surg flashcards
This neurological condition is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion. Diagnosis? Investigative test of choice?
Anterior cord syndrome; MRI is the best investigation to study the extent of neurological damage.
This neurological syndrome is characterized by burning pain and paralysis in upper extremities with relative sparing of lower extremities; it is commonly see in elderly secondary to forced hyperextension injury to the neck. Diagnosis?
Central Cord Syndrome.
This neurological syndrome is acute hemisection of the spinal cord and is characterized by ipsilateral motor and proprioception loss and contral lateral pain loss below the level of the lesion. Diagnosis?
Brown Sequard syndrome.
If a patient has a fracture of a long bone with the fragments being offset, what is the next best step in management?
Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.
This condition results in pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues; this is most common in young men, particularly those with large amounts of body hair. This is believed to develop following chronic activity involving sweating and friction of the skin overlying the coccyx within the superior gluteal cleft. Infection of hair folicles in this region may spread subcutaneously forming an abscess that then ruptures, forming a sinus tract. The chronic sinus tract may then collect hair and debris resulting in recurrent infections and foreign-body reactions. When the sinus become acutely infected, pain swelling, and purulent discharge occur in the midline postsacral intergluteal region. Treatment is by drainage of abscesses and excision of sinus tracts. Diagnosis?
PILONDIAL CYST!!!
In an anterior shoulder dislocation, which nerve is at most risk of being injured? If this nerve is injured what functions will be decreased?
Axillary nerve!!!; axiallary nerve injury can cause paralysis of the deltoid and teres minor muscles as well as loss of sensation over the lateral upper arm.
Pancreatic pseudocysts are defined as collections of pancreatic secretion within a fibrous capsule, usually within the pancreas. Pseudocysts may uncommonly become infected resulting in a pancreatic abscess. Pancreatic abscess is typically accompanied by fever and leukocytosis and may result in bacteremia. What is the treatment when a pseudocyst becomes an abscess?
Antibiotics and external drainage of the abscess.
What imaging study should be ordered in patients with pancreatitis?
Abdominal/RUQ ultrasound, as a cause for the pancreatitis should be sought. Choledocolithiasis is the most common cause of pancreatitis, and an ultrasound study early in the disease process may detect the offending stone before it is passed.
What investigational study is the best test for identifying retroperitoneal bleeding casued by pelvic fractures?
PELVIC ANGIOGRAPHY; not only does pelvic angiography provide the best means for identifying the source of retroperitoneal hemorrhage, but it can also be used to treat it. By embolizing the offending vessel, the bleed can be stopped and the hemodynamics can be stabilized.
In hemodynamicall unstable patients who have suffered blunt abdominal trauma and pelvic fracture, both intraperitoneal and retroperitoneal bleeding must be ruled out. What are the appropriate tests for establishing intraperitoneal bleeding? Retroperitoneal bleeding?
Focused Assessment with Sonography for Trauma (FAST) and diagnostic peritoneal lavage; if these tests are negative then the next best step in management would be pelvic angiography to search for retroperitoneal bleeding and possibly treating it via embolization of the offending vessel.
In a patient who is APNEIC and is also at risk of having a cervical injury, what is the best way to establish and airway in the patient?
Orotracheal intubation is the best way to restore the airway. AN orotracheal intubation needs hyperextension of the neck and should be done only after a cervical spine injury is ruled out OR IN THE CASE OF AN APNEIC PATIENT!!! Thus, though a patient may be at risk of having a cervical spine injury, being apneic makes the benefits of orotracheal intubation outweigh the risks, and so orotracheal intubation should be done with care not to move the head. Another option would be to do a surgical cricothyroidectomy.
Extremities subjected to at least 4-6 hours of ischemia can suffer from both intracellular and interstitial edema upon reperfusion. When edema causes the pressure within a muscular fascial compartment to rise above 30 mmHg, compartment syndrome occurs leading to further ischemic injury to the confined tissues. What are the five P’s” of compartment syndrome?”
1) Pain- the earliest symptom. It is classically increased by passive stretch of the muscles in the affected compartment.
2) Paresthesias- burning or tingling sensations that occur in the distribution of the affected peripheral nerve
3) Pallor- of the overlying skin is the result of tense swelling and compromised perfusion
4) Pulselessness- a late finding, so the presence of a pulse on exam does not rule out compartment syndrome
5) Paresis/paralysis - is also a late finding resulting from nerve and muscle ischemia and necrosis.
What is the most sensitive finding on chest x-ray for blunt aortic trauma in a patient who suffers blunt deceleration trauma (MVA or fall from > 10 feet)?
Chest X-ray is the initial screening test, and widening of the mediastinum is the most sensitive finding. Where history and chest x-ray findings are equivocal, chest CT and angiography are appropriate.
What is the most common cause of frank hematochezia in an elderly patient?
Diverticulosis.
Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggest what condition? (*other findings include pneumomediastinum and subcutaneous emphysema)
Tracheobronchial rupture.
What is the first-line modality for diagnosing a urinary stone?
NON-CONTRAST SPIRAL CT of the abdomen and pelvis. This test can be obtained relatively quickly and will visualize calcium stones and the majority of non-calcium stones.
What are the 4 categories of Eye Opening of the Glasgow coma scale?
Spontaneous- 4
To verbal command- 3
To pain- 2
None- 1
What are the 5 categories of Verval Response of the Glasgow coma scale?
Oriented- 5
Disoriented/Confused- 4
ppropriate words- 3
Incomprehensible sounds- 2
None- 1
What are the 6 categories of the Motor Response of the Glasgow coma scale?
Obeys- 6
Localizes- 5
Withdraws- 4
Flexion posturing (Decorticate)- 3
Extension posturing (Decerebrate)- 2
None- 1
What is the first step in management of a suspected urethral injury? Why is blind Foley catheterization a bad idea?
Retrograde urethrogram is the evaluation of choice, prior to insertion of a Foley catheter. The procedure can be used both to determine whether damage to the urethra has occurred and to determine the location of such damage within the urethra. Blind insertion of a Foley catheter is contraindicated because it can cause infection of a periurethral hematoma and cause abscess formation and could also increase the severity of the urethral tear.
This condition is most often seen in patients chronically hospitalized (could occur on say, the 5th day) in the intensive care unit with any of the following conditions: multiorgan failure, sever trauma, surgery, burns, sepsis or prolonged parenteral nutrition. The clinical sins of disease, such as fever and leukocytosis, are vague, and patients most vulnerable to this condition are typically noncommunicative due to their medical condition. The best way to make the diagnosis is to have a high degree of clinical suspicion and to confirm the diagnosis with imaging studies that demonstrate gallbladder distension, thickening of the gallbladder wall and the presence of pericholecystic fluid. Diagnosis? Tx?
Acalculous Cholecystitis; the pathogenesis of this condition is unclear, but it is most likely the result of cholestasis and gallbladder ischemia, leading to secondary infection by enteric organisms, edema of the gallbladder serosa and necrosis of the gallbladder. Most patients have no prior history of gallbladder disease. If left undetected, this condition can lead to sepsis and death. The immediate treatment is cholecystostomy, which may be followed by cholecystectomy when the patient’s medical condition improves.
Respiration and hemodynamics may be altered after repair of large hernias due to increased pressure within the abdominal cavity that results from replacement of the large hernia contents into the peritoneal cavity. The increased intraabdominal pressure impairs inferior motion of the diaphragm thereby causing hypoventilation. Anesthetics and postoperative pain control measures (narcotics) can also impair ventilation. venous return to the heart is also decreased due to increased intraabdominal pressure; this may result in hypotension is severe. Arterial blood gases seen in the patient will be consistent with hypoventilation i.e. slightly decreased pH (7.35), increased pCO2 (45), hypoxemia (70). What is the best next step in management of this postoperative condition?
Early physiotherapy and respiratory exercises (blowing against resistance) are indicated to prevent atelectasis, mucous plugging and pneumonia.
Isolated duodenal hematoma most commonly occurs in children following blunt trauma to the abdomen. Patients classically present with epigastric pain and vomiting due to the failure to pass gastric secretions past the obstructing hematoma. Most hematomas resolve spontaneously in 1-2 weeks. What is the conservative management of choice in these patients?
Nasogastric suction and parenteral nutrition. Surgery may be considered to evacuate the hematoma if this more conservative method fails.
This type of abscess causes perineal pain with a fluctuant mass palpable on the perineum. Pain with ambulation and defecation is common as well as urinary retention. Diagnosis?
Anorectal abscess.
This type of intraabdominal abscess presents with lower abdominal pain, malaise, low grade fever and the finding of a tender, fluctuant mass palpable only with the tip of the finger on rectal examination, which indicates its location in the rectovesical pouch. Diganosis? What is the most common cause in men vs. women?
Pelvic abscess; the most common cause in men is a ruptured appendicitis, while in women gynecologic issues are more commonly the cause.
In a patient with large amounts of hemoptysis the greatest danger is not exsanguination, but rather asphyxiation due to airway flooding with blood. What is the next best step in the management of a patient with this presentation?
Bronchoscopy, to localize and control the source of bleeding is the first step in managing massive hemoptysis. Rigid bronchoscopy has the additional benefit of providing good control of the airway.
Duodenal injury may occur during blunt trauma when the duodenum is compressed between the spine and an external solid structure like a steering wheel or seat belt during high-speed decelerating trauma. The second part of the duodenum, being retroperitoneal and therefore the least mobile, is the most commonly injured part of the duodenum in blunt abdominal trauma. Retroperitoneal air on abdominal x-rays is very suggestive. What is the most appropriate test to confim the diagnosis?
CT scan of the abdomen with oral contrast, confirms the diagnosis of duodenal injury and will disclose the presence of a concomitant duodenal hematoma. Noncontrast CT and ultrasound are not sensitive for duodenal injuries.
This is a cause of dependent edema that is uncommon. It may result from malignant obstruction, resection of structures, trauma, and filariasis. It classically affects the dorsa of the feet and causes marked thickening and rigidity of the skin. Diagnosis?
Lymphatic obstruction.
This is the most common cause of dependent lower extremity edema. It classically worsens throughout the day and resolves overnight when the patient is recumbent. Diagnosis?
Venous valve insufficiency.
What is the standard treatment approach for pelvic abscesses?
CT guided percutaneous drainage; surgical drainage may be attempted if percutaneous drainage fails.
Any gunshot wound below the 4th intercostal space (the level of the nipple) requires what surgical trauma management?
Exploratory laparotomy; any gunshot wond below the level of the nipple is considered to involve the abdomen because of the blast effect of the bullet. All penetrating traumas to the abdomen require exploratory laparotomy to ensure that there is no life-threatening injury, such as bowel trauma or hemorrhage.
This type of dislocation of the glenohumoral joint classically occurs during a tonic-clonic seizure or electrocution. On physical exam the arm is held adducted and internally rotated (fullness is palpable posteriorly, while the anterior shoulder is flat). Diagnosis?
Posterior dislocation of the shoulder joint.
Toxicity of this mineral manifests first with diarrhea, nausea, vomiting, and generalized muscle weakness. Deep tendon reflexes will be decreased of absent. Diagnosis?
Magnesium toxicity.
In this type of glenohumeral joint dislocation, the arm is held in a slight abduction and external rotation. Diagnosis?
Anterior dislocation of the shoulder joint.
When a patient presents with a pulsatile abdominal mass and hypotension, what is the next best step in management?
This is an AAA until proven otherwise, and no further studies are indicated. Thus, the patient should be immediately taken to the operating room for an emergent laporotomy for repair of the aneurysm. Mortality with this condition is approximately 50%; early recognition and operative intervention are essential.
A young individual presents with a fleshy immobile mass on the midline of the hard palate. This is a benign bony mass (exostosis), and the growth of bone arises from the midline suture in the hard palate. The patient will usually give a history that the lesion has been present for some time and will deny tenderness. The thin epithelium overlying the bony growth will tend to ulcerate and be slow to heal due to poor vascularity. No medical or surgical therapy is required unless the mass becomes symptomatic. The cause of this mass is unknown and is unrelated to trauma. Diagnosis?
Torus palatinus.
Patients with this condition usually have undergone some sort of trauma or surgical intervention to a limb. Classically the patient will complain of severe pain that is worsened on passive range of motion, paresthesias, pallor and paresis of the affected limb (pain not alleviated by narcotics). Diagnosis?
Compartment syndrome; pressure in the compartments can be measured directly using a needle and pressure transducing catheter system. Pressures over 30 mmHg may result in cessation of blood flow through the capillaries and should be treated emergently by fasciotomy.
What study is typically done following a neck trauma to rule our carotid artery injury?
Angiogram!!!; this will evaluate the aortic arch and its branches
When is ligation of a carotid artery done?
ONLY if there is uncontrolled hemorrhage from the vessel, or if it is occluded. It is not recommended to ligate carotid artery dissection; it may produce acute stroke.
When there is an intimal flap of the carotid artery, surgery is recommended to repair the vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia. Today, the availability of what technique may be an alternative option to surgery?
Stenting.
Which CN courses directly through the substance of the parotid gland? If a patient required removal of the parotid gland, or just had parotid surgery involving the deep lobe of the parotid gland, what complication would likely result?
CN VII (Facial Nerve); unilateral facial droop
What are the four criteria for SIRS (Systemic Inflammatory Response)?
- Fever or hypothermia
- Tachypnea
- Tachycardia
- Leukocytosis, leukopenia, or bandemia
*Patients meeting at least two of these four criteria are considered to have SIRS. SIRS due to an infection is called sepsis.
What is the definition of Sepsis? What is the definition of Septic Shock?
SIRS due to infection; Septic shock is diagnosed in cases of infection-related SIRS where hypotension is unresponsive to fluid resuscitation and vasopressors are required to maintain SBP > 90 mmHg.
In the first week following a burn, what bacteria is the most likely cause of wound infection? What about after one week?
S.aureus; Pseudomonas
Abdominal CT is used to detect intraabdominal injury in trauma patients who are hemodynamically stable. In hemodynamically unstable patients, what should be the initial test? What should be done next if that exam is inconclusive?
FAST is the first option; the primary tool used in this situation of a hemodynamically unstable patient to determine the need for emergent laparotomy, is a (F)ocused (A)ssessment with (S)onography for (T)rauma. This has 65 to 95% sensitivity for intraperitoneal hemorrhage. A limitation of the FAST exam is that image quality can vary based on operator experience and patient body habitus. Although rarely performed nowadays, a Diagnostic Peritoneal Lavage remains the diagnostic test of choice for detecting intraperitoneal hemorrhage in an unstable patient if the FAST exam is inconclusive.
This condition may complicate up to 7% of procedure on the aortoiliac vessels and most commonly affects the distal left colon/rectosigmoid junction. Common causes include loss of colateral circulation, manipulation of vessels with surgical instruments, prolonged aortic clamping and impaired blood flow through the IMA. Patients report dull pain over the ischemic bowel as well as hematochezia. Colonoscopy shows a discrete segment of cyanotic and ulcerated bowel. Diagnosis?
Ischemic Colitis!!!
Fever, chills, and deep abdominal pain suggest what condition?
Deep abdominal abscess.
What are the most common causes of infective aortic aneurysms?
Staphylococci and Salmonella.
Blunt trauma to the upper abdomen can cause a pancreatic contusion, crush injury, laceration or transection. Pancreatic injuries can later be complicated in what way?
By retroperitoneal abscess or pseudocyst.
If an unconscious patient is brought in to you with known head trauma, what should be the first step in management?
X-ray of the spine; patients with head trauma can have coexisting cervical spine injury, which should always be assessed before mobilizing the patient. Clinical evaluation of the cervical spine in a patient with blunt trauma is unreliable. Because of grave consequences of missing a cervical spine injury, it is important to rule out a fracture or dislocation of cervical spine vertebrae as the first priority.
Patients with Crohn disease, or any other small intestinal disorder resulting in fat malabsorption, are predisposed to what condition that can cause nephrolithiasis?
HYPEROXALURIA!!!; oxalate is obtained from the diet and is a normal product of human metabolism. Symptomatic hyperoxaluria is classically the result of increased oxalate absorption in the gut. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In patients with fat malabsorption, calcium is preferentially bound by fat, leaving oxalate unbound and free to be absorbed into the bloodstream. Failure to adequately absorb bile salts in states of fat malabsorption also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption.
What measure is necessary to take in order to reduce the risk of respiratory and cardiac complications after placement of a central line?
Chest x-ray confirmation of catheter tip location after placement.
Femoral shaft fractures are generally seen after severe direct trauma. Patients suffering traumatic fractures of the femoral shaft frequently present with signs of shock as a significant amount of blood can be lost into the thigh. On examination, the thigh is often deformed and ecchymotic. What is the preferred management for femoral shaft fracture?
Closed intramedullary fixation of the shaft with medullary reaming and intramedullary nailing. This allows for early mobilization, improved knee and hip function during recovery and decreased hospital cost. In this technique, closed reduction of the fracture segment is followed by intramedullary nail insertion through a small skin insertion over the greater trochanter.
This condition is characterized by severe respiratory distress, petechial rash, subconjunctival hemorrhage, tachycardia, tachypnea, and fever. It presents in patients with polytrauma, especially multiple fractures of long bones. Diagnosis? Tx?
FAT EMBOLISM!!!; diagnosis can be confirmed by presence of fat droplets in the urine or presence of intra-arterial fat globules on fundoscopy. It may occur from 12 to 72 hours after the injury. CNS dysfunction initially manifests as confusion and agitation but may progress to stupor, seizures, or coma and frequently is unresponsive to correction of hypoxia. Treatment of Fat Emboli includes prompt respiratory support. Use of heparin, steroids and low molecular weight dextran is controversial.
A classic petechial rash occurs with what type of embolism after trauma?
Fat Embolism!
The spleen is the most commonly injured organ in cases of blunt trauma. What is the main guide that is the determinant for surgical versus non-surgical management of patients with splenic trauma?
Hemodynamic stability and the ned for blood transfusion are the determinants; patients who present in obvious hemorrhagic shock should undergo immediate laparotomy and splenectomy, but most patients are managed nonoperatively with close ICU monitoring and fluid resuscitation. Some patients who have a hemorrhage but are otherwise hemodynamically stable may be candidates for angiography, which can demonstrate the exact site of hemorrhage and be used to treat the hemorrhage by embolization/
This nerve innervates the muscles of the anterior compartment of the thigh (i.e. quadreceps, femoris, sartorius, pectineus), and is therefore responsible for knee extension and hip flexion; it provides sensation to the anterior thigh and medial leg via the saphenous branch. Nerve?
Femoral nerve.
This nerve supplies the muscles of the posterior compartment of the thigh, posterior compartment of the leg, and plantar muscles of the foot. These muscles control flexion of the knee and digits, and plantar flexion of the foot. This nerve provides sensation to the leg (except medial side) and plantar foot. Nerve?
Tibial nerve.
This nerve innervates the medial compartment of the thigh (i.e. gracilis, adductor longus, adductor brevis, anterior portion of adductor magnus) and controls adduction of the thigh. It provides sensation over the medial thigh. Nerve?
Obturator nerve.
This nerve gives rise to two nerves that supply the muscles of the anterior and lateral leg. These nerves provide sensation to the anterolateral leg and dorsum of the foot. Nerve?
Common peroneal, which gives rise to the superficial and deep peroneal.
What is another name for the Common peroneal nerve?
Fibular nerve.
A patient presents with complaints of daytime fatigue, anorexia, significant weight loss, and visceral-type abdominal pain interfering with sleep; physical exam reveals a tender, full epigastrum. This combination suggests a malignancy affecting what parts of the body?
The upper GI tract or associated solid organs such as the liver, gallbladder or pancreas.
Necrotizing surgical infection is characterized by intense pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. What is the next most important step in management once this is recognized?
Early surgical exploration to assess the extent of the process and debride the necrotized tissues.
What is the typical age that Legg-Calve-Perthes disease presents in children?
4-10 year old boys.
Why is diaphragmatic hernia caused by trauma more common on the left hemidiaphragm?
The right hemidiaphragm is protected by the liver.
This is a condition that can be associated with blunt trauma of the abdomen and a sudden increase in intraabdominal pressure. It may cause compression of the lungs and mediastinal deviation. Patients may develop marked respiratory distress. Elevation of the hemidiaphragm on chest x-ray may be the only abnormal finding. The early recognition of this condition is extremely important since the mortality of undiagnosed injury is approx. 30%. Chest X-rays are abnormal in about 85% of cases; however the diagnosis is only made in 27% of cases!!! Diagnosis?
Diphragmatic rupture with leakage of intraabdominal contents into the chest.
In a steady resting state the Respiratory Quotient depends upon the proportions of CO2 produced to O2 consumed per unit time. A steady state RQ is close to 1.0 and indicates predominant oxidation of what type of nutrients being used by the body? What about an RQ of 0.8? 0.7?
A steady state RQ close to 1.0 indicates predominant oxidation of carbohydrates and net lipogenesis. The RQ for protein and lipids as sole sources of energy are 0.8 and 0.7, respectively.
Why is assessing the Respiratory Quotient (RQ) important when attempting to wean patients from mechanical ventilation?
Because overfeeding, especially with carbohydrates, can cause excessive CO2 production and make weaning more challenging. This factor is especially important in patients with preexisting lung disease.
The incidence of this malignancy is highest in the second decade of life; patients typically present complaining of persistent bone pain that may be worse at night; systemic manifestations and pathological fractures are uncommon; the ESR is normal while serum alk phos is elevated. An x-ray film in a 15 year old boy shows an osteolytic lesion of the distal femur along with periosteal inflammation; sun-burst appearance. Diagnosis?
Osteosarcoma.
This bone tumor is most common in the second decade of life and it is a small, blue cell (neuroectodermal) malignancy classically associated with systemic manifestations such as fever, malaise and weight loss; it typically affects the diaphyses of long bones as well as the spine and pelvis; x-ray shows an osteolytic lesion with onion-skin appearance. Diagnosis?
Ewing’s sarcoma.
This is a tumor of adults that often involves the epiphysis of the distal femur or proximal tibia. Radiology characteristically shows a soap-bubble appearance due to the osteolytic quality of the tumor. Diagnosis?
Osteoclastoma.
States of magnesium excess are characterized by generalized neuromuscular depression. Clinically, severe hypermagnesemia is rarely seen except in those patients with advanced renal failure treated with magnesium-containing antacids. However, hypermagnesemia is produced intentionally by obstetricians who use parenteral MgSO4 to treat preeclampsia. MgSO4 is administered until the first signs of hypermagnesemia are present. What is the earliest sign?
Loss of deep tendon reflexes (a deficit that occurs with modest hypermagnesemia, 4 mEq/L). Greater elevations of magnesium produce progressive muscle weakness, which culminates in flaccid quadrapelgia and in some cases respiratory arrest due to paralysis of the chest bellows mechanism. Hypotension can occur because of the direct relaxing affect of magnesium. Changes in mental status occur in the late stages of the syndrome and are characterized by somnolence that progresses to coma.
What FEna value supports a diagnosis of hypovolemia in the setting of an oliguric patient?
FEna < 1
This mineral deficiency is common in malnourished patients and patients with large GI fluid losses. The neuromuscular effects resemble those of calcium deficiency, namely paresthesia, hyperreflexia, muscle spasm, and ultimately, tetany. The cardiac effects are more like those of hypercalcemia. This mineral deficiency causes a functional hypoparathyroidism, which can lower serum calcium and thus result in a combined affect. This deficiency also causes potassium wasting by the kidneys. Diagnosis?
Hypomagnesemia.
Whenever bleeding is noted in the early postoperative period, what should the presumption of cause be?
An error in surgical control of blood vessels in the operative field; hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postoperatively.
What serum electrolyte abnormality is of concern when initiating refeeding in a patient who is chronically malnourished?
Hypophosphatemia due to refeeding syndrome”, which occurs in malnourished patients who are administered intravenous glucose. During periods of starvation, electrolytes are shifted to the extracellular space to maintain adequate serum concentrations. With refeeding, insulin levels rise and electrolytes are shifted back intracellularly, resulting potentially in hypokalmemia, hypomagnesemia, and hypophosphatemia. Additionally, refeeding results in an increased cellular need for phosphorous for energy production (ATP) and glucose metabolism”
A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requiring an urgent operation should undergo transfusion of FFP at what time in relation to the surgery in order to minimize the risk of bleeding?
Transfusions with FFP to replenish Vitamin K-dependent clotting factors should be administered on call to the operating room. The timing of transfusion is dependent on the quantity of each factor delivered and its half life. The half-life of the most stable clotting factor, factor VII, is 4 to 6 hours. Thus transfusion of FFP on call to the operating room ensures that the transfusion is complete prior to the incision, with circulating factors to cover the operative and immediate postoperative period.
What is the most common postoperative nosocomial infection? Tx?
Urinary Tract Infection; treatment involves removal of an indwelling catheter as soon as possible and antibiotic therapy for cultures with greater than 100,000 CFU/mL
What are the 7 factors that predispose to fistula formation and may prevent closure of a fistula?
Foreign body, radiation, inflammation, epithelialization of the tract, neoplasm distal obstruction, and steroids.
What is the agent used to prepare a Hemophilia A patient before surgery? What if the disorder is mild? What if it is severe?
Hemophilia A is a coagulation disorder resulting from a deficiency or abnormality of Factor VIII. Desmopressin (DDAVP) is a synthetic analogue of antidiuretic hormone that increases levels of Factor VII and von Willebrand factor. DDVAP can be used alone for mild Hemophilia A, but is ineffective in severe forms of the disease. For severe Hemophilia A, DDVAP is given in combination with an inhibitor of fibrinolysis such as E-aminocaproic acid (AMICAR). Other agents used in treatment of Hemophilia A include cryopreicpitate and specific Factor VIII concentrates.
This is a finding in patients with primary hyperparathyroidism and represents subperiosteal resorption, characteristically on the radial aspect of the middle phalanx.
Osteitis cystica fibrosa.
What are the malabsorptive complications that can arise from a Billroth II reconstruction of the stomach?
Patients who have undergone partial gastrectomy (Billroth II) may have impaired calcium absorption, impair fatty acid absorption, B12 deficiency, and Iron deficiency.
What ECG change is associated with Hypocalcemia? Hypercalemia?
Hypocalcemia is associated with Prolonged QT and may be aggravated by both hypomagnesemia and alkalosis; Hypercalcemia is associated with Shortened QT
Massive transfusion is associated with hypocalcemia secondary to chelation with citrate in banked blood. Severe, symptomatic hypocalcemia is most commonly encountered following parathyroid or thyroid surgery, or in patients with acute pancreatitis. What is the treatment for these patients?
IV Calcium Gluconate!!!
Delivery of this medicine causes a rise in serum pH and shifts K+ intracellularly in exchange for H+ to the serum, in an effort to symptomatically treat hyperkalemia. Medicine?
NaHCO3!!!; sodium bicarbonate.
Alopecia, poor wound healing , night blindness or photophobia, anosmia, neuritis, and skin rashes are all characteristic of what mineral deficiency?
Zinc deficiency.
The deficiency of this mineral is characterized by cardiomyopathy. Diagnosis?
Selenium deficiency.
The deficiency of this trace mineral is characterized by encephalopathy due to toxic accumulation of sulfur-containing amino-acids. Diagnosis?
Molybdenum deficiency.
This trace mineral deficiency can occur in patients on long-term TPN and is characterized by difficult-to-control hyperglycemia and peripheral neuropathy and encephalopathy. Diagnosis?
Chromium deficiency.
Normal saline and Lactated Ringer solution are examples of isotonic saline solutions. Following administration of large volumes of normal saline, a non-anion-ga metabolic acidosis can result from increased chloride concentrations. These fluids can be used to replace the volume of blood lost in a patient in what ratio?
3:1 (Fluids: blood)
The use of colloids in resuscitation of patients in hemorrhagic shock is controversial; in general, however, colloids can be used to replace blood volume lost at what ratio?
1:1 (colloid: blood)
What fluid is appropriate to resuscitate a patient with significant nasogastric suction or vomiting losses?
Isotonic saline; this is particularly useful in hyponatremic or hypochloremic states and whenever a tendency to metabolic alkalosis is present. When isotonic solutions are given in large quantities, they overload the kidney’s ability to excrete chloride ion, which results in dilutional acidosis. They may also intensify preexisting acidosis by reducing the base bicarbonate-carbonic acid ratio in the body.
Administration of what resuscitation fluid is appropriate for replacement of GI losses?
Lactated Ringer solution; this is appropriate for replacing GI losses and correcting extracellular fluid deficits. Lactated Ringer solution contains 130 mEq/L, and thus is hypoosmolar with respect to serum sodium, and provides ~150 mL of free water with every Liter given. Lactated Ringer is sufficiently physiological to enable administration of large amount without significantly affecting the body’s acid-base balance. It is worth noting that both isotonic saline and lactated Ringer are acidic with respect tot he plasma NS with 5% Dextrose has a pH of 4.5, while lactated Ringer hase a pH of 6.5.
Early sepsis is a physiologically hyperdynamic, hypermetabolic state representing a surge in catecholamines, cortisol, and other stress-related hormones. Changing mental status, tachypnea that leads to respiratory alkalosis and flushed skin are often the earliest manifestations of sepsis. What early hemodynamic change is indicative of occult sepsis?
Intermittent HYPOTENSION!!!; intermittent hypotension requiring fluid resuscitation to maintain adequate urine output is characteristic of occult sepsis. Hyperglycemia and insulin resistance are typical in diabetic as well as non-diabetic patients. This relates to the gluconeogenic state of the stress response. The cardiovascular response to early sepsis is characterized by an increased cardiac output decreased systemic vascular resistance, and decreased peripheral utilization of oxygen, which yields a decreased arteriovenous oxygen difference.
Trauma, stress, sepsis, burns and surgery all increase the BMR of the body. The BMR can be multiplied by stress factors to better approximate caloric requirements. What is the stress factor associated with routine operation? Multiple organ failure or severe injury? Less than 50% body surface area burns?
Routine operation = 1.1
Multiple organ failure or severe injury = 1.5
Less than 50% body surface area burns = 2.0
When a patient with a tracheostomy tube has a sentinel bleed from inside the tube days later, what is the proper course of action if the bleed has currently stopped? If it is ongoing?
A sentinel bleed such as this occurs from a tracheoinnaminate artery fistula, which carries a greater than 50% mortality rate. If the bleeding has ceased then immediate fiberoptic exploration in the operating room is indicated. If the bleeding is ongoing, stop gap measures such as hyperinflation of the tracheostomy ballon to attempt compression of the artery, reintubation of the patient with an endotracheal tube, and removal of the tracheostomy and placement of a finger through the site with anterior compression of the innominate artery can be attempted, while preparing for median sternotomy.
The rapid shallow index is a parameter used to determine the readiness for a patient to be removed from ventilation. Rapid shallow breathing index is the ratio of the respiratory rate to tidal volume. What index ratio has been suggested to predict successful extubation?
Index between 60 and 105.
What should the negative inspiratory force of a patient’s inspiration be, before they can be successfully extubated from a ventilator?
The negative inspiratory force should be at least greater than -20 cmH2O.
What PEEP should a patient be weaned to before they are extubated from a ventilator?
5 cmH2O PEEP.
What should the minute ventilation, which is the product of the tidal volume and respiratory rate, should be less than what value before attempting extubation from a ventilator?
< 10 min/L
Spontaneous respiratory rate should be below what value in a patient, before attempting to extubate them from the ventilator?
20 breaths/min
In a patient with a hemolytic transfusion reaction, what are the steps necessary to protect the kidneys from the damaging effects of hemoglobin precipitation in the renal tubules?
Mannitol and NaHCO3; the precipitation of hemoglobin in the renal tubules is inhibited in an alkaline environment and is promoted in an acidic environment. Stimulating diuresis with mannitol and alkalinizing the urine with sodium bicarbonate intravenously are indicated procedures.
This inhalation anesthetic has a low solubility compared with other inhalation anesthetics; it is more soluble in blood than nitrogen and is the only anesthetic gas less dense than air. As a result of these properties, this gas may cause progressive distension or air-filled spaces during prolonged anesthesia. This could be bad for operation on intestinal obstruction. Anesthetic?
Nitrous Oxide.
Why does banked blood shift the O2 dissociation curve to the left?!?
Because banked blood is low in 2,3-BPG, thus is shifts the curve to the left and the blood holds on to O2 better and therefore decreases tissue O2 uptake.
Dopamine at this level of dosage affects primarily the dopaminergic receptors. Activation of these receptors causes vasodilation of the renal and mesenteric vasculature and mild vasoconstriction of the peripheral bed, which thereby redirects blood flow to the kidneys and bowel. What is the dose level?
Low dose [1-5 mg/(kg x min)]
At this level of dopamine dosing B1-receptor activity predominates and the ionotropic effect on the myocardium leads to increased cardiac output and blood pressure. What level dosing is this?
Moderate [2-10 mg/(kg x min)]
At this level of dopamine dosing alpha-receptors are activated and cause strong peripheral vasoconstriction, shifting blood from the extremities to the organs, decreased kidney function, and hypoperfusion. What level of dosing is this?
High [>10 mg/(kg x min)]
How does Dopamine administration affect the coronary blood flow and any level of dosing?
It INCREASES CORONARY BLOOD FLOW; At all doses, the diastolic pressure can be expected to rise as a result of dopamine administration; since coronary perfusion is largely a result of the head of pressure at the coronary ostia, coronary blood flow can be expected to INCREASE.
This is a synthetic catecholamine that is becoming the ionotropic agent of choice in cardiogenic shock. As a B1-adrenergic agonist, it improves cardiac pump performance in pump failure both by positive ionotropy and peripheral vasodilation. With minimal chronotropic effect, this drug only marginally increases myocardial O2 demand. What drug is this?
Dobutamine!!!
Thoracic epidural narcotics have become an increasingly popular means of postoperative pain relief in thoracic and upper abdomnial surgery. Local action on gamma opiate receptors ensures pain relief and consequent improvement in respiration without vasodilation or paralysis. The less lipid-soluble opiates are effective for long periods. Their slow absorption into the circulation also ensures a low incidence of centrally mediated side effects, such as respiratory depression, or generalized itching. When these do occur what is the effective antidote?
INTRAVENOUS NALOXONE!!!; not epidural; the locally mediated analgesia is not affected.
The development of acute postoperative acalculous cholecystitis is an increasingly recognized complication of the severe illnesses that precipitate admissions to the ICU. The diagnosis is often difficult because the signs and symptoms may be those of occult sepsis. If diagnosis is delayed, mortality and morbidity are very high. What is the treatment for acalculous cholecystitis in the postoperative period?
Percutaneous drainage of the gallbladder!!!; this is usually curative and affords stabilizing palliation if calculous cholecystitis is present. Antibiotics without drainage are too cautious a choice for a patient with this potentially fatal complication. Operative intervention is indicated only if less invasive methods of treatment (percutaneous cholecstostomy tube) have failed.
What is the mechanism of action by which PEEP improves oxygenation?
Increasing Functional Residual Capacity; PEEP does this by keeping alveoli open at the end of expiration. Extravascular lung water is shifted from the alveolar to the interstitial space. The overall result is to increase surface area for diffusive exchange of gases.
What cardiac condition causes right atrial collapse and equalization of pressures in all four heart chambers?
CARDIAC TAMPONADE!!!; the equalization of pressures occurs because right atrial pressures and central venous pressure are increased and cardiac output is decreased.
What is the surgical significance of previous MI within 6 months, functional impairment such as dyspnea on exertion, age over 70 years, mitral regurgitation, more than 5 PVCs in a minute, and a tortuous or calcified aorta?
These are are the main cardiac risk factors associated in noncardiac surgical patients identified by a landmark study by Goldman in 1978.
Neurogenic shock is characterized by loss of sympathetic tone peripherally as well as bradycardia owing to loss of the reflexive increase in heart rate in response to hypotension. What is the appropriate first step in management of such a patient?
Initial treatment is with fluid resuscitation followed by initiation of vasoconstrictors such as dopamine or phenylephrine.
Accurate measurement of PCWP by a Swan-Ganz catheter may not be possible in the presence of positive air-way pressure with PEEP/CPAP; transmission of the positive airway pressure to the pulmonary microvasculature, via the alveoli, especially in the upper lung zones, results in the measurement of what pressure rather than LAP or LVEDP?
Alveolar pressure.
The risk of recurrent stroke appears to be comparable with that for surgical patients who do not have a history of prior stroke the those that do have a stroke history, when undergoing cardiac or peripheral vascular surgery? Most recurrent strokes occur within hours to days following surgery and do not appear to be directly related to operative events. Is mortality after a postoperative stroke high or low?
Mortality is HIGH after a postoperative stroke.
What is the initial treatment for someone having an anaphylactoid reaction with laryngeal obstructive signs and possible bronchospasm?
EPINEPHRINE!!!; is the initial treatment, followed by histamine antagonists (H1 and H2 blockers), aminophylline, and hydrocortisone. Conscious patients are usually stabilized with injected or inhaled epinephrine, while unconscious patients and those with refractory hypotension or hypoxia should be intubated. Vasopressors and fluid challenges may be given for shock.
Most transfusion reactions are hemolytic and are due to clerical errors that result in administration of blood with major (ABO) and minor antigen incompatibility. Intravascular hemolysis resultis in hemoglobinemia and serum haptoglobin levels are decreased (
A positive Coomb’s test.
Indirect hyperbilirubenemia and anemia may be seen in what type of transfusion reaction?
Delayed transfusion reaction, which occurs between 2-10 days after trasfusion. Delayed transfusion reactions can occur due to antibodies to Rh antigens and are indicative of extravascular hemolysis.
In a ventilated patient what parameters are used to determine ventilation status?
CO2 and PaCO2 levels; due to highly efficient diffusion characteristics these indicators are good measures of adequacy of alveolar ventilation.
What effect does hypokalemic metabolic alkalosis have on the urine pH?
It produces paradoxical aciduria, as the kidney excretes hydrogen ion in an effort to conserve potassium ion.
A rare but deadly complication of tracheostomy us a tracheoinnominate artery fistula (TIAF); when suspected, the diagnosis should be confirmed or ruled out in the operating room through bronchoscopic evluation. TIAFs can occur as early as 2 days after the tracheostomy or as late as 2 months after the procedure. TIAF formation is often associated with what functional aspect of the tracheostomy procedure?
Low placement of the tracheostomy (i.e. distal to the second and third tracheal rings).
What are the appropriate steps to manage a tracheoinnominate artery fistula (TIAF) that forms as a result of low placement of a tracheostomy (i.e. distal to the second and third tracheal rings)?
TIAFs result in a sentinel bleed 50% of the time, followed by very impressive bleeding. If a sentinel bleed is suspected, the patient should be transported immediately to the operating for evaluation. Initial maneuvers for management of TIAF include overinflation of the cuff on the tracheostomy or reintubation from above followed by removal of the tracheostomy and finger compression of the innominate artery against the sternum through the tracheostomy wound.
Although Factor VIII is deficient in patients with Von Willebrand disease, what is the only reliable IV solution that should be given to aid coagulation in such patients?
Cryoprecipitate!!!; this is because treatment requires correction of the bleeding time and providing factor VII R: WF (Von Willebrand factor). Only Cryoprecipitate is reliably effective. High purity Factor VIII:C concentrates that are effective in Hemophilia, lack the von Willebrand factor and are consequently undependable.
This intraoperative complication may show rigidity instead of anticipated relaxation as its first sign. Treatment should include prompt conclusion of the operative procedure and cessation of anesthesia, hyperventilation with 100% O2, and administration of dantrolene. The urine should be alkalinized to protect the kidneys from myoglobin precipitation. In addition to fever, the syndrome includes tachycardia, increased O2 consumption, increased CO2 production, increased serum K+ and, myoglobinuria, and acidosis. Diagnosis?
Malignant Hyperthermia due to halothane and succinylcholine administration.
Cholesterol embolism is a known complication of angiography or aortic manipulation during surgery and can result in lower extremity ischemia, acute myocardial infarction, ischemic bowel, and acute or chronic renal failure. What specific CBC cytologic finding is highly suggestive of cholesterol emboli?
EOSINOPHILIA!!!; this is strongly suggestive of cholesterol atheroembolization, and other laboratory findings include microscopic hematuria or proteinuria and elevated inflammatory mediators such as erythrocyte sedimentation rate.
What treatment should be considered in patients with neurological symptoms and carbon monoxide poisoning, as this treatment reduces the half-life of carboxyhemoglobin?
Hyperbaric O2.
What inhalation agent is most likely to cause a patient with a bowel obstruction to develop increasingly distended loops of bowel after induction?
Nitrous Oxide (N2O)!!!; this is becasue nitrous oxide is 30 times more soluble than nitrogen in the blood and enters a collection of trapped air at a rate faster than at which nitrogen leaves the collection. Thus, this leads to an increase in volume of trapped air such as loops of bowel leading to bowel distension.
Succinylcholine is a depolarizing neuromuscular blocking agent that causes what effect on serum electrolytes? What patients do you not want to use this in?
Increase in serum K+; it causes a rise in serum potassium of up to 1.0 mEq/L within a few minutes after administration. This is caused by efflux of potassium from the skeletal muscle at the neuromuscular junction. Patients with burns, trauma, severe infections or neuromuscular disorders have a greater than normal potassium efflux that occasionally causes severe hyperkalemia.
What neuromuscular blocking agent do you not want to use in patients with burns, trauma, severe infections or neuromuscular disorders, because these patients with have a greater than normal potassium efflux from their cells that occasionally causes severe hyperkalemia?
Succinycholine.
Rapid intravenous injections of Morphine may cause what effect on blood pressure?
Hypotension.
Pancuronium is a neuromuscular blocking agent that is associated with what effect on heart rate?
Tachycardia!!!
In a patient with CHF and low volume status who requires immediate surgery, what technique will allow physicians to assess his volume status ad need for ongoing ionotropic support, and help dictate further treatment (volume, afterload reduction, etc.)
Pulmonary Artery Catheterization!!!
PT is used for the extrinsic or intrinsic pathway?
EXTRINSIC!!!
PT detects deficiencies in what which coagulation factors?
Factors II, VII, IX, X and Fibrinogen, and is used to monitor patients receiving Warfarin.
What coagulation factor deficiencies does thrombin time assess?
Thrombin time assess the qualitative abnormalities in fibrinogen and the presence of inhibitors to fibrin polymerization. A standard amount of fibrin is added to a fixed volume of plasma and clotting time is measured.
The appropriate margin for wide excision of melanomas is dependent on the depth of the lesion. For thin lesions, less than or qual to 1mm in depth what is the minimal requirement for margins? For intermediate (1-4mm)? For thick (>4mm) lesions?
Thin melanomas (4mm) = 2cm margin
Inflammation, proliferation and remodeling are the sequence of events for what process?
WOUND HEALING!!!
What are the primary cells that enter a wound during the inflammatory phase of woud healing?
Neutrophils and Monocytes.
What are the biochemical mediators that are released during day 2 of wound healing when monocytes migrate into the wound site?
Monocytes secrete numerous growth factors such as TNF, TGF, PDGF and FBGF, all of which are essential to wound healing.
At what phase do angiogenesis and collagen formation take place during wound healing?
The proliferative phase.
When is the first point at which collagen deposition is maximal in a wound, during the process of wound healing?
2-3 weeks, at which time the remodeling phase begins.
Pyoderma gangrenosum is a rare cause of cutaneous ulcerations that can be associated with inflammatory bowel disease (Crohn’s and Ulcerative colitis) as well as other immune disorders. What is the mainstay of treatment for such wounds?
Systemic steroids and immunosuppressants.
What is the most effective method of rewarming in a patient with frostbite?
Water Immersion; rapid rewarming by immersion in water slightly above normal body temperature (40-44C; or 104-112F) is the most effective method, however, because the frostbitten region is numb and especially vulnerable, it should be protected from trauma or excessive heat during treatment. Further treatment may include elevation to minimize edema, administration of antibiotics and tetanus toxoid, and debridement of necrotic skin as needed.
The superficial flexor digitalis tendons inserts on what part of the fingers?
The middle phalanx.
The deep flexor digitalis tendons insert on what part of the finger?
The distal phalanx.
Does the superficial or deep flexor digitalis muscle have tendons that share a common muscle belly?
The deep flexor digitalis muscle; since the tendons of the deep flexors share a common muscle belly, only the superficial flexors can move a finger when the adjacent fingers are immobilized.
What is a tenoma and what type of anatomical structure is it involved in the healing of?
A tenoma is a tendinous inflammation that is formed in the process of healing tendon injury. A difficult balance has to be struck between the desire to prevent adhesions by early mobilization and the risk of rupturing an unhealed tendon.
This type of wound is a wound in which no part of the respiratory, gastrointestinal, or GU tract is entered (e.g. herniorrhaphy and breast surgery). What class of wound is this?
Clean wound; Class I
In this class of wound, the respiratory, GI, or GU tracts may be entered, but there is no evidence of active infection or gross spillage (e.g. cholecystectomy or elective colon resection, with adequate bowel preparation. What class of wound is this?
Clean-contaminated; Class II
These type of wounds include open accidental wounds encountered early after injury, those with extensive introduction of bacteria into a normally steile area of the body, or gross spillage of viscus contents such as from the intestine (e.g. include penetrating abdominal trauma, large tissue injury, and enterotomy during bowel obstruction. What class of wound is this?
Contaminated; Class III
This type of wound includes traumatic wounds in which a significant delay in treatment has occurred and in which necrotic tissue is present, those wounds created in the presence of purulent material, and those involving a perforated viscus accompanied by a high degree of contamination (e.g. perforated diverticulitis and necrotizing soft tissue infections). What class of wound is this?
Dirty; Class IV
