Surgery Flashcards
A female with one or more risk factors for breast cancer presents with a mass in the ———quadrant of the breast. Think: She’s at risk for cancer, and 50% of breast cancers occur in the that quadrant. Therefore, the mass is likely to be malignant
upper outer
Perform breast self-examination at same time each month (———is ideal timing).
1 week after menstrual period
Palpable breast masses should have a ——— biopsy (as opposed to an ———)
core needle
FNA
A 42-year-old woman presents with an undiagnosed breast mass. Next step?
Evaluate without delay. Observation is not an option if age >30.
A female presents complaining of nipple pain during breast-feeding with focal erythema and warmth of breast on physical exam. Dx? Workup/next step?
Dx: Mastitis ± breast abscess.
Next step: Workup may include ultrasound of the breast, and possible incision and drainage if fluctuance (abscess) is present.
A female presents complaining of nipple pain with focal erythema and warmth of breast on physical exam. Dx if lactating/breastfeeding vs not lactating/breastfeeding?
If lactating/breastfeeding, think Mastitis ± breast abscess
If a nonlactating women presents with similar picture, consider inflammatory carcinoma.
A 25-year-old female presents with a painful breast mass several weeks after sustaining breast trauma by a seat belt in a car accident. Dx?
Think: The most common cause of a persistent breast mass after trauma is fat necrosis.
Fat necrosis of breast: exam findings and treatment?
Findings: Irregular mass without discrete borders that may or may not be tender; later, collagenous scars predominate.
Tx: Excisional biopsy with pathologic evaluation for carcinoma.
Fibroadenoma: definition and risk factors?
Definition: Fibrous stroma surrounds ductlike epithelium and forms a benign tumor that is grossly smooth, white, and well circumscribed.
Risk factors: More common in black women than in white women. Most common breast lesion in adolescents and young females.
Fibroadenoma: Incidence, Signs, Dx with?
Incidence: Typically occurs in late teens to early 30s; estrogen sensitive (increased tenderness during pregnancy).
Signs and symptoms: Smooth, discrete, circular, mobile mass.
Diagnosis: FNA
A 20-year-old female presents with a well-circumscribed mass in her left breast. It is mobile, nontender, and has defined borders on physical exam. Think?
Fibroadenoma until proven otherwise.
A female presents complaining of acute pain in her axilla and lateral chest wall, and a tender cord is identified on physical exam. Think?
Mondor’s disease versus chest wall infection. Confirm with ultrasound.
Mondor’s disease most commonly develops along
the course of a single vein
A 35-year-old female presents with a straw-colored nipple discharge and bilateral breast tenderness that fluctuates with her menstrual cycle. Think?
Fibrocystic changes. Consider a trial of OCPs or NSAIDs.
Fibrocystic changes in breast: Presentation, exam, evaluation:
Presentation: Breast swelling (often bilateral), tenderness, and/or pain.
Physical exam: Discrete areas of nodularity within fibrous breast tissue.
Evaluation: Serial physical examination with documentation of the fluctuating nature of the symptoms is usually sufficient unless a persistent discrete mass is identified; definitive diagnosis requires aspiration or biopsy with pathologic evaluation. Symptoms thought to be of hormonal etiology and tend to fluctuate with the menstrual cycle.
A 45-year-old female presents with breast pain that does
not vary with her menstrual cycle
with lumps behind the nipple–areolar complex and a history of a nonbloody nipple discharge. Think?
Mammary duct ectasia (plasma cell mastitis)
There is no need for axillary node dissection in phyllodes tumor (cystosarcoma phyllodes), as
lymph node metastases do not occur. If malignant, will spread hematogenously.
Phyllodes tumor (cystosarcoma phyllodes): Characteristics vs Fibroadenoma, Exam, Dx, Tx?
Characteristics: Indistinguishable from fibroadenoma by US or mammogram. The distinction between the two entities can be made on the basis of their histologic features (phyllodes tumors have more mitotic activity).
Exam: Large, freely movable mass with overlying skin changes
Diagnosis: Definitive diagnosis requires biopsy with pathologic evaluation.
Treatment:
- Smaller tumors: Wide local excision; Larger tumors: Simple mastectomy.
- No need for sentinel lymph node biopsy.
A 35-year-old female presents with a 1-month history of a spontaneous unilateral bloody nipple discharge. Radial compression of the involved breast results in expression of blood at the 12 o’clock position. Think?
Intraductal papilloma (A benign local proliferation of ductal epithelial cells. Unilateral serosanguineous or bloody nipple discharge. Subareolar mass and/or spontaneous nipple discharge.)
Most common cause of unilateral bloody nipple discharge:
Intraductal papilloma. (A benign local proliferation of ductal epithelial cells. Unilateral serosanguineous or bloody nipple discharge. Subareolar mass and/or spontaneous nipple discharge.)
Green nipple discharge: if cyclical and nonspontaneous, likely due to
fibrocystic breast
Bloody nipple discharge: if unilateral, most likely due to
intraductal papilloma
Bilateral nipple discharge: if milky, consider
intracranial etiology, obtain prolactin level
A 14-year-old male complains of gynecomastia. Tx?
Wait and watch. Perform surgery only if progressive
Causes of gynecomastia:
■Increased estrogen (tumors, endocrine disorders, liver failure, obesity).
■Decreased testosterone (aging, primary or secondary testicular failure, Klinefelter’s, renal failure).
■Drugs (e.g., spironolactone).
Most common invasive breast cancer (80% of cases) and most common breast cancer in perimenopausal and postmenopausal women?
Infiltrating/invasive ductal carcinoma
Twenty percent of ——— breast carcinoma have simultaneous contralateral breast cancer.
infiltrating lobular
A 65-year-old female presents with a pruritic, scaly rash of her nipple–areolar complex and a bloody nipple discharge. Think?
Paget’s disease. Biopsy and pathologic exam required to confirm diagnosis.
Paget’s disease of ——— is a similar disease, presenting as a scaly, pruritic rash
vagina
A 45-year-old female presents with enlargement of her left breast with nipple retraction, erythema, warmth, and induration. Think?
Inflammatory breast carcinoma (Most lethal breast cancer. Frequently presents as erythema, “peau d’orange,” and nipple retraction.)
Greater than 75% of patients have axillary metastases at time of diagnosis of ——— breast carcinoma, and distant metastases are common.
inflammatory
Key risk factor for breast cancer is any change that causes increased exposure to
estrogen without the protective effects of progesterone.
Brest cancer associated with Li–Fraumeni syndrome , which results results from a ———
mutation.
p53: A tumor suppressor gene
Both BRCA1 and BRCA2 function as ——— genes
tumor-suppressor
Work up of a Breast Mass: U/S vs MRI
U/S can tell if solid or cystic.
MRI is good for eval dense breast tissue, evaluating nodes and determining recurrent cancer
Workup of breast mass: Best imaging for the young breast?
U/S
Workup of breast mass: ——— imaging good for determining fibroadenoma/cysto-sarcoma phyllodes.
U/S
Workup of breast mass: If cystic breast mass, need ———, and if solid breast mass need ———
Aspiration of fluid if cystic
FNA for cells if solid
Workup of breast mass: Send aspirated fluid for cytology if: (2)
its bloody or recurs x2
Workup of breast mass - Fibrocystic changes: Presentation? Tx?
Presentation: cysts are painful and change w/ menses. Fluid is typically green or straw colored.
Tx: Restrict caffiene, take vitamin E, wear a supportive bra
Workup of breast mass: Excisional biopsy if: (2)
palpable or if fluid recurs
Breast cancer RFs: (4)
BRCA1 or 2
person hx of breast cancer
nulliparity
endo/exogenous estrogen
DCIS tx?
Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT.
(If small (<2 cm): Lumpectomy with either close follow-up or radiation; If large (>2cm): Lumpectomy with 1-cm margins and radiation; If breast diffusely involved: Simple mastectomy)
LCIS key feature? Tx?
Feature: More often bilateral.
Tx: Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hx of breast cancer
(None; bilateral mastectomy an option if patient is high risk)
Infiltrating ductal/lobular carcinoma- Tx?
– If small and away from nipple, can do lumpectomy w/ ax node
sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
– Modified radical mastectomy w/ ax node sampling w/o adjuvant RT gives same prognosis.
Paget’s Dz - Presentation? Workup?
Presentation: Looks like eczema of the nipple.
Workup: Do mammogram to find the mass.
Inflammatory carcinoma: Presentation?
Red, hot, swollen breast. Orange peal skin. Nipple retratction.
Single, rubbery, mobile breast mass in a 21 yo F
Fibroadenoma (observe!)
Most common cause of a bloody nipple discharge
Intraductal Papilloma (get this right!)
Risk factors for breast cancer include: (7)
(“Basically anything that increases your exposure to estrogen increases your risk of breast cancer”)
female sex
early menarche
late menopause
nulliparity
E2 exposure
BRCA mutations
obesity (“fat contains aromatase, converts androgens to estrogens”)
The most common breast cancer is
infiltrating ductal carcinoma
Bloody nipple discharge =
Intraductal Papilloma on your test
The most common breast mass in a 30-50 yo F is
fibrocystic change
(“If describe female with lumpy bumpy breast, think about fibrocystic change”)
The most common breast mass in a teen/female in her 20s is
fibroadenoma
(“Single mobile breast mass, young female”)
A breast mass with a peau d’orange appearance(/fever?) is
inflammatory breast cancer
In a female < 30 with a breast mass, consider ——— as the first imaging test of choice
an ultrasound
(Want to get U/S first not mammogram in this age group because “Younger ladies tend to have very dense breasts so won’t see much with a mammogram”)
For breast mass, ultrasound is useful for differentiating
cystic from solid masses
(“If see solid mass, want to biopsy”; “If see cystic mass, fna”)
Note the potential for a ——— many years after an axillary LN dissection.
lymphangiosarcoma
(If suspect breast cancer and do a sentinel lymph node biopsy: if negative, done. If positive, want to do full ancillary lymph node dissection. Common complication of axillary lymph node dissection? Lymphedema. If describe patient with 10y h/o lymphedema and necrotic mass around that region and lost a ton of weight- lymphangiosarcoma!)
In the presence of a cystic mass on breast US, consider a ——— as the next step. If you get serous fluid, ———. If you see blood, ———
FNA
stop here (may send for cytology) (“follow-up U/S in a few weeks: if cyst gone on next U/S, she is good to go; but if see recurrence of cyst, get biopsy”)
proceed to a biopsy
In general, an older female (40s and upward) who presents with a breast mass needs a ———. If negative but a mass was palpated on exam, next step?
mammogram
some kind of biopsy must be done (excisional, core needle, etc)
Mention of necrosis in the setting of a breast mass should clue you into
comedocarcinoma
(demonstrates comedonecrosis, which is the central necrosis of cancer cells within involved ducts; a comedo-type, high-grade ductal carcinoma in situ (DCIS))
Recent physical trauma to the breast in the presence of a palpable, mobile breast mass is ——— although you should still ———
fat necrosis
get imaging and in an older lady, biopsy
The first step in management of a trauma patient with a mangled, bleeding leg is
to ASSESS THE AIRWAY. Don’t get tunnel vision.
ALWAYS follow your ABCs!
ABCs of Trauma:
■■ Airway (with cervical spine precautions)
■■ Breathing and ventilation
■■ Circulation (and Control of hemorrhage)
■■ Disability (neurologic status)
■■ Exposure/Environment control
■■ Foley/Fingerstick/FAST exam
AVPU scale:
Alert
Verbal
Pain
Unresponsive
The GCS may be used as a tool for classifying ———: severe vs moderate vs mild scores?
head injury
Severe head injury: GCS 8 or less
Moderate head injury: GCS 9–13
Mild head injury: GCS 14 or 15
A 19 yo college student is brought to the ED by EMS 30 mins after getting into a severe motor vehicle accident as the unrestrained driver. On initial evaluation by EMS, his eyes are closed, his back is arched upward with his UEs in an extensor stance, and he continually moans in pain. What is his GCS score?
The best answer here is 5. This patient has his eyes closed (1 E), is moaning (incomprehensible sounds, 2V), and has decerebrate posturing (2M). His GCS is 5. He should be intubated ASAP.
Next step for airway if trauma patient comes in unconscious?
Intubate!
Best step for airway if GCS < 8?
Intubate!
If guy stung by a bee, developing stridor and tripod posturing?
Intubate!
(The 2 most common errors associated with mortality in severe anaphylaxis are delays in intubation and delays in administration of epinephrine)(The cornerstone of treatment of anaphylaxis is epinephrine intramuscularly, early intubation, and aggressive fluid resuscitation.)
If guy stabbed in the neck, GCS = 15 (“talking to you like nothing is wrong”), expanding mass in lateral neck?
Intubate!
If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues (“feels like rice crispies under his skin”)?
Be careful while intubating; fiberoptic broncoscope
(Crackly rice crispies subcutaneous emphysema; May have a laryngeal injury or airway injury so want to take a look at what doing with fibroptic bronchoscope if at all possible)
If huge facial trauma (can’t see what’s nose vs face vs mouth), blood obscures oral and
nasal airway, & GCS of 7?
cricothyroidotomy (if can’t assess where putting airway, this is good indication to do cricothyroidotomy)
An emergency surgical airway, cricothyroidotomy is created by puncturing through the
cricothyroid membrane, situated anteriorly, between the thyroid cartilage and the cricoid cartilage
In infants, the emergency surgical airway of choice is a ———, not a ———
tracheostomy
cricothyroidotomy
So you intubated your patient… next best step?
Check bilateral breath sounds
So you intubated your patient… If decreased breath sounds on the left?
Means you intubated the right mainstem bronchus
(Equal breath sounds indicate proper placement of the ET tube)
So you intubated your patient… (incorrectly) intubated the right mainstem bronchus – What to do? Next step?
Pull back your ET tube
Check pulse ox, keep it >90%
Abdominal aortic aneurysm (AAA): presents with ——— on physical exam.
Pulsatile mass
Twenty percent of patients have an ——— spleen
accessory spleen
Identify the aneurysm (in each color):
Identify the aneurysm on top and bottom:
Aortic aneurysm may cause ———, which is a sign of leaking, dissection, or imminent rupture.
abdominal and/or back pain
Thoracic aortic aneurysm is associated with (1)
cystic medial degeneration
Thoracic aortic aneurysm risk factors include (4)
hypertension
bicuspid aortic valve
connective tissue disease (eg, Marfan syndrome)
3° syphilis (obliterative endarteritis of the vasa vasorum)
Thoracic aneurysm with aortic root dilatation may lead to
aortic valve regurgitation
Abdominal aortic aneurysm risk factors include (4)
***tobacco use
age
male sex
family history
AAA may present as ——— and rupture may present as triad of ———
palpable pulsatile abdominal mass
pulsatile abdominal mass, acute abdominal/back pain, and resistant hypotension
AAA often located ——— (distribution of vasa vasorum is reduced).
infrarenal
The most common cause of aneurysm
Degenerative—due to atherosclerosis
75% AAA presentation
Asymptomatic
AAA screening criteria
Abdominal US one time for males age 65–75 with history of smoking.
Assessment of acute abdominal pain should include PQRST:
Precipitating or palliative factors
Quality of pain: Stabbing, shooting, boring, dull
Radiation
Severity
Timing
Think ——— in acute abdominal pain with blood in stool (positive guaiac).
Think ruptured ——— in acute abdominal pain with back pain and/or blood in urine (communicating fistula).
mesenteric ischemia
AAA
Mortality for ruptured AAA is———%. (Of those who reach the hospital alive, mortality is still ———%) Mortality is further increased with (4)
90
50
history of CAD, hypotension on arrival, and renal insufficiency, and is also increased by inexperienced surgical team.
You are called to the emergency department to see a 65-year-old male with a history of AAA, for which he is followed by the vascular service. He now complains of abdominal pain and reports syncope at home. Think:
Syncope and abdominal pain or hypotension in a patient with known AAA is presumed to be rupture unless proven otherwise. Notify the OR and mobilize your team.
In pregnant women, iliac artery aneurysms are associated with
fibromuscular dysplasia
Screening for AAA?
men 65-75 who have ever smoked. Do abdominal U/S.
——— lung is a more common site for inhaled foreign bodies because main stem bronchus is
Right
wider, more vertical, and shorter than the left.
Key sxs for AAA
pulsatile abdominal mass
Treat AAA conservatively if:
if <5cm and asymptomatic, monitor growth every 3-12mo.
Surgery indicated for AAA if:
> 5cm, growing <4mm/yr
(Size at which AAA is considered for surgical repair: 5.5 cm. Increasing size: >1 cm per year; monitor with CT/US every 6 months.)
Ruptured AAA presents with (3)
severe sudden abdomen, flank or back pain
shock
tender pulsatile mass
With Ruptured AAA, ——— die before reaching the hospital.
50%
Post-op complications for AAA surgery: #1 cause of death
MI
(Myocardial infarction is the leading cause of postoperative death after AAA repair and accounts for as many as 50% of all postoperative deaths. The 5-year mortality rate from MI in patients who had preoperative evidence of heart disease is four times higher than that for patients without CAD.)
Post-op complications for AAA surgery: Bloody diarrhea
Ischemic colitis
(Ischemic colitis (5%): Bloody diarrhea, elevated WBC, peritonitis)
Post-op complications for AAA surgery: Weakness, decreased pain w/ preserved vibr, prop
ASA syndrome
(The anterior spinal artery syndrome refers to ischemic infarction of the spinal cord resulting from direct occlusion of the anterior spinal artery, artery of Adamkiewicz, or generalized hypoperfusion (Pattern seen with injury to the anterior portion of the spinal cord or
with compression of the anterior spinal arteries or artery of Adamkiewicz); Involves full or partial loss of bilateral pain and temperature sensation (STT)
and paraplegia (CST) with preservation of posterior column function; Often seen with flexion injuries; Carries a poor prognosis)
Location in spinal cord and role: Dorsal columns vs CST vs STT
STT: anteriolateral
CST: posterolateral
Dorsal columns: posterior
Post-op complications for AAA surgery: 1-2 yrs later if have brisk GI bleeding
Aortoenteric Fistula
A 70-year-old white male with a history of hypertension develops cramping lower abdominal pain 1 day s/p AAA repair. A few hours later he develops bloody diarrhea. What’s the diagnosis?
Think: Ischemic colitis should be suspected in any elderly patient who develops acute abdominal pain followed by rectal bleeding. Furthermore, the most common setting for ischemic colitis
is the early postoperative period after AAA repair when impaired blood flow through the IMA may put the colon at risk.
Ischemic colitis:
Acute or chronic intestinal ischemia secondary to decreased intestinal perfusion or thromboembolism:
■Embolus or thrombus of the IMA.
■Poor perfusion of mucosal vessels from arteriole shunting or spasm.
The SMA supplies the bowel from ———. The IMA supplies ———. The ——— also has collaterals to supply the intestine.
the lower part of the duodenum to two-third of the transverse colon
large intestine from the distal one-third of the transverse colon to the rectum
celiac artery
Bowel ischemia can be classified as small intestine ischemia, which is commonly known as ——— and large intestine ischemia, which generally referred to as ———.
mesenteric ischemia
colonic ischemia
Two main areas in the colon prone to ischemia:
splenic flexure (Griffiths point) - between SMA and IMA supplies
and
rectosigmoid junction (Sudek’s point) - between the IMA and hypogastric supplies
(‘watershed’ areas, which mean the regions in the colon between 2 major arteries that supplying colon)
Ischemic colitis often affects the
splenic flexure
Symptoms and imaging findings for ischemic colitis
Sxs: Mild lower abdominal pain and rectal bleeding, classically after AAA repair.
Imaging:
■Plain abdominal x-ray—may reveal pneumatosis (air in bowel wall) or “thumbprinting” (submucosal edema)
■CT scan of the abdomen may reveal segmental thickening of bowel wall.
■Colonoscopy may show pale mucosa with petechial bleeding.
A 66 year old man presents to a PCP to establish care. He has not seen a physician within the last five years. Past medical records indicate a recent colonoscopy which was negative 5 years ago. He is married to his wife of 25 years and quit smoking 7 years ago after he retired. He does not drink or use illegal drugs. He previously worked on a shipyard. Physical exam is notable only for an increased body habitus. What is the next best step in the management of this patient?
a. Upper GI Series.
b. IV Pyelography.
c. Screening CXR.
d. Cystoscopy with biopsy.
e. Abdominal Ultrasound.
The best answer is E, abdominal ultrasound.
-This man has a past history of smoking so the USPSTF recommends a 1 time abdominal US for men (not women) b/w the ages of 65-75 who have smoked in the past as a screen for AAA.
If a AAA ——— is found in men, it is dealt with surgically. If ———, it is f/u with ———. Growth ——— is an indication for surgery. Another indication for surgery is a ——— AAA.
> 5.5 cm
< 5.5 cm
a 6 mo US
> 0.5 cm in 6 mo
symptomatic
Remember that the biggest risk factor for a AAA is ———, not ——— (RFs are HY for most exams!).
smoking
atherosclerosis
Note that a ——— is recommended to screen for lung cancer in individuals with a > 30 pack year smoking hx who currently smoke or who quit within the last 15 years aged b/w 55-80.
low dose annual CT
A 56 yo M presents to his PCP with a 1 mo history of shortness of breath. CBC on admission shows a hemoglobin of 6.5 (super low), an MCV of 60 (super low), decreased ferritin/transferrin saturation with an increased TIBC. His other labs are within normal limits. He has a 45 pack year smoking history. He recently had surgery (7 months ago) for repair of an asymptomatic 6.5 cm AAA (remember treat if more than 5.5). CXR and EKG are unremarkable. FOBT is positive. What is the most likely diagnosis?
a. Hemorrhagic pleural effusion secondary to pulmonary malignancy.
b. Aortoenteric fistulizing tract.
c. Chronic blood loss secondary to an undetected colonic malignancy.
d. Chronic blood loss secondary to peptic ulcer disease.
e. Hyperviscosity syndrome secondary to an EPO secreting pulmonary malignancy.
The best answer here is B, an aortoenteric fistula.
-It is relatively HY to know this unusual association.
-People with a hx of AAA repair who present with sxs of anemia and a positive FOBT should clue you into a diagnosis of an aortoenteric fistula.
(Fistula b/w descending aorta and GI tract; surgical emergency - fix like pronto b/c can have life threatening hemorrhage and die which is not ideal)
(Tried to trip u up with colon cancer b/c if u see positive fobt in guy greater than 50, iron def anemia, hemoccult positive stool - thinking colon cancer; but put qualifier in question of AAA treatment, need to think aortoenteric fistula)
(For peptic ulcer disease, pain is not epigastric so that’s wrong)
(This patient’s hematocrit should be a lot higher for them to have an EPO secreting malignancy of any sort)
Hypotension, severe tearing abdominal pain with radiation to the back, pulsatile abdominal mass - think?
ruptured AAA (needs to go to surgery, “almost 100% mortality”)
Anterior Cord Syndrome is associated with loss of
all tracts with the exception of the posterior columns
Anterior Cord Syndrome: The common mechanism of injury is a
burst fracture of a vertebral body
Consider anterior spinal artery syndrome in the setting of
pain and temperature loss, bowel/bladder incontinence, and LE paralysis in the setting of an AAA repair
(Could relate to disruption of artery of Adamkiewicz)
——— at increased risk for mesenteric ischemia (embolism) because of emboli to mesenteric arteries
Atrial fibrillation
The three major mesenteric arteries that perfuse the small and the large intestines are:
(1) the celiac trunk, which supplies the hepatobiliary system, spleen, and proximal small bowel;
(2) the SMA, which supplies the small intestine and proximal middle colon;
(3) the inferior mesenteric artery (IMA), which supplies the distal colon and the rectum
——— is the most common vessel involved in AMI
SMA
Define AMI
Rapid onset of intestinal hypoperfusion. Causes include SMA embolism (50% of all AMI), SMA thrombosis (acute), Vasospasm (nonocclusive mesenteric ischemia), Venous obstruction
Most emboli that cause AMI originate in the
heart (left atrial or left ventricular thrombi)
Ninety-five percent of patients with AMI will have a history of
cardiovascular disease (atrial fibrillation or myocardial infarction)
——— has somewhat of a low sensitivity for detecting arterial AMI. Therefore, if a patient has high suspicion for AMI, then patient should undergo ———
——— has high sensitivity (>90%) for detecting acute mesenteric venous thrombosis
CT
angiography despite negative CT results
CT
Patients with acute mesenteric venous thrombosis should be evaluated for
hereditary and acquired thrombophilias
AMI: presentation?
Acute abdominal pain in a pt w/ A-fib subtherapeutic on warfarin or pt s/p high dose vasoconstrictors (shock, bypass)
(surgical emergency!)
AMI: Work up?
angiography (aorta and SMA/IMA)
AMI: Tx?
embolectomy if thrombus, or aortomesenteric
bypass
In a patient with a hx of Afib that presents with sudden onset abdominal POOP (pain out of proportion) to the exam, consider ——— as the underlying dx, which requires ——— for workup
acute mesenteric ischemia
CT angiography
Define CMI:
Slow progressing stenosis (req stenosis of 2.5 vessels (Celiac, SMA and IMA).
Insidious, episodic, or constant state of intestinal hypoperfusion.
(Rarely leads to infarction of small bowel due to development of collateral circulation over time.
Can be caused by: Arterial ischemia (most common) associated with atherosclerosis of more than one mesenteric and splanchnic vessels; Venous thrombosis; Vasculitis)
Hallmark sxs of AMI and CMI:
AMI: Abdominal pain out of proportion to tenderness on physical exam
(One of the distinctive findings in mesenteric ischemia is that the abdominal pain is out of proportion to their physical exam. The patient may be screaming in pain, but their initial abdominal exam can be soft with no guarding or rebound.)
CMI: “Intestinal angina”: Dull, crampy, postprandial abdominal pain leading to food aversion and weight loss
65 yo M with a PMH of CAD presents with a 6 mo history of a 30 Lb weight loss. He has no smoking history but has regular episodes of LUQ abdominal pain that often lasts for 45 mins after every meal. He has been a missionary for the past 30 years with regular trips 8 times a year to Costa Rica. He has no history of osteoarthritis. Hct is 45% and Fe studies are normal. Total bilirubin is 0.7 and alkaline phosphatase measurements are wnl. What is the next best step in the management of this patient?
a. Trial of omeprazole.
b. Abdominal CT angiography.
c. Abdominal US to screen for AAA.
d. Endoscopic Retrograde Cholangiopancreatography.
The best answer is B. The most likely diagnosis here is Chronic Mesenteric Ischemia (consider in the setting of chronic postprandial pain). (Think if it as intestinal angina - when eat give gi tract a work out - why pt may stop eating and lose weight)
-There’s no smoking hx here so a screening US for AAA is not indicated. There’s no indication of biliary pathology, so an ERCP is not an appropriate first step (that’s more like for pancreatitis -found expect liver or pancreas lab abnormalities - notice this info not given).
-A trial of Omeprazole seems reasonable but severe weight loss, normal Fe studies, hx of CAD, and LUQ pain (splenic flexure- watershed region) are more consistent with mesenteric ischemia and less consistent with PUD (pain should be epigastric).
Weight loss and postprandial abdominal pain in a old person with multiple risk factors should clue you into
chronic mesenteric ischemia
Chronic Mesenteric Ischemia: Presentation?
Severe MEG pain after eating, food fear and weight loss. “Pain out of proportion to exam”
CMI: Dx w/
duplex or angiography
CMI: Tx w/
aortomeseteric bypass or transaortic mesenteric endarterectomy.
“Scoring” of pulses:
0 = no palpable pulse
1+ = present, but barely palpable
2+ = normal
3+ = normal, strong
4+ = hyperdynamic, abnormally strong
A pseudoaneurysm does not contain
all three layers of the arterial wall
(distinguished from true aneurysms, which are bounded by all three layers of the arterial wall)
Contrast contains ——— and is ——— excreted.
iodine
Renally
(Therefore, you should use <200 cc of dye, and use with caution in patients with renal dysfunction. Ask patients about iodine and shellfish allergies. Hydrate patients prior to and after contrast use)
You are asked to see a patient with bleeding from an angiogram puncture site. She has an oozing, pulsatile expanding mass in her groin at the puncture site. Think:
Expanding hematoma. Maintain direct pressure for 30 minutes. If bleeding continues, wound exploration may be indicated.
You are asked to localize a lesion on a patient. You can palpate a femoral pulse but no popliteal or pedal pulses on the right side. Left- sided pulses are present. Think:
Localize lesion to the vessel above site where pulse is first lost. The lesion is likely to be in the superficial femoral artery (SFA). Tissue ischemia will extend one joint level distal to segment of artery occluded.
The 6 Ps of acute arterial insufficiency/occlusion:
Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Poikilothermia
(Paresthesia and paralysis are most important signs because nerves are most sensitive to ischemia)
Acute arterial occlusion: presentation?
5P’s/no dopplerable pulses
Acute arterial occlusion:
Tx w/?
– Complications = compartment syndrome during reperfusion perioddo fasciotomy watch for myoglobinuria.
immediate heparin + prepare for surgery
Surgery (embolectomy or bypass) done w/in 6hrs to avoid loss
Thrombolytics may be possible if: no surg in <2wks, hemorrhagic stroke
Acute arterial occlusion:
Complications?
compartment syndrome during reperfusion period
(do fasciotomy watch for myoglobinuria)
Rhabdomyolysis causes ——— release, which can cause ———
myoglobin
renal failure
(Maintaining a high urine output together with alkalinization of the urine can help prevent the renal failure by reducing precipitation of myoglobin in the kidney.)
Arterial occlusion progresses to irreversible ischemia in ——— hours, depending on collateral circulation.
6–8
Definition compartment syndrome:
Increased pressure within a compartment with subsequent compromise to the circulation and tissue function
(Muscle groups of limbs are divided into compartments by unyielding fascial membranes)
Causes of compartment syndrome:
■■ Fractures.
■■ Soft tissue crush injuries.
■■ Vascular injuries.
■■ Drug overdose with prolonged limb compression.
■■ Burn injuries.
■■ Trauma.
■■ Muscle hypertrophy and nephrotic syndrome.
Do not delay treatment of compartment syndrome! Elevation of pressure to ———mmHg for ——— hours leads to irreversible tissue death.
> 30 mmHg
> 8 hours
Sxs compartment syndrome
5Ps
Hallmark finding: PAIN! Pain in a conscious and fully oriented person that is out of proportion to injury or findings
5 Ps of compartment syndrome:
■■ Pain
■■ Paresthesia
■■ Pallor
■■ Pulselessness
■■ Poikilothermia (sometimes paralysis listed instead)
■ Pressure in compartment ——— mmHg usually will not produce a compartment syndrome.
■ Pressure ——— mmHg is an indication for fasciotomy.
treatment
<30
> 30
Tx compartment syndrome
Complete fasciotomy: Goal is to decompress all tight compartments and salvage a viable extremity.
A 66 yo M is sent to the medicine floor 2 days after presenting to the ED with chest pain requiring coronary catheterization and stent placement. He is in stable condition. 6 hrs after admission to medicine, he begins to complain of acute onset 10/10 pain in his left leg. Dorsalis pedis pulses are strong on the right but barely palpable on the left. The leg is exquisitely tender to palpation and appears whiter than the contralateral right extremity. What is the next best step in the management of this patient?
a. Oral Warfarin administration.
b. Vascular surgery consultation.
c. Heparin bolus administration followed by continuous infusion.
d. Emergent left lower extremity fasciotomy.
e. Serial limb exams for 2 hrs and supportive care.
-The best answer here is C. This patient most likely has acute limb ischemia secondary to embolization with his recent hx of a myocardial infarction.
(Sudden onset leg pain In someone with recent cardiac problems, or like an a fib history - Think acute limb ischemia; They will always try to trick you to give warfarin, but don’t do that- warfarin won’t kick in fast enough)
(HY history for acute limb ischemia- recent mi (like days after) or hx AF)
-The next step is immediate anticoagulation PRIOR to vascular surgery consultation. -It is really important to read answer choices carefully on an exam.
-Another common scenario with a similar presentation involves an individual with an “irregularly irregular beat” indicating atrial fibrillation.
-Remember the signs of compartment syndrome-POOP on passive movement of the extremity, paresthesias, poikilothermia, a tense muscle compartment, paralysis. Common associations include midshaft tibial fractures, recent burns, crush injuries, etc. Proceed to immediate fasciotomy.
(Serial exams are like almost never the correct answer on nbme)
Pain, pallor, paresthesias, poikilothermia, paralysis, and pulselessness in an extremity-
compartment syndrome (immediate fasciotomy)
Sudden onset leg pain in the setting of an irregularly, irregular interval
Acute Limb Ischemia
If chronic ischemia occurs at locations other than —(3)—, the patient is likely to have a comorbid disease, such as diabetes (increased risk at —(2)— vessels) or an inflammatory disorder (increased risk at ———arteries).
infrarenal aorta, iliacs, or SFA
profunda femoris and tibial
axillary
An 83-year-old female with a history of diabetes, HTN, and atherosclerosis presents with painless, monocular vision loss that lasted a few minutes and has now completely resolved. She has no other neurologic deficits. Think?
Amaurosis fugax or transient visual loss (transient blindness due to occlusion of the ophthalmic artery (favorite question of surgeons!))
(harbinger of an imminent stroke; Amaurosis fugax is a result of an occlusion or stenosis of the internal carotid artery circulation)
Peripheral arterial disease clarification: sxs?
Pain in butt, calf, thigh upon exertion
Peripheral arterial disease clarification: Best test? Test interpretation?
Ankle-Brachial Index: SBP ankle (via Doppler)/highest SBP in upper extremities.
– Normal- >1
– Claudication & Ulcers- 0.4-0.8, (use medical management)
– Limb ischemia- 0.2-0.4, surgery is indicated
– Gangrene <0.2, may require amputation
Leg pain that is worse at night in a 60 pack year smoker-
Peripheral Arterial Disease.
Drug shown to improve walking distance in the setting of PAD
Cilostazol (PDE inhibitor)
Painful ulcer beneath the toes in a long time smoker-
ulcers secondary to PAD.
Next best step in the management of an individual with leg pain with activity-
Ankle Brachial Index.
Unilateral leg swelling and tenderness in a pregnant woman, woman on OCPs, truck driver-
DVT.
Postsurgical patient with chest pain, SOB, tachypnea, right axis deviation on EKG-
pulmonary embolus
About one third of apparently healthy patients with DVTs of unknown cause will be ——— within 2 years.
diagnosed with a malignancy
——— is responsible for one third of upper extremity DVTs.
Central line placement
Two thirds of DVTs are
asymptomatic
DVT and PE: High risk after
surgery (esp orthopedic)
DVT: Dx w/
Duplex U/S & also check for PE
DVT: Tx w/
heparin, then overlap w/ warfarin for 5 days, then continue warfarin for 3-6mo
DVT: Complications
post-phlebotic (thrombotic) syndrome = chronic valvular incompetence, cyanosis, and edema
PE: Random signs =
right heart strain on EKG
sinus tach
decr vascular markings on CXR (westermark sign- focal peripheral hyperlucency secondary to oligemia resulting in a collapsed appearance of vessels distal to the occlusion)
wedge infarct (“Hampton’s hump” (wedge-shaped consolidation at the lung periphery)
ABG w/ low CO2 and O2
PE: Next steps if suspected
give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard.
PE: Tx w/
heparin warfarin overlap. Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. Surgical thrombectomy if life threatening. IVC filter if contraindications to chronic coagulation.
Ventilation/perfusion = 0 significance?
“Oirway” obstruction (shunt)
In shunt, 100% O2 does not improve Pao2 (eg, foreign body aspiration)
Ventilation/perfusion = ∞ significance?
blood flow obstruction (physiologic dead space)
Assuming < 100% dead space, 100% O2 improves Pao2 (eg, pulmonary embolus)
Name vessels:
