bypass?
The aorta will have to be cross clamped which can lead to anterior spinal artery syndrome by blocking the artery of adamkiewicz
85
What is the medical mgmt of achalasia? Surgical mgmt (3)
Nitrates, CCBs (like diffuse esophageal spasm) but often develop tachyphylaxis; pneumatic dilation, endoscopic botulinum toxin injxn, Heller Myotomy of LES
86
What is pain at the site of a DVT that has been treated called?
Post-Thrombotic syndrome
87
What FENa is prerenal? What is intrinsic renal
89
What is the surgical mgmt of lung abscess?
Wedge resection and chest tube drainage
89
What is defined as massive diverticular bleeding and what is done?
Requires 4 blood transfusions in 24 hrs; mesenteric angiography with coil embolization
90
What are 4 surgically correctable causes of HTN?
Pheochromocytoma, Coarctation, Aldosterone-secreting adrenal mass, and renovascular HTN
91
What is a common cause of abdominal comparment syndrome in a person who was being treated for shock?
Overaggressive fluid resuscitation (compression of visceral vessels) Tx = laparotomy to release
92
Why is stenting often not done when there is bad SFA disease?
Because of extremes of motion at the SFA can lead to fracture of the stent
93
What procedure can be done for definitive cure of UC and still maintain continence?
Total proctocolectomy with Kock's Continent Ileal Reservoir
95
What is complete iliofemoral venous thrombosis with massive edema called? What if the leg becomes white?
Phlegmasia cerulea dolens; Phlegmasia alba dolens
96
Plummer-Vinson syndrome and Tylosis both increase the risk of developing what?
SCC of esophagus
97
What is the first step in vfib and pulseless vtach? Followed by?
Defibrillation; f/b pressor to increase perfusion and then amiodarone
97
What is associated with Zenker's diverticulae? What is the diagnostic test? Surgical mgmt?
TIA and CVA d/t denervation; Barium swallow since endoscopy can perf; myotomy of cricopharyngeus or diverticulectomy or diverticulopexy
98
How is the vagus nerve tested when evaluating a possible brain death? How many cranial nerves must be tested?
Atropine; All
98
What is an enormous right-sided colonic distention without mechanical obstruction? How is it treated?
Ogilvies syndrome; IV neostigmine to prevent breakdown of Ach; if that fails may need a rectal tube inserted
99
When is PRBC indicated in managing shock?
When the pt is acutely bleeding; the mortality actually goes up in critical care pts who have Hgb above 9 and are not actively bleeding
100
How do you treat a transected pancreas in trauma?
Distal pancreatectomy
101
Briefly summarize the difference between early dumping syndrome and late dumping syndrome
Early dumping syndrome occurs 15 min after eating and is due to hyperosmolar chyme; Late dumping is 3 hrs after eating and from rapid glucose and insulin shifts so hyperglycemia with reflex hypoglycemia
102
What is the rationale for calling a Stanford Type A aneurysm a "surgical emergency" rather than txing with antihypertensive meds?
Aneurysms in the ascending aorta can go retrograde and rupture in the pericardial cavity
103
What are the ABCDE's of the primary survey?
Airway, Breathing, Circulation, Disability (neuro status), and Exposure
105
What are the top 3 causes of colonic obstruction (i.e. SBO is most common overall but I'm asking about colonic)
Cancer, Cicatricial obstruction from recurrent diverticulitis, volvulus (cecal, sigmoid)
106
What is the major cause of death in acute liver failure?
Cerebral edema and resultant herniation
106
What is a psuedopolyp in the colon?
When lots of crypt microabscesses in UC coalesce into a "polyp"
108
Which malignant gastric mass is a submucosal growth? Tx?
GIST; Imatinib (anti-CD117 ab)
108
What are the BMI indications for bariatric surgery
35-40 with comorbid conditions; \> 40 with or without comorbidities
109
Why are suprarenal AAA's more technically challenging?
they require either suprarenal or supraceliac clamping or both which puts the kidnes in jeopardy (can precipitate ESRD)
110
T/F always order a CXR to confirm dx of tension ptx
False just immediately use needle decompression
111
What 3 issues can arise from a patent processus vaginalis?
Indirect hernia, communicating hydrocele, noncommunicating hydrocele
113
Why might a person with diverticulitis develop a UTI?
Colovesical fistula formation
115
T/F it is important to treat TBI to reverse the primary defect
False but you can prevent secondary propagation of the TBI
116
Which approach to open AAA repair has fewer pulmonary problems?
Retroperitoneal approach (would not be done in an emergent setting, that is ex lap)
117
Which muscle essentially forms the anterior and posterior rectus sheath superior to the arcuate line? (Semicircular line of Douglass)
Internal abdominal oblique
118
What is a bronchopulmonary segment
Part of lung that gets its own bronchus and branch of pulmonary artery
119
A person with a Bilroth II antrectomy develops vomiting with motor oil consistency after eating? Tx?
Afferent loop obstruction = kink in afferent limb leads to trapping of hepatobiliary secretions (motor oil like); conversion to B1 or roux-en-Y
121
What is the role of PPIs in slowing the development of Barrets?
Controversial
122
What is the initial step in cardiogenic shock? What can you do next?
Inotropic support and then possibly IABP
123
Why do you order a CXR in cases of PE?
To r/o other chest pathology but CTA is the Dx test of choice
124
Where does the esophagus start and stop? How long is it?
AT cricoid cartilage (C6) to below diaphragm (T11); 25 cm
125
What is going on if there is new or worsening renal function in a cirrhotic pt?
Hepatorenal syndrome (Tx is midodrine/octreotide)
126
What is the bimodal distribution of UC?
15-30 and then not until 55
128
Which nerve innervates suprapubic skin? Which travels on the spermatic cord? Which travels within the spermatic cord?
Iliohypogastric, ilioinguinal, and genital branch of genitofemoral nerve
129
What is a Littre's hernia?
a hernia containing a Meckel's diverticulum
130
What are the vagus nerves called as the course along the lesser curvature of the stomach? Where do the terminate? What is this called?
Anterior and Posterior nerves of Laterjet; Pylorus; Crow's foot
132
What is a Spigelian hernia?
Occurs when the hernia is through the arcuate line (often incarcerates bc between aponeuroses)
134
What is the time frame for revascularization in extremity trauma (i.e. transection of SFA)
6 hours
135
What is an important imaging study to evaluate post-gastrectomy complications?
Upper GI series
137
What is the main esophageal substitute used if esophagectomy is needed secondary to caustic substance ingestion and why?
Colon; stomach used otherwise but in this situation the stomach is usually involved as well
138
A Stanford B dissection is distal to what structure?
L subclavian
139
What is the mortality rate in myxedema coma?
\>60%
141
What is a normal GCS score? What is a comatose pts score?
15; 8
143
What are the 4 grades of internal hemorrhoids and mgmt
I = anoscope required to visualize can be txd with fiber; II = prolapse with defecation and return spontaneously, banding; III - prolapse with defectation and require manual reduction, banding; IV = not reducible, surgical hemorrhoidectomy
144
What are the AXR findings of cecal or sigmoid volvulus?
massively dilated cecum or sigmoid with loss of haustra, and a KIDNEY BEAN APPEARANCE
145
What is the immediate concern in cervical esophageal ruptures?
Sepsis. Classically a Posterior Descending Mediastinitis
146
What is the most important test to follow a pt with known aortic stenosis when trying to plan surgery?
Echocardiography
148
Name 8 post-gastrectomy complications
Early dumping syndrome, Late dumping syndrome, Post-vagotomy syndrome, Afferent loop obstruction, blind loop syndrome, alkaline reflux gastritis, marginal/recurrent ulcer dz, gastric atony
149
Why do most AAAs occur in the infrarenal aorta?
Poorly formed vasa vasorum in this area
150
What is the most common cause of stroke in CABG?
UNRECOGNIZED carotid stenosis; prior to CABG should always check carotids
150
What is a more accurate test for H. pylori active infxn - fecal antigen test or blood serology?
Fecal antigen; serology would be positive if you were infected at any point in your life
151
What are some sequalae to mitral stenosis?
Afib and Pulm HTN (but does not affect LV fxn)
152
What is the most important medication to give in thyroid storm?
BB because the main cause of death is CHF; also need to give PTU/Potassium Iodide
153
What spinal injury causes weakness in the arms more so than the legs?
Central cord syndrome (from hyperextension injury in pt with spc canal narrowing secondary to osteophytic change)
154
What is the usual adjuvant chemotherapy for colon CA?
FOLFOX = 5-FU, Leucovorin, and oxiplatin; Bevacizumab and Cetuximab (but cetuximab not in K-ras +)
154
Where is the anatomic location of the autonomic pacer of the stomach?
Fundus
155
What is an Amyands hernia?
A hernia containing the appendix
156
Why are umbilical hernias and femoral hernias susceptible to strangulation?
Linea alba forms rigid walls; femoral canal is also rigid (lacunar ligament etc.)
157
how do you tx alkaline reflux gastritis operatively
Divert duodenal contents away with a Roux-en-Y
158
What drugs can be used in post-vagotomy diarrhea? What is the operative mgmt?
Loperamide to slow transit, cholestyramine to bind up the bile salts; Reversed Jejunal interposition graft to create reverse peristalsis
160
T/F a HIDA scan is a better diagnostic test than US for acalculous cholecystitis
False; Doesnt show anything, US can show pericholecystic fluid or wall thickening (edema)
161
Define ARDS clinically
Bilateral alveolar infiltrates without evidence of CHF (normal PCWP)
161
What are the 2 ends of the spectrum of feared thyroid complications in the SICU
Thyroid storm (hyperthyroid crisis); Myxedema coma (hypothyroid crisis)
162
What surgery for PUD preserves the Crow's foot? Significance?
Parietal cell vagotomy (highly selective vagotomy) = conserves pylorus fxn so no Heineke Mikulicz pyloroplasty needed
164
What is volume control on the ventilator? What are AC and IMV?
Gives a preset tidal volume up to a certain pressure to prevent barotrauma; IMV = Intermittent mandatory ventilation and AC = assist control
164
What are 3 approaches to the esophagectomy? Which is best if lung fxn is poor?
Thoracotomy, Transhiatal, and Minimally Invasive? Transhiatal avoids a thoracotomy so is best if poor lung fxn
164
Achalasia is a degenerative disorder of what?
Auerbach's myenteric plexus
165
What is the mgmt of sigmoid volvulus? Cecal volvulus?
Sigmoid volvulus = sigmoidoscopy with rectal tube insertion for decompression (if unsuccessful or perf then ex lap); usually R hemicolectomy and transverse ileostomy, rarely with cecopexy
167
What are 2 things that can be given to decrease cerebral edema
Mannitol and Hypertonic saline
169
What are 3 situations in which ED thoracotomy is NOT performed?
Prolonged cardiac arrest, PEA, massive blunt trauma with prehospital cardiac arrest
170
What is the surgical incision to treat BAI?
Left thoractomy (not median sternotomy)
171
What is the mgmt of an umbilical hernia that develops with concomittant ascites?
Manage the ascites i.e. diuretics, peritoneovenous shunt, TIPS etc. because it may go away and also if you place a mesh in a cirrhotic pt it will probably get infected and can lead to SBP (i.e. \>250 neuts/ml)
172
What is the technical definition of an aneurysm?
Focal dilation of an artery to \> 1.5 the native diameter
173
What is a DVT of the left iliac venous system called?
May-Thurner Syndrome: due to R iliac artery compressing it
175
What is the Cushing reflex?
An increase in MAP when there is increased ICP because you are essentially trying to push past that pressure
176
When are colostomies needed in trauma?
Rarely unless there is significant rectal injury and you need to protect the distal anastomosis; i.e. if it is below the peritoneal reflection you need to divert to avoid perineal infxn; if hypotensive you may need one as this may lead to ischemia of the anastomosis
177
What are the 4 SIRS criteria?
1) Temp above 38.5 or below 36 (hypothermia worse) 2) HR \> 90 3) RR \> 20 or PaCO2 \< 32 implying hyperventilation or 4) Total leukocyte ct \> 12,000 or \> 10% bands or \< 4000 with neutropenia as a poor prognosis
179
What 2 chemicals are responsible for the smell of farts?
Indole and skatole
181
What is a Type II endoleak?
Persistent flow in and out of either the lumbars or IMA in an endovascular AAA repair? No real net expansion
182
70% of bleeding distal to the ligament of trietz is due to \_\_\_\_
Diverticular bleeding
183
What is the first line tx from coagulopathy of liver failure?
FFP (i.e. the most important "LFT " is the INR (also PT and aPTT)
184
What is the most common sign of an anastomotic leak post-bariatric surgery?
Unexplained tachycardia as typical s/s of peritonitis may not be present in an obese person
185
Which vessels are affected in cerebral contusions
Pia vessels
185
What is the most likely sign of angina in DM pt? why
DOE, since autonomic neuropathy would partially preclude the development of pain
186
To further decrease acid production what is often done in combination with an antrectomy?
Truncal vagotomy
187
In whom are splenic aneurysms most likely to rupture?
Pregnant women
189
How do you manage toxic megacolon?
Aggressive medical care and elective colectomy bc the walls of the colon will be paper thin = NGT decompression, Abx, IVF, hyperalimentation, eliminate other meds esp. anticholnergics
190
Where is the most common site of an aortoenteric fistula?
3rd part of the duodenum
191
How can you treat uremic coagulopathy (i.e. qualitative platelet defect)?
DDAVP or conjugated estrogens
191
Why do ppl with tension ptx go into shock?
They have not venous return since the pressure compresses the IVC
193
What is the main utility of endoscopic ultrasound?
Good for getting detailed information about the esophageal wall and for T staging. Also can allow for adjacent LN evaluation and Bx for N staging; and intramural lesions like leiomyomas
194
What is the leading cause of death in the first 44 years of life?
Trauma
194
What arteries supply the esophagus superiorly, in the middle, and inferiorly
Inferior thyroid (from thyrocervical trunk); thoracic aorta's esophageal arteries, and left gastric
195
Why is an aortogram the test of choice (after initial CXR) to determine traumatic injury to aorta?
Because mediastinal widening can be caused by mediastinal hematoma
196
What is the operative mgmt if the gallbladder is injured?
Cholecystectomy is better than repair
196
When is the anticipated date of discharge after CABG
POD 4-5
198
What is a "lateral cutaneous nerve"?
Anterior ramus passing through the transversus abdominis muscle and the internal oblique muscle
199
Spc innervation to appendix
T10
201
Tx of Systemic ischemic reperfusion syndrome?
Vigorous hydration, Alkalinization of urine, ppx fasciotomy
202
Why shouldn?t you order an upper GI series in a pt with suspected SBO?
They will throw up the contrast, this will worsen metabolic derangements and make them dehydrated poss. Precipitating AKI
203
What is the most common cause of an incisional hernia?
Deep wound infxn
205
Umbilical nodules in gastric CA
Sister Mary Joseph nodule
207
What is the most common benign chest wall tumor? Most common malignant?
Fibrous dysplasia; Chondrosarcoma
209
Differentiate a Bilroth I from a Bilroth II for gastric ulcer
B1 = antrectomy with gastroduodenal anastomosis; B2 = Antrectomy with a limb of proximal jejunum and a gastrojejunostomy, good when the duodenum is scarred from PUD
210
What is a marginal ulcer?
An ulcer that forms on the jejunal side of a gastrojejunostomy anastomosis (2 cm from staple line)
211
What are the basic steps in SIRS?
Give empiric antibiotics and crystalloid fluids; if refractory then vasopressors, if refractory order cortisol level
211
If surgery is planned for a Type I hiatal hernia what is usually done?
A collis gastroplasty with Nissen Fundoplication for the symptomatic GERD i.e. a type I has a short esophagus which is why GE jxn slides in and out. This would necessitate the production of a neoesophageal conduit
213
What classic syndrome is associated with vertebrobasilar disease?
Subclavian steal syndrome
214
What does it mean to say that the primary toxins of shock are endogenous?
Most of the toxins are related to cellular injury such that shock may progress even when O2 is restored (cytopathic hypoxia)
215
Why do you remove cord lipomas?
The pt may think that they still have a hernia
217
What is an abdominoperineal resection?
for very low rectal CA it takes out sigmoid, rectum, and anus and leaves you with a permanent sigmoid colostomy
218
Why do you do a tracheostomy as opposed to long term intubation?
Prevents subglottic stenosis
220
What is the feared complication of gadolinium dyes in ESRD?
Subcutaneous fibrosis
220
A person with h/o bariatric procedure p/w SBO is suspicious for what
Internal hernia i.e. herniation of bowel through holes in mesentery made when freeing up the bowels in bariatric surgery
221
T/F ileus can be common in situations with severe inflammation
True (recall the ICU pt at AVH; enough succus can accumulate that it can essentially cause SBO in addition to the fact that there is paralytic ileus
222
Why are superficial veins likely to varicose while deep ones are not?
Superficial veins are not surrounded by muscles to push them together
223
How do you evaluate post-renal azotemia
Place a catheter and get a renal US
224
What should you think if you see duodenal polyps?
Like gastric polyps, probably a polyposis syndrome (definitive tx of FAP = total proctocolecotmy with either end ileostomy or ileoanal pull-through)
225
What is the survival rate of a diabetic with a limb amputation
50% in 2 years
226
What is the first organ system to fail in MODS?
Respiratory
227
What is the diagnostic test for diffuse esophageal spasm? Medical mgmt? Operative mgmt?
Esophageal manometry; nitrates and CCBs; esophageal myotomy from aortic arch to stomach
228
What is the defintion of spontaneous bacterial peritonitis based on paracentesis? What is empiric Tx?
\>250 neuts/ml; Fluoroquinolones + 3rd genereation cephalosporin
230
ASA is shown to prevent development of which GI malignancy?
Colon CA
231
Palpable L supraclavicular node
Virchows node - gastric CA
233
How do you diagnose ventilator associated pneumonia? Why?
Bronchoalveolar lavage because the CXR may already be abnormal and you cant really get a sputum sample on a ventilated person; \>10^4-5 bacteria
234
What is Kussmauls sign?
Increase in JVD on inspiration in cardiac tamponade
235
Define acute liver failure
Rapid decline in liver fxn in combination with new onset encephalopathy not attributed to other cause
236
When a colostomy is made from the proximal end of bowel, the blind distal end is referred to as a \_\_\_\_; if it also brought out as a stoma it called a \_\_\_\_
Hartmann's pouch; mucous fistula
237
How do you treat renovascular HTN when caused by fibromuscular dysplasia vs. atherosclerosis
FMD = dilation only, can cure; atherosclerosis = dilation WITH stenting, rarely cures
239
How do you treat avulsion injuries of the diaphragm?
Permanent interrupted or running sutures to minimize recurrence (since it is mobile with respiration) watch out for branches of the phrenic
240
Which part of the BMP or CMP is the best way to evaluate for AKI?
Creatinine! BUN can be affected by lots of things including the persons muscle mass
241
What happens if you delay tx of an empyema for too long?
It can congeal into a peel/rind and require decortication
243
What is a CRBSI?
Catheter Related Blood Stream Infxn
245
What is the operative mgmt of a colovesical fistula?
Primary closure of the bladder with sigmoid resection and primary anastomosis
247
What 4 things can be measured with a Swan Ganz catheter?
CVP, Pulmonary artery pressure, PCWP, and CO
248
How might a pt present with ischemic orchitis after hernia repair?
Testicular atrophy or chronic testicular pain (relieved by orchiectomy)
249
What is the number one cause of varicose veins?
Incompetence of the valve at the junction of the GSV with the SFV at the inguinal region
250
What isnt a GI series really that helpful in gastric CA?
Can miss the superficial spreading type
252
Approximately how much volume can the stomach accommodate?
1 L
253
What is the first line Tx for hepatic encephalopathy? What Abx can be used and why?
Lactulose to acidify colon and decrease ammonia levels; Neomycin, metronidazole, and rifaximin to kill urease + bugs
254
Explain the classic triad of Sx in neurogenic shock. Tx?
Hypotension, warm extremities, bradycardia (loss of sympathetic chain leads to bradycardia and dilated peripheral vessels so open capillaries); IVF (crystalloids)
254
What if a labeled RBC scan is positive?
Do mesenteric angiography to coil embolize the bleeding vessel
255
How do you test for an anastomotic leak in GI procedures?
Upper GI series or abdominal CT with contrast
256
What is the screening protocol for AAA?
US in men 65-75 who have ever smoked
258
How far up does the diaphragm extend (i.e. what is your superficial landmark)?
Nipple line
259
What is first line Tx for PEA or asystole?
Vasopressor to increase coronary perfusion
259
What is Goodsall's rule
Anterior fistulae in ano have a straight trajectory whereas posterior ones tend to be curved
260
What are the most common organs that bleed when a person has hypotension after abdominal trauma?
Liver and spleen
261
What is Scarpa's fascia called in the penis and scrotum
Colles in the penis and Dartos in the scrotum
263
Why do you make abdominal incisions in the plane of a nerve (dermatomal) or midline?
This avoids denervating muscle leading to post-op bulge/incisional hernia; midline is avascular
265
Name 2 diseases assoc with thymoma
Myasthenia gravis, pure red cell aplasia
267
What incision is made to access the esophagus and why?
Right thoracotomy because the aorta is on the left
269
What is the eponym of a hernia through the superior lumbar triangle? Inferior lumbar triangle?
Grynfelts hernia; Petits hernia
270
When the stomach is used for an esophageal substitute, which arteries are divided?
L gastric (celiac) and short gastrics (splenic) to allow it to be mobilized. Lives off of R gastric and gastroduodenal, gastroepiploics
271
What is the definition of massive hemoptysis?
\> 600 ml hemoptysis in 24 hr; requires immediate diagnostic and therapeutic evaluation, if not massive can be done as outpt
273
What are the 4 types of hiatal hernias?
Type I = "sliding hiatal hernia" the GE jxn slides in and out of the hiatus; Type II = paraesophageal so GE jxn still in abdomen; Type III = combo of I + II; Type IV = herniation of any other organ through the diaphragm
275
In which pts would you need to be careful giving mannitol to decrease increased ICP?
Hypotensive pts bc can precipitate hypovolemic shock
276
What is Cytopathic Hypoxia
Occurs in sepsis when there is enough inflammation that it alters cell function such that the cell actually behaves as if it doesnt have enough O2
277
What is the ross procedure?
When an autograft of the pulmonary valve is taken and put on the aortic valve position with homograft replacement of the pulmonic valve
278
How many mesenteric arteries are typically occluded when mesenteric ischemia starts?
2 of 3 as there will be collateral flow through the other
280
What esophageal disorder can be Tx'd with NTG?
Diffuse esophageal spasm
282
Where is the Gastrinoma triangle?
Jxn of cystic duct with CBD, jxn of 2nd and 3rd parts of duodenum, and neck of pancreas
284
When do you treat a popliteal aneursym?
If greater than 2cm or causing blue toe syndrome
285
What would you think in an adult with a scaphoid abdomen, respiratory distress, and bowel sounds in the thorax? (trauma)
Blunt rupture of the diaphragm (in kid could be a hernia of bochdalek or morgagni)
286
What is a Type III endoleak?
Due to disconnection of components of the dacron graft, requires fixing
287
What is the most common nutrient deficiency post-op in bariatric procedrues?
Fe deficiency
288
When can you excise a thrombosed external hemorrhoid?
In the first 48 hours
289
What is pressure control on the ventilator? What are the pros and cons
Gives a preset pressure to prevent barotrauma but tidal volume is variable so there can be hypercarbia
290
What drug may help some of the s/s of early dumping syndrome?
Octreotide
292
What is the number one cause of esophageal bleeding?
Ulcerative esophagitis
293
What is the best initial mgmt of acute arterial occlusion?
IV heparin
294
Why arent central lines necessarily the greatest for volume repletion?
They are long so they impede flow; rather peripherally inserted large bore IV's are better because short. If peripheral access cannot be attained then go central
295
What has a better prognosis, gastric adenocarcinoma or gastric lymphoma?
Gastric lymphoma
297
What is a source that you should consider for sepsis in a SICU pt?
Ventilator-Associated Pneumonia (do a BAL showing \> 10 ^4-5 organisms)
297
What are primary, secondary, and tertiary peristaltic waves in the esophagus?
Primary = normal and is relaxation of LES after swallowing, Secondary = abnml and due to dilatior or irritation, Tertiary = basically "fibrillation" of the esophagus correlated with high anxiety states
298
T/F: Crohns fistulae follow Goodsall's rule
FALSE
300
In addition to CT for staging esophageal CA (which is often done after a barium swallow) what else is used to stage?
EUS to get better T staging from mucosal involvement and N staging from US guided bx of nearby LNs
302
What is the best workup of suspected diverticulitis?
Plain abdominal series to rule out pneumoperitoneum and then CT scan (barium enema CI for 2-3 weeks)
303
How do you treat late dumping syndrome?
Eat a light snack 1-2 hrs after eating to blunt the quick changes in glucose and insulin levels
304
What happens when you make a "relaxing incision" into the rectus abdominis muscle?
it becomes another tendinous intersection
306
Development of cholelithiasis is so common after bariatric procedures that __________ is given for ppx
Ursodeoxycholic acid
308
What is the 5 yr survival of esophageal CA?
20%
309
How do you confirm diagnosis of cardiac tamponade?
FAST (Focused Assessment with ultrasonography in Trauma)
310
What are the malabsorptive bariatric procedures?
Biliopancreatic diversion with or without duodenal switch; Roux-en-Y bypass
311
What is a Pantaloon hernia?
Simultaneous direct/indirect hernia that straddles the inferior epigastrics like pantaloon pants
312
How do you treat anal malignancy?
Pelvic radiation with 5-FU and mitomycin C; if residual CA after then APR is indicated
313
What is the operative goal for splenic injuries?
Splenic salvage but that needs to be balanced with the risk of bleeding and death
314
What is the usual resting pressure of the LES?
6 mmHg
315
What is Cooper's ligament? What is the lacunar ligament? What is the conjoint tendon?
Cooper's ligament is periosteum of the pubic tubercle, the lacunar ligament is the part of the internal abdominal oblique that fuses to the Cooper's; Conjoint tendon is the aponeurosis of the internal abd. Oblique and the transversus abdominis
316
What does abdominal breathing in a trauma pt often indicate and why?
C-spine injury because it knocks out the intercostal innervation
318
How is a Hesselbach's hernia different from a femoral hernia?
It occurs lateral to the femoral vessels whereas a femoral hernia is medial to them
319
What is the EKG in a person with aortic dissection?
Normal, this can help diff. from ischemic causes
321
What is the number 1 priority when someone has swallowed caustic substance?
Maintenance of airway d/t rapid airway edema
322
How do you treat DVT's in a pt with C/I to heparin? i.e. H/O HITT
They may need an IVC filter
323
Why does hyperammonemia cause hepatic encephalopathy?
Ammonia stimulates GABA receptors in brain leading to somnolence
324
What is an extra-anatomic bypass?
Done when a pt has a "hostile abdomen" i.e. ax-fem bypass or fem-fem bypass
325
What is the use of Barium Esophagography (esophagram)?
Assess motility for hiatal hernia, diverticula, or obstruction (if a hiatal hernia is suspected pt may be imaged in diff. positions to alter pressures). Good initial study
326
What are the 5 layers seen on endoscopic US (EUS) of the esophagus?
5. Mucosa seen as superficial mucosa and deep mucosa, submucosa, muscularis propria, adventitia
327
What are the 2 primary tests for achalasia? Why use endoscopy?
Barium swallow (birds beak), manometry; to rule out "pseudoachalasia" i.e. from a stricture or obstructive CA
328
What is an "abdominal series"
Flat and upright plain films of the abdomen
329
Hypermobile cecum increases risk for what?
Cecal volvulus
331
What is the Tx of fistula-in-ano? What is the primary concern in this treatment?
Fistulotomy to unroof the fistula and allow it to heal by secondary intention; could possibly cause incontinence!
333
Where is the arcuate line located?
Midway between the umbilicus and pubic symphysis
334
Which kind of effusion usually does not require chest tube (exudate or transudate)
Transudate because you should direct tx at the underlying cause
335
Why should you do a DRE in case of abdominal trauma?
To evaluate for high riding prostate which would be a contraindication to Foley catheter placement as urethra is probs damaged. You want the Foley to guide resuscitation goals
336
Paralysis of the intrinsic muscles of the foot due to diabetic neuropathy is called \_\_\_\_\_
Charcot's foot
337
What are the most common benign mucosal/submucosal lesions in the esophagus?
Granular cell tumor/ Fibrovascular polyp
339
What is the most common association of a diastasis recti?
Rapid weight loss leading to midliine fascial WEAKNESS (not a defect)
340
What is an isolated decrease in T3 with normal TSH? Tx?
Sick Euthyroid syndrome; no Tx indicated it is likely an adaptation to critical illness
342
At what size is a gastric ulcer concerning for CA?
\> 3cm
343
What is the tx of massive hemothorax?
Tube thoracostomy with volume resuscitation (possibly autotransfusion of the blood in thorax to decrease the use of banked blood)
344
What is the significance of stage II a esophageal CA and lower?
These cancers have lower local invasion and no lymph node mets; there is a 50% 5-yr survival vs. 20-30%
346
What if you suspect BAI but a CXR is equivocal?
CT with IV contrast
347
Tx of ZES?
High dose PPIs, removal of tumor, truncal vagotomy
348
What is a sliding hernia?
When part of a hernia sac is made up of an intra-abdominal organ
349
What bladder cather pressure is concerning for abdominal compartment syndrome?
25 mmHg
350
What tool can be used to T stage gastric CA?
Endoscopic US
351
What is obstipation?
No stool no flatus
352
What is severe sepsis? What is Septic shock? What is MODS?
Sepsis + organ malfunction; Sepsis + hypotension; Multiorgan Dysfunction Syndrome (\>1 organ malfunctional)
353
Differentiate between a Type Ia endoleak and a Type Ib endoleak
Type Ia is a proximal endoleak in AAA endovascular repair near the renals, Type Ib is a distal one near the iliacs? Both require repair
354
If you have resuscitated a person from a major arrhythmia and they are comatose what should you do?
Make them hypothermic with cold IV crystalloids and ice packs
355
What is often the main AE of palliative mgmt of esophageal ca?
Perforation i.e. stents, pneumatic dilation, laser/photodynamic, chemoradiation
356
Why do you extend an antrectomy into the proximal duodenum when treating for PUD?
To reduce the risk of retained antrum which would lead to G cell hyperplasia and recurrence (i.e. G cells are found in the antrum)
357
How is pain due to spinal stenosis often relieved?
By leaning forward when walking
358
What study can confirm gastric atony (post-gastrectomy) and gastroparesis from DM? Tx?
99m Tc-labeled egg albumin study (gastric scintigraphy scan); erythromycin and metoclopromide
359
What drugs should all pts with carotid stenosis be on?
BB, statin, and antiplatelet agent
361
What is the best test to screen for MEN I when a gastrinoma is found i.e. Zollinger Ellison?
Serum calcium (i.e. looking for hyperparathyroidism as well, if positive probs MEN I; obviously need to exclude renal dz so prob should check PTH as well)
363
What is the easiest way to assess a persons airway?
Ask them to speak
364
Which spc levels provide cutaneous innervation to the anterior abdominal wall?
T7-L1
365
How does CHF differ clinically from cardiogenic shock?
BP is maintained in CHF because there is increased sympathetic activity and RAAS activation
366
Where do the taenia coli typically disperse and disappear?
Sacral promontory
367
What if a person has PUD and then suddenly has the inability to tolerate oral intake and they vomit? Immediate mgmt?
Gastric outlet obstruction d/t ulcer scarring; correct electrolyte abnormalities
368
What is a pulsion diverticula called in the cervical esophagus? Differentiate pulsion vs. traction diverticulum
Zenker's; Pulsion d/t motility disorder and false; Traction d/t lymph node reactivity with traction on esophaus, true diverticula
369
What is seen endoscopically in alkaline reflux gastritis? Histologically?
Caused by alkaline pancreaticobiliary products refluxing into a denervated stomach so will be very edematous and bile-stained; corkscrew appearance of submucosal vessels
370
What surgery is done in combination with a Nissen fundoplication if esophageal shortening is present?
Collis gastroplaty (stomach is used to make an abdominal neoesophagus)
371
What are the 4 endoscopic appearances of gastric adenocarcinoma? Which is most common?
Ulcerated, polypoid, scirrhous, and superficial spreading
372
What are 2 conditions in which hamartomatous polyps are seen?
Peutz-Jehgers and Juvenile polyposis
373
How is AICI (Adrenal Insufficiency of Critical Illness) different from Addison's dz?
AICI does not present with typical Addisonian features, rather there is hypotension unresponsive to catecholamines and there may still be hyponatremia/hyperkalemia and hypoglycemia
374
Why is continuous dialysis better than intermittent in the SICU setting?
Intermittent dialysis will cause hypotension and electrolyte shifts
375
T/F pulmonary artery catheters improve outcomes in SICU pts
False no studies corroborate that
376
What would make PUD "complicated" (4)
Perforation, Hemorrhage, Gastric outlet obstruction, intractability
378
What kind of graft material is required for below the knee revascularization procedures?
Venous (GSV) vs. gortex because better patency rates
379
What are the indications for surgery of gastric ulcers?
Nonhealing ulcers, obstructing ulcers, or refractory gastric ulcers (all may be malignant, obviously a malignant ulcer is also a cause for surgery)
380
What are the 3 factors of the MELD score?
Creatinine, Serum bilirubin, and INR (Model for End-stage Liver Dz)
381
How does a thoracic esophageal tear usually present?
Acute onset of sepsis, RDS, and pleural effusion
383
How do you tx acalculous cholecystitis?
Empiric abx, IVF and lap chole if tolerable if not then percutaneous cholecystostomy
384
What is the site of venous stasis ulcers called? Where does PAD ulcers occur?
Gaiter zone (medial malleolus); PAD ulcers at the metatarsal joints
385
Explain a "Daily interruption of Sedation in Critical care setting"
Every day sedation should be stopped and restarted at half the dose an titrated up so to avoid over sedating as this can lead to longer lengths of stay in the hospital
386
Why is fiber used to decrease diverticulosis?
By bulking the stool, less intraluminal pressure is required to propel it along, decreases the risk of pulsion diverticulae
387
What is the T3/4 and TSH level in thyroid storm?
High T3/4 and NON-DETECTABLE TSH
388
The cauda equina starts approximately where?
L1-L2
389
What is the only major circulatory deficit that can be worsened by giving fluid?
Cardiogenic shock because it will just pool in lungs; use inotropic support instead
390
What is the difference between hibernating myocardium and stunned myocardium?
Both are temporarily nonfunctional states but hibernating myocardium is due to chronic ischemia and stunned myocardium is due to acute episode
391
What is a volvulus?
Rotation on an axis formed by the mesentery that leads to blockage of the vessel (sigmoid and cecum most common, cant really happen in ascending/descending bc no mesentery)
392
What is the first branch of the hepatic artery proper?
Gastroduodenal
393
Avulsion injuries of the diaphragm are more likely to be complicated by herniation of viscera on which side?
Left because the liver probably will not herniate but stomach can
394
What is the number 1 cause of death in bariatric surgery?
PE (adipose is thrombogenic, pushes on deep leg veins increasing stasis, and obese ppl less mobile)
395
What is end stage venous stasis disease at the gaiter zone called (i.e. when it is brown)
Lipodermatosclerosis from hemosiderin
397
What is the technical definition of Pulsus Paradoxus?
decrease in SBP by \>10 mmHg with inspiration
398
Where should you palpate for lymphadenopathy in anal CA?
Inguinal lymph nodes
399
What is overexpressed in Menetrier's disease? Why would these pts be edematous?
TNF-B; This can lead to protein-losing gastropathy
400
How do you follow up a person who had colon resected for CA?
Visits q 3 months for 2 years, then 6 months for 3 years, then yearly until 10 years s/p resection (get colonoscopy and CEA measurements)
401
What are the 6 H's and 4 T's associated with and what are they?
These are the causes of PEA and asystole? Hypovolemia, Hypoxia, H ion (acidosis), Hypokalemia, Hyperkalemia, Hypoglycemia, Hyperthermia? Toxins, Tension Ptx, Tamponade, Thrombosis
402
In a critical care setting what is more useful for diagnosing adrenal crisis? Cortisol level or Cosyntropin stimulation test?
Cortisol level
404
What drugs must be d/c'd several days prior to Esophageal pH monitoring? How long is the study? What is the main utility for it?
PPI's and H2 antags; 24 hrs; it is good at determining if you need surgical intervention for GERD by calculating a composite "DeMeester Score"
405
Why is a surgical site infection a big deal in a hernia repair?
The mesh is a foreign body and can become a nidus for infection
406
The GCS is the sum of the best score of what 3 clinical tests?
Eye opening, Best verbal response, Best motor response
407
What are 2 good first initial tests to evaluate a person with extremity ischemia?
ABI and continuous wave arterial doppler
408
Are there national standards for brain death?
No only state laws and hospital proticols
409
What are some diseases in which esophageal manometry can be used (3)
Achalasia, Esophageal spasm, and GERD
410
What are the basic surgical principles in operative mgmt of GERD?
Restore intra-abdominal segment of esophagus (i.e. if hiatal hernia), reconstruct esophagus, and reinforce LES with a fundoplication
411
What are the biggest risk factors for SCC of the esophagus? Where is it usually located vs. adeno?
EtOH and tobacco; proximal
412
Where will you find an aortoenteric fistula?
Endoscopically will see dacron graft into the 3rd (horizontal) duodenum
413
Where do most colonic diverticulae develop?
Sigmoid colon where branches of the marginal artery of drummond pierce (i.e. they are weak points)
414
Why is rightward deviation of an NGT a sign of widened mediastinum from aortic injury?
Aorta lies left of esophagus so pushes it rightward
415
Terrible T's of anterior mediastinal tumors
Teratoma, Terrible lymphoma, substernal thyroid tumor, thymoma
416
What is the immediate Tx of tenion ptx? Definitive tx?
Needle decompression; chest tube placement with drainage
417
Why does TPN make a pt hyperglycemic?
They don?t get as much insulin from TPN as oral diet
418
What are the 3 caues of aortic stenosis?
Congenital bicuspid aortic valve, senile calcification, and rheumatic heart dz
419
How should layperson rescuers perform CPR? Trained professionals?
100 compressions/min; 30:2 compression: ventilation for trained
