Surgery Flashcards
Example of depolarising neuromuscular drug
suxamethonium
key adverse events from suxamethonium
malignant hyperthermia
hyperkalaemia
reversal agent for malignant hyperthermia
IV dantrolene
MoA of suxamethonium
binds nACh, constant depolarisation of motor plate through non-competitive agonism
contraindications to suxamethonium
penetrating eye injuries
acute narrow angle glaucoma
this drug increases intra ocular pressure
use of suxamethonium
rapid sequence intubation
due to rapid onset and short duration of action
examples of non-depolarising neuromuscular blocking drugs
Tubocurarine, atracurium, vecuronium, pancuronium
MoA of non depolarising NMDs
Competitive antagonist of nicotinic acetylcholine receptors
main adverse effect of non depolarising NMD
hypotension
reversal agent for non depolarising NMD
neostigmine (Acetylcholinesterase inhibitor)
treatment of local anaesthetic toxicity
20% lipid emulsion
symptoms of local anaesthetic toxicity
agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, and dysarthria
consequences of local anaesthetic toxicity
seizures, respiratory arrest, and/or coma.
drugs that can cause ED
beta blockers
SSRIs
most common type of prostate cancer
adenocarcinoma (95%)
most common type of bladder cancer
transitional cell carcinoma
which airway adjunct is suitable for a seizing patient
nasopharyngeal
RELATIVE contraindication for nasopharyngeal airway
basal skull fracture
what is the main complication of axillary lymph node clearance
lymphoedema and functional arm impairment
how is the risk of DVT reduced in superficial thrombophlebitis
LMWH
where is the lesion in subclavian steal syndrome
proximal stenotic lesion of the subclavian artery results in retrograde flow through vertebral or internal thoracic arteries
main presentation of subclavian steal syndrome
syncope
aetiology of aortic coarctation
aortic stenosis at site of ductus arteriosus
how does inflammatory breast cancer present
progressive erythema and oedema in the absence of signs of infection such as WCC or CRP, fever or discharge
what size lump is the cut off for wide local excision
< 4cm
what size lump is the cut off for mastectomy
> 4cm
first line treatment of lactational mastitis
12-24 hours of effective milk removal i.e. continue breastfeeding
don’t start Abx just because they present after one day of symptoms
features of duct ectasia
nipple retraction
milky or cheesy or green discharge
describe the breast screening programme in the NHS
for women between 50 to 70, screened every 3 years
Over 70s are usually not invited but can request screening via their GP
what is the chemotherapy treatment for node positive breast cancer
FEC-D chemotherapy
what is the chemotherapy treatment for node negative breast cancer requiring chemo
FEC chemotherapy
first line mx of patient with mild symptoms related to varicose veins [4]
elevate legs
compression stockings
lose weight
regular exercise
key investigation of varicose veins
venous duplex ultrasound
demonstrates retrograde flow
when should varicose veins be referred to vascular [5]
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
what are the surgical treatments for varicose
endothermal ablation: using either radiofrequency ablation or endovenous laser treatment
foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
surgery: either ligation or stripping
4 skin changes associated with varicose veins/chronic venous insufficiency
varicose eczema (also known as venous stasis)
haemosiderin deposition → hyperpigmentation
lipodermatosclerosis → hard/tight skin
atrophie blanche → hypopigmentation
what poses the greatest risk to developing TRALI
infusion with plasma components
what is normal CVP
In a healthy adult, the normal range for CVP is typically between 2 to 8 mmHg (millimeters of mercury) when measured at the end of expiration while the individual is at rest and in a supine (lying down) position.
signs of bowel perforation
what investigation must be done
severe abdominal pain, guarding, and rigidity.
An erect chest X-ray is the most appropriate initial imaging study for suspected bowel perforation because it can detect free air under the diaphragm (pneumoperitoneum)
what are the indications for thoracotomy in haemothorax
> 1.5L blood drained initially or losses of >200ml per hour for >2 hours
which congenital hernias can be managed conservatively and which ones need repair ASAP
conservative for umbilical till 4-5years old
repair for inguinal
examples of benign liver lesions [8]
hemangiomas
Liver cell adenoma
Mesenchymal hamartomas
Liver abscess
Amoebic abscess
Hyatid cysts
Polycystic liver disease
Cystadenoma
which nerve is at risk of damage when doing a carotid endarterectomy
how does damage present?
hypoglossal
It presents as ipsilateral tongue deviation towards lesion.
preferred method of detecting free air in the abdomen
CT abdo
difference between incarcerated and strangulated hernias
strangulated ones are painful unlike incarcerated hernias
what is the general treatment of inguinal hernias
treat medically fit patients even if they are asymptomatic
i.e. refer routinely to open mesh repair
how are surgically unfit patients treated for inguinal hernias
a hernia truss
how are unilateral inguinal hernias treated compared to bilateral hernias
surgical approach
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
Parkland formula for burns fluid resus
how is resus fluid distributed over the 24 hours
SA% x body weight x 4ml gives fluid replacement over 24 hours
50% over the first 8 hours
50% over the next 16 hours
which fluids are used in burns resus
crystalloids only
Hartmans and Ringers
what fluids are used in burns resus after 24 hours
colloids including albumin and FFP
which analgesia should be avoided post kidney transplant
NSAIDs
What should you do to ascertain the anatomy and subtype of inguinal swelling?
press on the deep inguinal ring and ask the patient to cough
where in the body should lidocaine never be used
it must never be used near extremities due to the risk of ischaemia
radiological sign indicating free air in the abdomen
rigler’s sign
nerve lesion due to Posterior triangle lymph node biopsy
accessory nerve lesion
nerve lesion due to Lloyd Davies stirrups
common peroneal nerve
nerve lesion due to Thyroidectomy
laryngeal nerve
nerve lesion due to Anterior resection of rectum
hypogastric autonomic nerves
nerve lesion due to Axillary node clearance
long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve
nerve lesion due to Inguinal hernia surgery
ilioinguinal nerve
nerve lesion due to Varicose vein surgery
sural and saphenous nerves
nerve lesion due to Posterior approach to the hip
sciatic nerve
what size fibroadenoma is surgically excised
> 3cm
or causing discomfort and pain
what is Whipple’s procedure for
pancreatic tumours
management of those who’ve always had difficulties maintaining an erection
routine referral to urology
how can you check for rectal anastomotic leak
gastrograffin enema
treatment of acute anal fissure
1) soften stool
dietary advice: high-fibre diet with high fluid intake
2) bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
3) lubricants such as petroleum jelly may be tried before defecation
4) topical anaesthetics
5) analgesia
treatment of chronic anal fissure
- use acute treatment
- 1st line: topical glyceryl trinitrate (GTN)
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
type of resection for Caecal, ascending or proximal transverse colon
right hemicolectomy
type of resection for Distal transverse, descending colon
left hemicolectomy
type of resection for Sigmoid colon
high anterior
type of resection for Upper rectum
anterior resection
type of resection for Lower rectum
anterior resection (low TME)
type of resection for Anal verge
Abdomino-perineal excision of rectum
management of caecal volvulus
right hemicolectomy
management of sigmoid volvulus
rigid sigmoidoscopy with rectal tube insertion
when is a Hartmann’s procedure done
emergency resection of bowel especially perforation
main investigation for diffuse axonal injury
MRI brain
appearance of ileostomy
spouted
appearance of colostomy
flushed
outputs of ileostomy
liquid
outputs of colostomy
solid
main investigation for chronic pancreatitis
CT abdo
monitoring for risk of diabetes in someone with chronic pancreatitis
annual HbA1c
treatment of post op ileus
NBM and NG tube
at which positions do haemorrhoids develop
3,7 and 11 o clock
treatment of refractory crohns
infliximab
position of anal fissures
6 and 12 o clock
staging of oesophageal or gastric cancer
CT
most common cause of chronic pancreatitis
chronic alcohol
treatment of Gastric MALT lymphoma
treat the H.pylori with triple therapy
will respond if low grade
head trauma related causes of third nerve compression
extradural bleed
transtentorial herniation
treatment of thrombosed haemorrhoids
if presenting within 72 hours of onset of pain –> Surgery
Beyond 72 hours –> conservative management
how does a thrombosed haemorrhoid present
typically present with significant pain and a tender lump
examination reveals a purplish, oedematous, tender subcutaneous perianal mass
diagnostic investigation of boerhaaves syndrome
CT contrast swallow
treatment of boerhaaves
Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
what may be observed in the chest wall of someone with boerhaaves
Subcutaneous emphysema
presents as crepitus
which stoma is usually used after rectal cancer surgery
loop ileostomy
4 risk factors of atherosclerotic vascular disease
smoking
HTN
hypercholestrolaemia
DM
how does intermittent claudication present?
pain after walking. Gripping, tightening, burning pain in thighs, buttocks.
intermittent claudication vs spinal stenosis
spinal stenosis pain is worse at rest and better with exercise.
most common location of varicoceles
left side (80%)
investigation of varicoceles
ultrasound with Doppler studies
what does RUQ pain with bilious fluid in abdominal drain suggest
biliary leak usually post cholecystectomy
which renal stones are semi opaque
cystine stones
how does Pagets disease of the breast present
Reddening and thickening of nipple and areola
weeping, crusty lesion nipple when areola is spared sometimes
adverse effects of aromatase inhibitors [4]
osteoporosis: NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
MoA of aromatase inhibitors
reduces peripheral oestrogen synthesis
what should patients with PAD be started on [2]
statin e.g. atorvastatin 80mg and clopi
naftidrofuryl oxalate (in those with poor quality of life)
what size segment should endovascular revascularization be used for in severe PAD/CLI
<10cm /short
also aortic iliac disease and high-risk patients
what size segment should surgical revascularization be used for in severe PAD/CLI
> 10 cm /long
also multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
1st line management of PAD
supervised exercise programme
what does surgical revascularisation in PAD consist of [2]
surgical bypass with an autologous vein or prosthetic material
endarterectomy
what does endovascular revascularisation in PAD consist of
percutaenous transluminal angioplasty +/- stent placement
women with no palpable axillary lymphadenopathy at presentation should have a …{investigation}
what if this investigation is negative….
pre-operative axillary ultrasound before their primary surgery
if negative then they should have a sentinel node biopsy to assess the nodal burden
when is axillary node clearance indicated
when there is palpable axillary lymphadenopathy
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates ….[pathology]
extracapsular breast implant rupture.
due to leakage of the silicone, which then drains via the lymphatic system, giving the ‘snowstorm appearance’ both in the breast and the lymph nodes.
diagnosis of Pagets disease of the breast [3]
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
treatment of Raynaud’s disease
calcium antagonists
Dukes classification for colorectal cancer (A-D)
Tumour confined to the mucosa
Tumour invading bowel wall
Lymph node metastases
Distant metastases
indication for CT head within the hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
features of biliary colic
colicky right upper quadrant abdominal pain
worse postprandially, worse after fatty foods
the pain may radiate to the right shoulder/interscapular region
nausea and vomiting are common
in contrast to other gallstone-related conditions, in biliary colic there is no fever and liver function tests/inflammatory markers are normal
elective lap chole
what BMI can be referred straight to bariatric surgery
> 50
> 35 if weight is causing/affecting a medical condition
where do Lynch syndrome tumours tend to be found
ascending colon and hepatic flexure
complications of NG feeding
diarrhoea
aspiration
hyperglycaemia
refeeding syndrome
what agent causes hydatid cysts
where is it endemic to
Echinococcus granulosus
Mediterranean and Middle Eastern countriesin
investigation of hydatid cysts
USS –> CT abdo to differentiate between pyogenic and amoebic cysts
serology
remove surgically
amoebic abscess
Liver abscess is the most common extra intestinal manifestation of amoebiasis
Between 75 and 90% lesions occur in the right lobe
Presenting complaints typically include fever and right upper quadrant pain
Ultrasonography will usually show a fluid filled structure with poorly defined boundaries
Aspiration yield sterile odourless fluid which has an anchovy paste consistency
Treatment is with metronidazole
hemangioma
Most common benign tumours of mesenchymal origin
Incidence in autopsy series is 8%
Cavernous haemangiomas may be enormous
Clinically they are reddish purple hypervascular lesions
Lesions are normally separated from normal liver by ring of fibrous tissue
On ultrasound they are typically hyperechoic
liver mass associated with COCP use
liver cell adenoma
Solitary rectal ulcer
Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
Dermatofibroma
Solitary dermal nodules
Usually affect extremities of young adults
Lesions feel larger than they appear visually
Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues
triad of gastric volvulus
vomiting, pain and failed attempts to pass an NG tube
McEvedy’s
Groin incision e.g. Emergency repair strangulated femoral hernia
Lanz
Incision in right iliac fossa e.g. Appendicectomy
Gable
Rooftop incision
The H causes of pancreatitis
Hypertriglyceridaemia
Hyperchylomicronaemia
Hypercalcaemia
Hypothermia
emergency surgery in fulminant UC
subtotal colectomy
Gingko leaf sign post laparoscopic surgery
subcutaneous emphysema
If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the ‘ginkgo leaf’ sign.
treatment of fissure in any
Stool softeners, topical diltiazem or GTN, botulinum toxin, Sphincterotomy
infectious disease that causes sigmoid volvulus
Chagas disease
