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NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB > Surgery. > Flashcards

Surgery. Flashcards

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1
Q

Which Surgerys are high, medium, and low risk for perioperative cardiac complications?

A
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2
Q

What percentage of perioperative deaths are due to cardiac events?

A

⅓-½

DMs have a 50% increased risk of perioperative morbidity and mortality

Pulmonary = second most common cause of morbidity and mortality

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3
Q

ASA classifications

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4
Q

Types of Anesthesia

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5
Q

Epidural vs Spinal Anesthesia

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6
Q

Electrolyte composition of different body fluids and electrolyte abnormalities of surgery

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7
Q

Nutritional Status of the Surgical Patient: Ebb & Flow

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8
Q

Ebb Phase of Starvation & Stress

A
  • Immediate
  • Tissue hypoperfusion
  • decreased metabolism
  • catecholamine release
    • norepi
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9
Q

Flow Phase of Starvation/Physiologic Stress

A
  • Catabolic & Anabolic
  • increased cardiac output
  • Peaks 3-5 days
  • hypermetabolic
  • hyperglycemia
  • Anabolic
    • corticoid withdrawal
    • repletion
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10
Q

Lab Indicators of Illness and Perioperative Morbidity

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11
Q

Nutritional Support for Surgery Pts

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12
Q

Phases of Wound Healing & Care

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13
Q

Factors that Affect Wound Healing

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14
Q

Types of Wounds

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15
Q

Classifications of Surgical Wounds and infx risk

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16
Q

Primary Intention vs Secondary Intention Wound Healing

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17
Q

Postoperative Complications

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18
Q

Outpt Surgery vs Short Stay Inpatient

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19
Q

Inpatient Surgeries & Pediatric Surgerys

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20
Q

Acute Abd Pain Red Flags

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21
Q

Peritonitis (Overview)

A
  • Pt looks sick
  • lie still → minimizes discomfort
  • rebound tenderness & tenderness to percussion
  • pain with light palpation and bumps
  • diminished bowel sounds
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22
Q

Causes of Abd Pain by Location

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23
Q

What is an acute Abdomen?

A

requires a stat surgical consult/ to OR

sxs of obstruction or peritonitis

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24
Q

Initial Diagnostics in Abd pain

A
  • CBC with diff
  • BMP/CMP
  • AST/ALT, Alk phos, total bili
  • Lipase
  • UA
  • Urine hcG in women
  • abd imaging
    • plain film
    • CT U/S
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25
Q

How do you rule in/out peritonitis?

A

US or CT

but be careful with use of CT in children (1 CT may increase a child’s risk of CA, 1/1000)

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26
Q

Acute Abd Pain Tx while you wait for surgical intervention

A
  • IV, give fluids → this is a top priority!
  • Pain control
  • NPO (until they have been ruled out for surgery)
  • Abx when indication
  • Monitor for sxs of sepsis & shock
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27
Q

Abx prophylaxis before GI surgery

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28
Q

Acute Cholecystitis Tx

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29
Q

Steps of the Laparoscopic Cholecystectomy

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30
Q

Choledocholithiasis

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31
Q

Management of Pancreatitis

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32
Q

Best abx for pancreatic abscess?

A

Imipenem

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33
Q

Gastric Cancer Overview

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34
Q

Dx and Tx of Splenic Abscess vs Infarct

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35
Q

Acute Abd Pain Helpful Hints

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36
Q

Meckel’s Diverticulum

A
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37
Q

Mesenteric Ischemia Management

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38
Q

Appendicitis Management

A
  • Perioperative Abx
    • Lower infectious complications
    • Recommend 3-5 days in pts with confirmed perforated appendicitis
    • (ceftriaxone + metronidazole)
  • Appendectomy
    • Open
    • Laparoscopically
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39
Q

Steps of an Appendectomy

A
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40
Q

Complications Associated with Appendicitis

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41
Q

Diverticulitis Tx

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42
Q

Terminology of bowel Surgery

A
  • Ostomy:
    • new passageway for stool or urine → create an opening in abd wall
  • Stoma:
    • portion o fthe intestine outside the abdomen
  • Ileostomy:
    • small bowel divided
  • Colostomy:
    • colon divided → proximal end brought through the abd wall
  • Hartmann’s Procedure:
    • colostomy with distal end oversewn and placed in peritoneal cavity as blind limb
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43
Q

Colostomy vs Loop Colostomy

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44
Q

Ileostomy

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45
Q

Stoma

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46
Q

Types of Colon Resections

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47
Q

Which arteries to clip during an extended right colectomy vs a colectomy for proximal transverse colon cancer

A
48
Q

Small Bowel Obstruction: % of Acute Surgical Admissions and Major Causes

A
49
Q

Red Flags Associated with SBO

A
  • Pneumoperitoneum
  • Retroperitoneal air
  • Peritoneal Signs
  • Shock
50
Q

What etiology should you think of when approaching SBO with no hx of surgery or IBD and no hernia on exam?

A

TUMOR

51
Q

Paralytic Ileus

A
  • Obstipation (no stool or flatulence) and intolerance of oral intake
  • Due to non-mechanical factors
    • decreased motility (absent or hypoactive bowel sounds)
    • certain degree is normal following abd and non-abd surgery
    • more common with larger incisions, lower abd operations
  • Diagnostics:
    • same as SBO → since you are trying to rule SBO
    • plain film will show bowel dilation involving small and large bowel
  • Tx:
    • fluids & electrolytes
    • pain management → not narcotics
    • NGT in some, not most
    • PPN, TPN
    • Ambulation
52
Q

Physiologic vs Pathologic Ileus

A
53
Q

Partial vs Complete LBO Tx

A
54
Q

Sigmoid Volvulus Causes

A
55
Q

Sigmoid Volvulus: Presentation, PE, Imaging, DDx, Tx

A
56
Q

Cecal Volvulus

A
57
Q

What is the MCC of rectal bleeding?

A

Internal Hemorrhoids

58
Q

Internal vs External Hemorrhoids

A
59
Q

Diagnostic Eval of Hemorrhoids

A
60
Q

Degrees of Hemorrhoids

A
61
Q

Tx of Hemorrhoids

A
62
Q

Perianal Infections and Anorectal Abscess Overview

A
63
Q

Anorectal Abscess Tx & Perianal Infx Tx

A
  • Anorectal Abscess Tx:
    • Surgical drainage
    • broad spectrum abx
    • wound care
  • Perianal Infx management:
    • shallow peri-anal abscess can be drained in office
    • incision & drainage under anesthesia
    • some require drain placement
    • Abx based on cx
      • not all need abx, but all require I&D
    • Commonly associated with fistulas
64
Q

% chance of getting a anal fistula after anal abscess?

A

50%

65
Q

Fistulas (Overview)

A
66
Q

Anal Fissures

A
67
Q

Rectal Foreign Body Management

A
68
Q

Rectal Prolapse

A
69
Q

Atherosclerotic Aneurysms

A
70
Q

Thoracic Aortic Aneurysm: S/sxs & Repair

A
71
Q

Aortic Dissection: Sxs, workup, Imaging, & Initial management

A
  • S/xs:
    • CP, back pain (esp between shoulder blades), HTN in ⅔ of patients
    • neurologic changes, distal ischemia, Acute cardiac failure ( Aortic Regurg, Coronary Ischemia)
    • Hypotension & shock → Rupture
    • 15-20% mortality initially → then 1% per hour for 1st 48 hours
  • Signs:
    • HTN, different blood pressures
    • Widened mediastinum
    • pleural capping (d/t blood in pleural space in the apex), pleural effusion, hoarse voice
  • Imaging:
    • Spiral CT = gold standard
    • MRI
    • TEE: transesophageal echo, but may miss distal tears, good for eval of aortic valve proximal root
  • Initial Management:
    • Reduce systolic BP (<100-120mmHg)
    • Decrease LV dP/dT
    • Pain Control
    • Beta-blockers 1st = ESMOLOL then add vasodilators like nipride
72
Q

Type A vs Type B Aortic Dissection Management

A
73
Q

Triad of Aortic Dissection

A
  1. Tearing abd pain that radiates to the back
  2. mediastinal and/or aortic widening on CXR
  3. HTN +/- Discrepant BP or pulse (absence of a proximal extremity)
74
Q

Tx or Ruptured or Symptomatic AAA

A
75
Q

Thoracic Aortic Transection

A
76
Q

Blunt Cardiac Injury: Myocardial Contusion

A
77
Q

Hypovolemic Shock: Definition, Etiologies, Pathophys, S/sxs

A
  • Definition:
    • reduction in intravascular volume/preload → decreased CO → insufficient perfusion
  • Etiologies:
    • hemorrhagic: trauma, GI bleed, ruptured aneurysm, post-operative, open central line
    • non-blood fluid loss: vomiting, diarrhea, 3rd spacing, burns, dehydration, DKA, over-diuresis
  • Pathophys:
    • loss of blood/fluid volume → increased HR & vasoconstriction, increased epi, vasopressin, & angiotensin
  • S/sxs:
    • tachycardia/tachypnea
    • narrowed pulse pressure (d/t vasoconstriction)
    • oliguria (d/t decreased CO)
    • hypotension
    • pale, cool dry skin and extremities
    • cap refill >3 sec
    • decreased skin turgor
    • dry mucous membranes
    • AMS
78
Q

Features of Hypovolemic Shock

A
  • Preload: decreased (volume depletion)
  • Cardiac Output: decreased
  • Afterload: increased (vasoconstriction)
  • BP: low
  • Organ perfusion: decreased
  • AVO2 Difference: high (b/c heart is delivering less blood so tissues are using more O2 from the available blood)
79
Q

Phases of Hypovolemic Shock

A
  • Compensated: 0-24.9% blood loss (500-1250cc)
    • normal SBP/pulse pressure/ pulse, alert
  • Uncompensated: 25-40% (1250-2000cc)
    • decreased SBP/ pulse pressure, tachycardic, anxious
  • Irreversible: >40% blood loss
    • decreased SBP/ pulse pressure, very tachycardic, lethargic
80
Q

Tx of Hypovolemic Shock

A
  • ABCs
  • Volume resuscitation: Crystalloids (LR or NS)
    • usually 3-4 liters:
      • initially 1-2 NS boluses to restore tissue perfusion and continued at rapid rate until clinical signs of hypovolemia improve
  • control the source of hemorrhage +/- packed RBCs if severe
  • maintain body temp (prevent hypothermia)
81
Q

Distributive Shock: Definition, Pathophys, & Etiologies

A
  • Definition: excessive vasodilation in small vessels & altered distribution of blood flow with shunting from vital organs to non-vital tissues
  • Pathophys:
    • dilation of all blood vessels so the “tank” becomes too big
  • Etiologies:
    • Septic: overwhelming infx → systemic inflammatory response → systemic vasodilation
    • Anaphylactic: severe rxn to allergen → systemic histamine release → widespread vasodilation
    • Neurogenic: acute spinal injury that results in loss of sympathetic tone that normally keeps vessels constricted → vessel walls veno/vasodilate
    • Endocrine: adrenal insufficiency
82
Q

Distributive Shock: S/sxs of Sepsis, Anaphylaxis, and Neurogenic Shock

A
  • Sepsis: “Warm shock” “warm shock”
    • warm, flushed extremities (d/t systemic vasodilation of capillaries)
    • wide pulse pressure
    • bounding pulses
    • hypotension
  • Anaphylactic Shock:
    • pruritus, urticaria
    • angioedema
    • hoarseness
  • Neurogenic:
    • warm skin
    • bradycardia or normal HR
    • wide pulse pressure
83
Q

Features of Septic Shock

A

Type of Distributive Shock

  • Preload: decreased
  • Afterload: decreased
  • Cardiac Output: decreased
  • BP: low
  • Organ perfusion: decreased
  • Mixed venous O2: HIGH (oxygen is not reaching tissues and is not getting used due to loss of vascular tone)
  • AVO2 difference: LOW (oxygen is not reaching tissues and is not getting used due to loss of vascular tone)
    • so mixed venous o2 is high and arterial o2 is also high
84
Q

Features of Neurogenic Shock

A

Type of Distributive Shock

  • Preload: decreased
  • Afterload: decreased
  • Cardiac Output: increased
  • BP: low
  • Organ Perfusion: normal (b/c of good cardiac output so normal organ perfusion)
  • AVO2 difference: normal
85
Q

Tx of Distributive Shocks

A
  • Septic Shock:
    • broad spectrum IV abx
    • IV fluid resuscitation, then a vasopressor (vasoconstrictor: epinephrine, norepi/phenylephrine)
  • Anaphylactic Shock:
    • -Epi
    • -Airway management
    • -antihistamines
  • Neurogenic Shock:
    • IV fluid resuscitation
    • vasopressors +/- corticosteroids
  • Endocrine Shock:
    • hydrocortisone
86
Q

Obstructive Shock: Definition, Etiology & Tx

A
  • Definition: mechanical block to heart’s outflow or inflow
  • Etiology:
    • very large PE
    • pericardial tamponade
    • tension pneumo
    • aortic dissection
  • Tx: Tx the underlying cause
    • PE: heparin, thrombolytics (TPA, TKI)
    • Tamponade: pericardiocentesis
    • Tension Pneumo: needle decompression
    • oxygen, isotonic fluids, inotropic support (dobutamine, epi, milrinone)
87
Q

Cardiogenic Shock: Definition, Etiology, & S/sxs

A
  • Definition: primary myocardial dysfunction (pump failure) → low cardiac output → inadequate tissue perfusion
  • Etiology:
    • Pump Failure:
      • ischemia (CAD), acute MI, myocarditis, valve dysfunction (mitral regurg secondary to papillary rupture), cardiomyopathy, post-operative, myocardial contusion, acute ventricular septal or L ventricular rupture
    • Arrhythmia, toxic/metabolic
  • S/sxs:
    • Acute hypotension (you can only compensate with increasing afterload [vasoconstriction) BP <90/60
    • tachycardia, tachypnea
    • weak pulses
    • mottled skin
    • diaphoretic
    • AMS
    • anxiety/restlessness
    • Elevated JVP
    • oliguria
88
Q

Features of Cardiogenic Shock

A
  • Preload: increased (due to decreased stroke volume)
  • Afterload: increased
  • Cardiac Output: decreased
  • BP: low
  • Organ Perfusion: decreased
  • AVO2 difference: high (b/c heart is delivering less blood, so tissues are using more O2 from the blood available)
89
Q

Tx of Cardiogenic Shock

A

Tx the underlying cause

  • if acute MI: revascularize
  • inotropic Support(dobutamine, epinephrine, milrinone)
  • can use a vasodilator if BP is okay (dobutamine, milrinone)
  • if hypotensive then use vasopressor (Epi, norepi/phenylephrine)
  • intra-aortic balloon counterpulsation
  • oxygen
  • isotonic fluids: AVOID large amounts of fluid
    • if you use fluids, will eventually need to diurese (Lasix [furosemide])
90
Q

Cardiac Tamponade: Definition, Etiology, S/sxs, & PE

A
  • Definition:
    • pericardial effusion causing significant pressure on the heart, impeding cardiac filling, leading to decreased cardiac output and shock. The Rate of accumulation of fluid is more critical than volume. (slow accumulation of large volume is OKAY if pericardium is compliant)
  • Etiology:
    • Malignancy, idiopathic pericarditis, & uremia (renal failure) are the most common causes
  • S/sxs:
    • Dyspnea
    • Fatigue
    • peripheral Edema
    • BECK’s Triad:
      • distant (muffled) heart sounds
      • increased JVP
      • systemic hypotension
  • PE:
    • EKG:
      • Electrical Alternans (alternating amplitudes of the QRS complexes)
      • low QRS voltage
    • Echo:
      • pericardial effusion & diastolic collapse of teh cardiac champers
    • CXR:
      • “water bottle” appearance
91
Q

Cardiac Tamponade: Tx

A
  • immediate: oxygen, IV fluids, type & culture
  • Don’t give pain meds, sedate, or intubate (causes vasodilation which will lower BP even further)
  • Pericardiocentesis
92
Q
A

“water bottle” appearance

associated with pericardial effusion/ cardiac tamponade

93
Q

Beck’s Triad

A

Associated with Cardiac Tamponade

  1. elevated JVP
  2. muffled heart sounds
  3. systemic hypotension
94
Q

Mnemonic to Remember Medical Tx of STEMI

A

MOAN & BASH

Morphine, oxygen if O2 <90%, Aspirin 162 mg, Nitro q 5 min (don’t give to pts with systolic <90, or to inferior MI with R ventricular involvement → dependent on preload and nitro decreases preload)

Beta blockers (Decrease remodeling, decrease oxygen demand of heart, decreases HR, improve L ventricular hemodynamic funx, reduce incidence of ventricular arrhythmias; Contraindication in Heart block, high risk for cardiogenic shock) , ACE-I/ARB (more for long term use → improve L ventricular EF, mortality rate), Statin, Heparin (antithrombotic therapy → impede progression of thrombus in coronary artery)

TPA if pt cannot have reperfusion from cath lab in <90minutes from door to lab

95
Q

Peri-Myocardial Infarction Emergencies

A
96
Q

Bypass Surgery Common Post Op Complications

A
97
Q

Traumatic Diaphragmatic Hernia

A
98
Q

Pulmonary Contusion

A
99
Q

Esophageal Perforation

A
100
Q

Acute Mesenteric Ischemia: Causes, Dx, Workup & Management

A
101
Q

Tx of Mesenteric Arterial Occlusion, arterial Thrombosis, and Venous Thrombosis

A
102
Q

Diverticulitis Management

A
103
Q

Features of Shock

A
104
Q

Bariatric Surgery: Indications and candidates

A
105
Q

Types of Bariatric Procedures Including description of Roux En Y

A
106
Q

Vertical Banded Gastroplasty, Gastric Banding, Sleeve Gastrectomy, Mini-Gastric Bypass

A
107
Q

Pre-Operative Assessment for Bariatric Surgery Includes:

A
108
Q

Inguinal Hernia

A
109
Q

At what point does hypotension occur in hemorrhagic shock in pediatrics?

A

25-30% blood volume loss → so should look at HR and tachycardia as a better indicator for circulation

bolus warm fluids 20ml/kg, may repeat x 2, 10ml/kg of blood (PRBCs)

110
Q

Negative Effects of Hospitalization in Elderly and Common Complications

A
111
Q

PeriOperative Considerations in Pts with recent or current steroid use

A
112
Q

Who needs perioperative steroid coverage, does not need coverage and how to evaluate

A
113
Q

Anesthetic Inductions: types of Anesthetics and Inductions

A
114
Q

Risks of Post-Operative Nausea and Vomiting

A
  • Gas anesthetics and opioids > IV anesthetics
  • Volatile Anesthetics > IV > Regional
115
Q

Types of Fluids and which Compartment they end up in

A
116
Q

Typical Complications of Appendectomy, Cholecystectomy, Nissen Fundoplication, Colon Resection, Thyroid surgery, Breast Surgery

A

NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB (9 decks)

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