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Internal Medicine > Surgery > Flashcards

Surgery Flashcards

1
Q

When is cryoprecipitate used?

A

DIC - for the fibrinogen

Cryoprecipitate has Factor 8, 13, fibrinogen, vWF

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2
Q

Malignant hyperthermia - pathophysiology

A

Exposure to halothane/succinylcholine –> Calcium ryanodine receptors remain open –> skeletal muscle contraction everywhere

This is due to an autosomal dominant mutation

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3
Q

Succinylcholine - possible adverse effect

A

Malignant hyperthermia

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4
Q

Malignant hyperthermia - signs

A

Rising end-tidal CO2
Muscle spasms
Rising heat

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5
Q

Malignant hyperthermia - treatment

A

Dantrolene
Cooling blankets
ICU monitoring

Next day: U/A for myoglobinuria

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6
Q

Necrotizing fasciitis - signs, treatment

A

Postoperative day 0/1:
High fever
Extreme pain
Gray-colored abdominal fluid

Treatment:
Wide resection
Broad-spectrum antibiotics

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7
Q

What are the prophylactic skinbiotics?

A

2nd-generation cephalosporins: cefazolin, cefoxitin, cefotetan

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8
Q

How does treatment differ between abscess with anastomotic leak vs without?

A

No leak: percutaneous drainage
Leak: surgery, washout, repair

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9
Q

Postoperative abscess - signs, diagnosis

A

POD 5-7:
Fever with abdominal pain or ileus that fails to resolve

Use CT with contrast to diagnose

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10
Q

Due to risk for aspiration, how long should patients be NPO prior to surgery?

A

Small meals: 6 hours
Clear liquids: 4 hours

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11
Q

If you suspect paralytic ileus, what initial imaging should you do?

A

KUB X-ray - should show distended small/large bowels

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12
Q

How would fascial dehiscence present?

A

Gush of salmon-colored fluid (blood + peritoneal fluid)

Use abdominal binder, wait for adequate healing of intact skin, then elective OR

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13
Q

What should you do in the case of evisceration?

A

Wet, warm dressings
Do NOT push bowel back in until washout is performed in the OR

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14
Q

When is a temporary abdominal vacuum wound enclosure indicated?

A

When abdominal contents and skin are too tight from volume overload to close effectively

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15
Q

What is the first thing to do in a postop patient with zero urinary output and a Foley in place?

A

Reposition it

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16
Q

In a perianal abscess, in whom is systemic antibiotic therapy indicated?

A
  1. Systemic symptoms (e.g. fever) or cellulitis
  2. Risk of severe infection (e.g. diabetes, immunocompromised)
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17
Q

How long is postoperative atelectasis possible?

A

Common up to 5 days after abdominal procedures
Presents with hypoxemia and dyspnea

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18
Q

When are wet-to-dry dressings used? When should they be discontinued?

A
  1. infected wounds
  2. Freshly debrided wounds
  3. Devitalized tissue

Discontinue one healthy granulation tissue (red, well-vascularized connective tissue) appears
Replace with nonadherent, moisture-retaining dressings

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19
Q

When is emergent thoracotomy indicated for hemothorax?

A

> 1500 ml or >200 ml/hr for 2+ hr

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20
Q

CO2 insufflation side effects during laparoscopy

A

Peritoneal stretch receptors –> increased vagal tone:
1. Severe bradycardia, AV block, asystole
2. Increased BP due to mechanical increase in systemic vascular resistance

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21
Q

Inhaled halogenated anesthetics (e.g. halothane) can cause what organ toxicity?

A

Hepatoxicity with significantly elevated aminotransaminase levels

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22
Q

Diagnostic peritoneal lavage is used in what cases of blunt abdominal trauma?

A

Hemodynamically unstable, equivocal FAST for intraabdominal hemorrhage

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23
Q

What is the most sensitive predictor of postoperative anastomotic leak?

A

HR >120/min

Symptoms usually develop within first week and also include:
Fever, abdominal pain, tachypnea

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24
Q

Succinylcholine indication and risks

A

Depolarizing neuromuscular blocker (binds to ACh receptors to trigger Na influx + K efflux, thereby causing temporary paralysis through delayed repolarization of skeletal muscle membrane

Risks:
Cardiac arrhythmia due to severe hyperkalemia, particularly in patients with skeletal crush injury (rhabdomyolysis –> hyperkalemia; injury also upregulates postsynaptic ACh receptors)

Should use nondepolarizing neuromuscular blocker (e.g. vecuronium, rocuronium) instead

25
Which are the nondepolarizing neuromuscular blockers?
Vecuronium Rocuronium
26
What conditions cause upregulation of ACh receptors (and thus should not use depolarizing neuromuscular blocker succinylcholine)?
1. Skeletal crush injury 2. Burn injury 3. Disuse muscle atrophy 4. Denervation (e.g. stroke, Guillain-Barre, critical illness polyneuropathy)
27
Propofol adverse effect
Severe hypotension due to myocardial depression
28
Nitrous oxide affects vitamin B12 how?
Inactivates --> inhibition of methionine synthase --> subsequent neuropathy in patients with preexisting B12 deficiency
29
Etomidate adverse effect
Inhibits 11b-hydroxylase --> adrenal insufficiency
30
What tissue is injured most by electrical shock?
Bone has most resistance and generates most thermal energy from electrical energy; muscles will be damaged, leading to acute compartment syndrome, rhabdomyolysis, heme pigment release/AKI
31
How does acute tissue injury affect platelets?
Thrombocytopenia - due to consumption and dilution from aggressive resuscitation
32
What is associated with increased risk of surgical site infection?
1. Smoking - affects inflammation, perfusion, collagen synthesis; try to cease 4-6 weeks before surgery 2. Obesity 3. Diabetes 4. PAD
33
Nissen fundoplication - possible complications
1. Dysphagia - usually self-resolves within 12 weeks (if >12 weeks, use barium swallow or esophageal manometry to identify narrowing of distal esophagus, then dilate with EGD) 2. Gas-bloat syndrome (bloating and inability to belch) - conservative management (simethicone, avoid carbonated beverages) 3. Gastroparesis - diagnose with scintigraphic gastric emptying scan (+ EGD to rule out obstruction)
34
Who requires massive transfusion protocol?
>=2 of the following: 1. SBP <=90 2. Pulse >=120 3. Positive FAST 4. Penetrating mechanism of injury 1:1:1 FFP/pRBCs/platelets (to minimize risk of coagulopathy) Limit to ~1L crystalloids if patient is hypotensive
35
What is the purpose of incisional exploration and packing?
Manage superficial wound dehiscence or subcutaneous fluid collection (e.g. seroma, hematoma)
36
Penetrating abdominal trauma - indications for laparotomy
1. Hemodynamic instability (SBP <90) 2. Peritonitis 3. Evisceration Peritoneal penetration and significant organ injury (imaging, local wound exploration)
37
What is delayed emergence?
Longer than 15 min after anesthesia or without intact protective (e.g. gag) reflexes after 30-60 minutes of last anesthetic or adjuvant agent
38
What can cause delayed emergence from anesthesia?
1. Drug effect - preoperative or increased anesthetic dose/duration 2. Metabolic - hyper/hypoglycemia, hyper/hypothermia, hyponatremia, liver disease 3. Neurologic - intraoperative stroke, seizure, or elevated ICP
39
What should any patient with sternal wound discharge have?
Chest and sternal imaging via CT - look for pneumomediastinum or mediastinal fluid collections
40
Primary survey for trauma patient + adjunct imaging
Primary survey: Intact airway, normal breathing, hemodynamic stability Adjunct imaging: Portable chest and pelvic x-rays FAST Cervical spine imaging (CT) - high-energy mechanism of injury, or 1 of NEXUS criteria
41
NEXUS low-risk criteria for cervical spine imaging
Any 1 of the following: 1. Neurologic deficit 2. Spinal tenderness 3. Altered mental status 4. Intoxication 5. Distracting injury
42
What "-itises" can happen after surgery or trauma?
Acalculous cholecystitis Acute pancreatitis
43
Volume of blood loss at which emergent surgical thoracotomy is indicated following trauma
>20 mL/kg
44
How do SIRS and burn wound sepsis criteria differ?
Burn wound temp >39, instead of 38 Burn wound tachypnea >30, instead of 20
45
What is prothrombin complex concentrate?
Cryoprecipitate minus antithrombin and factor XI
46
How long does postoperative fever from tissue trauma last?
Fever and leukocytosis generally <3 days; manage with acetaminophen and observe
47
Cloudy-gray discharge at surgical site
Necrotizing surgical site infection (dishwater drainage) Accompanied by paresthesia/anesthesia at wound edges, subcutaneous gas/crepitus Occurs more commonly with diabetes Usually polymicrobial
48
Valvular heart disease - when is valve repair needed prior to noncardiac surgery?
If asymptomatic and moderate/severe VHD: Intermediate/high risk surgery and transthoracic echo showing decreased EF or pulmonary artery hypertension
49
Order of noncardiac surgery risk assessments
RCRI --> METS --> cardiac evaluation impact management? --> pharmacologic stress test
50
Risk of positive pressure mechanical ventilation in hypovolemic patient
Acute increase in intrathoracic pressure --> collapse venous capacitance vessels --> cut off venous return --> acute circulatory failure and cardiac arrest
51
List processes of wound healing
Hemostasis --> inflammation --> proliferation of superficial epithelial layer, fibroblast production of type III collagen and ground substance that forms amorphous gel layer for capillaries to grow into --> maturation replaces type III with type I collagen, reorganizes fibers along tension lines, and cross-links Takes at least 6 weeks for surgical wounds to regain most (~80%) of their original tensile strength
52
When is urgent surgical repair indicated in penetrating injury of extremity?
Signs of vascular injury: 1. Pulsatile bleeding 2. Bruit or thrill over injury 3. Expanding hematoma 4. Signs of distal ischemia If hard signs are absent, look for soft signs --> need for additional testing (e.g. injured extremity index --> CT or conventional arteriography + surgery
53
Which is more effective for warfarin reversal: FFP or PCC?
PCC better, takes <=10 min for effect FFP requires multiple units and increases risk of volume overload
54
Colloid vs FFP
FFP contains albumin
55
Albumin transfusion indications
1. Hepatorenal syndrome 2. Spontaneous bacterial peritonitis
56
When is desmopressin given preoperatively?
Mild hemophilia A to prevent excessive bleeding; indirectly increases factor VIII by causing vWF release from endothelial cells
57
Postop management of pituitary surgery
Serum electrolytes: Arginine vasopressin deficiency in first few days lasting a week SIADH arises several days later and lasts several weeks
58
When is cholestasis seen with parenteral nutrition?
After 2 weeks
59
What is the greatest risk with parenteral nutrition?
Central line-associated bloodstream infection

Internal Medicine (23 decks)

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