Surgery Flashcards
If O2 sats are below 90, do
ABG
Normal bicarb =
24
Cardiac output =
Stroke volume x Heart rate
Stroke volume =
End Diastolic Volume - End Systolic Volume
Total peripheral resistance =
Mean arterial pressure - Mean venous pressure
Blood pressure =
Cardiac Output x Total Peripheral Resistance
Immediately perform __ in pericardial tamponade
Immediately place ____ into pleural cavity at ___ intercostal space
pericardiocentesis
large bore needle or IV catheter; 2nd
In preparation for immediate exploratory laparotomy in a abdominal trauma, do a bunch of things simultaneously:
2 large bore IV lines Type and cross Give fluids and blood Insert foley Administer IV antibiotics
Children <6 years old –> intraosseous cannulation in the proximal tibia
Surgery is always done for ___ head injuries, even if the patient is asymptomatic!
comminuted or depressed skull fracture
All patients with open skull fractures should receive
tetanus toxoid and prophylactic antibiotics
Management of basal skull fracture =
CT scan of head/nec CSF leak sill stop by itself (NO Antibiotics needed) Facial palsy may occur 2-3 days later
All epidermal hematomas (Lens, biconvex; Middle meningeal artery; lucid interval) require
emergency craniotomy
Epidural hematoma = injury to
middle meningeal artery
Subdural hematoma = injury to
bridging veins
Only do an emergency craniotomy in case of subdural hematoma if
there are lateralizing signs and midline displacement
Surgery cannot help in this head injury that is caused by acceleration-deceleration injuries to the head
diffuse axonal injury
Gradual dilatation of one pupil and a decreasing responsiveness to light is an important sign of
elevating intracranial pressure (Medical emergency)
DO NOT EVER DO THIS
perform an LP before getting a head CT. If you perform a lumbar puncture on a person with increased intracranial pressure, you will HERNIATE THE BRAIN, KILL THE PATIENT, GET CHLAMYDIA AND DIE.
Hyperventilation causes vaso___ and decreased blood volume in the brain, causing ICP to ___
constriction; lower ICP
First line measures for high ICP are
elevated head of bed hyperventilation avoid fluid overload second line: mannitol, sedation/hypothermia
Anisocoria =
Ptosis of the left eye, Anisocoria, droopy left eyelid dx?
caused by?
Best initial test ?
Tx?
unequal size of pupils
3rd CN palsy
posterior communicating artery aneurysm
MRI of the brain with Angio
embolization thru endovascular repain
When is surgery the answer for acute abdomen?
Peritonitis (excluding primary peritonitis), Abdominal pain/tenderness plus sepsis signs, Pneumoperitoneum, Acute intestinal ischemia
Rule out pancreatitis first in all the above cases
Treatment for spontaneous bacterial peritonitis is
immediate paracentesis; diagnosis is made when fluid contains neutrophils greater than 250 cells per cubed mm
Treat SBP with
ceftriaxone and albumin at 1.5g/kg on day 1 and day 3 of hospitalization
First study of choice for esophageal perforation is
gastrografin contrast esophagram
Most accurate test for adult with GI obstruction is
Volvulus (ex: sudden abdominal pain in elderly)Dx ? Tx?
CT scan of abdomen and pelvis with contrast
Proctosigmoidoscopy w/ rigid instrument
Sigmoid resection
When diagnosing acute diverticulitis, don’t forget to order
DX w/
a pregnancy test in women of reproductive age!
CT WITH contrast
___ is absolutely contraindicated in acute diverticulitis
Colonoscopy
When palpation of the LLQ causes pain n the RLQ, think
acute appendicitis (Rovsing’s sign)
It’s important to administer ___ before appendectomy
IV antibiotics: -cipro and metronidazole -ampicillin/sulbactam -levofloxacin and clinda -cefoxitin or cefotetan
If chronic UC has been present for more than 20 years, ___ is indicated
elective surgery also if high dose chronic steroids are needed or toxic megacolon is present
What three major GI arteries arising from the abd aorta supply the gut?
Abdominal pain out of prportion to the physical findings; acidosis; sign of sepsis
TX: during sugery ? During Angio
celiac axis, the SMA, and the IMA; SMA is most commonly affected by ischemia
Mesentric ischemia
embolectomy & revascularization or resection; vasodilators and thrombolysis
The best initial and most accurate test for ischemic colitis is
CT abdomen showing thickening of the bowel in a segmental pattern
Therapy for ischemia colitis
IV fluid hydration and bowel rest
In chronic mesenteric ischemia, ___ is both therapeutic and diagnostic
computed tomography angiography
Development of symptoms (postprandial abd pain, unrelenting nausea, anorexia, weight loss) after a recent dramatic weight loss
Median Arcuate Ligament Syndrome treat by surgical decompression of the celiac artery
Always do what to an intra-abdominal abscess?
Drain it!
Which two ducts merge to form the common bile duct?
Common hepatic duct and Cystic duct
CT scan of obstructive jaundice caused by a tumor will show
double duct sign (aka simultaneous dilatation of both the common bile duct and the pancreatic duct)
Treat acute cholecystitis is
NG suction NPO IV fluids antibiotics then cholecystectomy after 6-12 weeks
Reynold’s pentad:
jaundice RUQ pain fever AMS shock
Treat acute ascending cholangitis with
IV antibiotics Emergency decompression of the common duct ERCP or percutaneous transhepatic cholangiogram Surgery isn’t often necessary
The most accurate test for fecal incontinence is
anorectal manometry
Do not perform surgery in patients with multiple
derangements in hepatic risk factors
*Bilirubin >2; albumin <3; PT >16; encephalopathy
The most lethal cause of post-op disorientation if not recognized and treated early is
COPD (FEV1 <1.5) increases post surgical risk of ___
hypoxia, so order an ABG
Pneumonia
The leakage of fecal, gastric, or duodenal contents to the outside postoperatively is ___
not an indication for emergency surgery! observe stable patients; if the patient had fever and internal fistual than do drainage and surgery maybe
Manage malignant hyperthermia (fever >104) after administration of halothene or succinylcholine by
IV dantrolene, 100% O2, acidosis correction, cooling blankets watching for development of myoglobinuria
Manage bacteremia and fever >104 with
blood cultures x3 and empiric abx
The most important step before surgery at birth is
check for congenital anomalies and look for VACTERL constellation
If excessive salivation or chocking spells are noted shortly after first feeding, it could be
esophageal atresia
What causes esophageal atresia?
Ventrally displaced location of the notochord in an embryo
Confirm diagnosis of esophageal atresia with
Tx: if the surgery needs to be delayed
NG tube, which becomes coiled in the upper chest on x-ray
Gastrostomy (feeding tube)to protect the lungs from acid reflux
If anal atresia is suspected, look for
a fistula nearby; if no fistula present, perform a colostomy
The primary abnormality of congenital diaphragmatic hernia is
hypoplastic lung with fetal type circulation
Treat CDH with
endotracheal intubation, low pressure ventilation, sedation, NG suction
delay repair 3-4 days to allow lungs to mature
Where is the defect in gastroschisis?
To the right of the umbilical cord due to failure of neural crest cells to migrate; no protective membrane
Incomplete fusion during the fourth week of development results in
omphalocele
*has a thin membrane cover
Which trisomies are a/w omphalocele?
Edwards syndrome and Patau syndrome
Exstrophy of the urinary bladder requires
(abdominal wall defect over the pubis)
Surgical repair in the first 1-2 days of life! Transfer to a specialized center
What can present with double bubble sign?
They all require ?
Annular pancreas, malrotation (most dangerous), duodenal atresia
Surgical correction
Intestinal atresia is not associated with___
Presents with
other congenital abnormalities bc this is caused by vascular accident in utero
Green vommit and multiple air fluid levels thoughout the abdomen
A sign of sepsis in newborns is
rapidly dropping platelet count
The most common pathogens in necrotizing enterocolitis are
NE presentation ___
E. coli and Klebsiella pneumonia
Feeding intolerance in PREmature infants on 1st feed; abdominal distension + rapidly dropping platelets
Pneumatosis intestinals – gas w/in bowel wall
Feeding intolerance + bilious vomiting + CF =
X-ray shows__ in CF
meconium ileus
Multiple dialated loops of bowel & ground glass appearance in lower abdomen
In meconium ileus, ___ is both diagnostic and therapeutic
gastrografin enema
Diagnose hypertrophic pyloric stenosis with
sonogram showing target sign
Treat pyloric stenosis by
first correcting metabolic abnormalities (Hypochloremic, Hypokalemic metabolic alkalosis) and dehydration, then performing a pyloromyotomy
Persistent progressively increasing jaundice in 6-8 week old babies =
biliary atresia: no excreation of bile from liver to gallbladder to duodenum
Abnormal narrowing or blockage of the duct leading to Bile accumulating inside the liver and causing damage and scarring of the liver cells leading to:
complications: cholestasis, fibrosis –> cirrhosis
Treat biliary atresia with
HIDA scan after 1 week of phenobarbital, then surgery if that doesn’t work
diagnose Hirschsprung Disease (neurocrest cells fail to migrate) with
full-thickness biopsy of rectal mucosa
When does intussusception show up?
6-12 months of age, chubby healthy looking kids with brief episodes of colicky abdominal pain
w/ Currant jelly stools and vague mass on the right side of abdomen & empty lower quadrant
Lower GI bleeding in a child of pediatric age =
Meckel diverticulum
When a fracture is suspected, order
2 views at 90 degrees to one another and always include the joints above and below the broken bone
When a fracture is displaced severely or angulated or cannot be aligned, what should you do?
Open reduction and internal fixation
When does an open fracture need to be reduced?
within 6 hours from time of injury
Neuro dysfunction, petechial rash, respiratory distress, fracture =
fat embolism
Fixing a long-bone fracture within ___ reduces the incidence of respiratory distress from embolic phenomena
24 hours
Which type of shoulder dislocation is possible in a patient with a recent seizure?
Posterior shoulder dislocations. Otherwise, anterior shoulder dislocations are the most common
What type of xray should you order in a patient with a recent seizure and shoulder pain?
axillary or scapular views of the affected shoulder
Painful wrist + dinner fork deformity =
Colle’s fracture
Direct blow to the ulna or radius results in a combo __ and __ fracture
diaphyseal and displaced dislocation. Treat w/ ORIF
Suspected scaphoid fracture, treat w/
thumb spica cast
Treat femoral neck fractures with
femoral head replacement
Intertrochanteric fractures are treated with
open reduction and pinning
Femoral shaft fractures are treated with
intramedullary rod fixation
Posterior dislocation of the hip (knees hit dashboard in MVA) =
orthopedic emergency! Leg is internally rotated and shortened
Symptoms caused by tapping the nerve over the flexor retinaculum and awaiting parasthesias =
Tinel’s sign for CTS
Flexing the wrist gently and holding the position =
Phalen’s test for CTS
Signs of a __ injury include inability to dorsiflex (extend) the wrist
oblique distal humerus, complicated by radial nerve paralysis
The most important intervention for a urologic obstruction is
a ureteral stent or percutaneous nephrostomy
A child who has hematuria from a trivial trauma has ___ until proven otherwise
A child who has UTI has ___ until proven otherwise.
Tst to order?
undiagnosed congenital urologic anomaly
Undiagnosed congenital urologic anomaly
voiding cystogram
A teenager drinks large volumes of beer and develops colicky flank pain
Ureteropelvic Junction Obstruction -only symptomatic with diuretics
obstruction is a partial or intermittent total blockage of the flow of urine that occurs where the ureter enters the kidney. UPJ obstruction is the most common pathologic cause of antenatally detected hydronephrosis.
Treat subclavian steal syndrome with
bypass surgery
Classic symptoms of subclavian steal syndrome are
visual symptoms, equilibrium problems, and claudication in the arm during arm exercises
DON’T CONFUSE it with thoracic outlet symdrome which presents with vascular sxs but NOT neurological sxs
Can result from thoracic trauma
present w/ Distended neck veins or High Central venous pressure
Pericardial temponade
Tension pneumothorax
