Surgery Flashcards
Number one factor prior to surgery
History of cardiovascular disease
Important CV risk factors for surgery
EF
Other CV risk factors
Age >45
DM
HTN
Hyperlipidemia
Surgical clearance in pt under 35 w/ no hx cardiac disease
EKG
Surgical clearance in pt w/ hx cardiac disease
EKG
Stress test
Echo
When to do PFTs before surgery
Known lung disease
Smoking Hx
Current smoker needs surgery
Stop -68 wks before, use nicotine patch
Pt w/ renal disease needs surgery
Keep adequately hydrated
How to ensure adequate kidney perfusion before surgery
Fluids before and during surgery
Dialyze 24hrs prior to surgery
Maintaining the AIRWAY
No facial trauma - Orotracheal tube
Facial trauma - Cricothyroidotomy
Cervical spine injury - Orotracheal tube w/ flexible bronchoscopy
Maintain BREATHING
O2 sat above 90%
Maintain CIRCULATION
2 large bore IVs
SIRS criteria
Temp 38
HR > 90
RR >20 or PCO212
Define sepsis
2/4 SIRS + source
Define severe sepsis
Sepsis + organ dysfunction
Define septic shock
Severe sepsis + hypotension
Which kind of shock present as pale and cool
Hypovolemia
Cardiogenic
Which kind of shock present as warm
Neurogenic
Septic
Which kind of shock has elevated central venous pressure
Cardiogenic
Which kind of shock has elevated CVP and SVR
Hypovolemic
Cardiogenic
Which kink of shock has elevated CO
Septic
Which kind of shock has elevated LVEDP or PCWP
Cardiogenic
Which kind of shock is treated with fluid and pressors
Hypovolemic
Neurogenic
Septic (+ABX)
How is cardiogenic shock treated
Treat the cardiac problem
MCC hypovolemic shock
Massive hemorrhage
MCC cardiogenic shock
MI
MCC neurogenic shock
Spinal cord injury
MCC septic shock
E. coli and S. aureus
Blunt abd trauma and has abd pain radiating to back
Hemorrhagic pancreatitis
How long after pancreatitis do pseudocysts develop
6-8 weeks
ABD pain and Bruising around umbilicus
Cullen
Hemorrhagic pancreatitis, ruptured AAA
ABD pain and Bruising in the flank
Grey Turner
Retroperitoneal hemorrhage
ABD pain and Pain in left shoulder
Kehr
Splenic rupture
ABD pain and Dull percussion on L and shifting dullness on R
Balance
Splenic rupture
ABD pain and Bruising where seatbelt is
Seatbelt
Deceleration injury
Best initial test for free air under diaphragm
Upright CXR
Presentation of tension PTX
Decreased breath sounds on one side and tracheal deviation
Signs, Sx of pericardial tamponade
JVD
Hypotension
Muffled heart sounds
Electrical alternans
Signs, Sx of PTX
CP
Hyperresonance
Decreased breath sounds
Signs, Sx of tension PTX
CP
Hyperresonance
Decreased breath sounds
Tracheal deviation
Signs, Sx of Hemothorax
Absent breath sounds
Dullness to percussion
Dx test in pericardial tamponade
Echo
Dx test in PTX of any kind
CXR
Dx test in hemothorax
Blunting of costophrenic angle on CXR
CT
Rx cardiac tamponade
Pericardiocentesis
Rx PTX
Chest tube
Rx Tension PTX
Needle decompression then chest tube
Rx hemothorax
Chest tube drainage
Possible thoracotomy
Evaluation of urethral disruption
XR kidneys, ureter, bladder then Retrograde urethrogram
Most appropriate next step in suspected mesenteric ischemia
Angiography
MC sx in bowel ischemia
Abd pain after eating
bloody diarrhea
Best initial test for bowel ischemia
CT
Most accurate test for bowel ischemia
Angiography
Rx bowel ischemia
IV NS then surgery
2 MC locations for bowel infarction
Splenic and hepatic flexures
Causes of RUQ pain
Cholecystitis
Biliary colic
Cholangitis
Perforated duodenal ulcer
Causes of LUQ pain
Splenic rupture
IBS
Causes of RLQ pain
Appendicitis
Ovarian torsion
Ectopic pregnancy
Cecal diverticulitis
Causes of LLQ pain
Sigmoid volvulus or diverticulitis
Ovarian torsion
Ectopic pregnancy
Causes of midepigastric pain
Pancreatitis
Aortic dissection
PUD
MI pain refers to
Left chest, arm, jaw
Gallbladder pain refers to
Right shoulder, scapula
Pancreas pain refers to
Back pain
Pharynx pain refers to
Ears
Prostate pain refers to
Tip of penis, perineum
Appendix pain refers to
LLQ
Esophagus pain refers to
Substernal CP
Pyelonephritis, nephrolithiasis pain refers to
CVA
Presentation of esophageal rupture
Retrosternal CP
Odynophagia
Hamman sign “snap crackle pop”
Left shoulder pain
What is Boerhaave
Full thickness tear 2/2 severe retching and vomitting
Boerhaave is commonly seen in
Alcoholics
Location of Boerhaave
Left posterolateral aspect of distal esophagus
MCC esophageal tear
Iatrogenic
MC procedure causing esophageal tear
Upper endoscopy
Mortality in Boerhaave
25%
What is Mallory-Weiss
Mucosal tear 2/2 vomitting
Location of Mallory-Weiss
GE junction
Most accurate test for esophageal tear
Esophogram using gastrografin showing leakage outside esophagus
Rx esophageal tear
Surgical exploration and debridement of mediastinum
Complication of esophageal tear
Mediastinitus
MCC gastric perforation
Ulcer disease
RFs for gastric perforation
H. pylori NSAIDs Burns Head trauma CA
Role of alcohol and smoking in ulcer disease
Delays healing
Presentation of gastric rupture
Acute, progressively worse abd pain radiating to R shoulder 2/2 acid irritation of phrenic nerve
Signs of peritonitis
Best initial test for gastric perforation
Upright CXR
Most accurate test for gastric perforation
CT
Rx gastric perforation
NPO
NG tube
IV NS, broad spectrum ABX
Surgically repair
Consider in RLQ pain in female of childbearing age
Ectopic pregnancy
Cysts
Torsion
Always get in a female pt w/ abd pain
Beta-HCG
Pelvic sonogram
Rx first time diverticulitis
Medically
Rx recurrent diverticulitis
Surgical resection
MC complication of diverticulitis
Abscess
Contraindicated in diverticulitis
Barium enema
Colonoscopy
MC site of diverticulitis
Sigmoid
Dx abd abscess
CT
Rx abd abscess
I & D
ABX
Abd pain that radiates to back
Pancreatitis
Aortic dissection
PE Signs of appendicitis
Rovsing
Psoas
Obturator
Signs of appendicitis
Anorexia
Fever
Periumbilical pain with RLQ tenderness
Elevated WBC w/ left shift
Signs of acute pancreatitis
Fever
Severe midabdominal pain radiating to back
N/V
Signs of diverticulitis
Fever
Nausea
LLQ pain
Peritonitis
Signs of cholecystitis
Fever
RUQ pain
Murphy sign
Most accurate test appendicitis
CT
Best initial test for pancreatitis
CT
Amylase is sensitive, Lipase is specific
Best initial test for diverticulitis
CT
Most accurate test for diverticulitis
CT
Best initial test for cholecystitis
U/S
What is seen on ultrasound in cholecystitis
Pericholecystic fluid
GB wall thickening
Stones
Sonographic murphy’s
Rx Appendicitis
Laparoscopic removal
Rx acute pancreatitis
Aggressive IV fluids
NPO
Rx diverticulitis
ABX for first attack
Resection if recurrent or perforates
Rx cholecystitis
14 days ABX
Laparoscopic/open cholecystectomy if no better
Complications of appendicitis
Abscess
Gangrenous perforation
Complications of acute pancreatitis
Hemorrhagic pancreatitis
Pseudocyst formation
Complications of diverticulitis
Abscess
Complications of cholecystitis
Perforation
Most accurate test for cholecystitis
HIDA
- Delayed emptying
Characteristics of bowel obstruction
Failure to pass stool or flatus Waves of intermittent crampy abd pain Hyperactive bowel sounds "tinkling" N/V Fever Hypovolemia due to 3rd spacing
Types of bowel obstruction
Partial
Complete
MCC bowel obstruction
Adhesions
Other causes of bowel obstruction
IBD Hernias Intussusception Volvulus Neoplasms Foreign bodies Intestinal atresia Carcinoid
Hallmark sign of bowel obsctruction
Elevated lactate with marked acidosis
Best initial test for bowel obstruction
Abd XR - air fluid levels
Most accurate test for bowel obstruction
CT - transition zone
Rx bowel obstruction
NPO
NG tube
IV fluid
Emergent surgical resection
What is fecal incontinence
Continuous/recurrent uncontrolled passage of fecal material for at least 1 month in an individual over 3
Best initial test for fecal incontinence
Clinical hx combined w/ flex sig or anoscopy
Most accurate test for fecal incontinence
Anorectal manometry
Best initial test for fecal incontinence if there is hx of anatomic injury
Endorectal manometry
Medical rx for fecal incontinence
Bulking agents - fiber
Biofeedback rx for fecal incontinence
Control exercises
Muscle strengthening exercises
Last resort rx for fecal incontinence
Surgery
Decreases incontinence episodes by 50%
Dextranomer/hyaluronic acid (Solesta)
Fractures are always diagnosed with
XR
Types of fracture correction
Closed reduction
Open reduction and internal fixation
Open fractures - close skin, bone set in OR w/ debridement
Types of fractures
Comminuted Stress Compression Pathologic Open
What is a comminuted Fx
Bone broken in multiple pieces
MCC comminuted Fx
Crush
What is a stress fracture
Complete fracture from repetitive insults to bone
Which bone is MC fractured in stress fx
Metatarsals
How to dx stress Fx
CT or MRI
Rx stress Fx
Rehabillitation, reduced physical activity, casting
Locations of compression fractures
1/3 lumbar
1/3 thoracolumbar
1/3 thoracic
Who gets compression fractures
Osteoporosis
Common vignette for pathologic Fx
Older person fractures rib from coughing
Pathological conditions that can cause fractures
Paget’s
Multiple Myeloma
Bone mets
Rx pathologic Fx
Surgical realignment
Rx underlying disease
What is an open Fx
Bone pierces skin
Rx open fx
Surgery
Common vignette for stress Fx
Athlete w/ persistent pain
Most common type of shoulder dislocation
Anterior
Causes of posterior shoulder dislocation
Seizure
Electrical burn
Cause of clavicular Fx
Trauma
Cause of scaphoid Fx
FOOSH
Signs of anterior shoulder dislocation
Arm held to side, externally rotated, severe pain
Signs of posterior shoulder dislocation
Arm medially rotated held to side
Signs of clavicular Fx
Pain over location
Signs of scaphoid Fx
Persistent pain in “snuffbox”
Best initial test for shoulder injuries
XR
Most accurate test for shoulder dislocations
MRI
Rx anterior shoulder dislocations
Shoulder relocation and immobilization
Rx posterior shoulder dislocations
Traction and surgery if pulses or sensation diminished
Rx clavicular fx
Simple arm sling
Rx scaphoid Fx
Thumb spica cast
Finger flexed and painful. Loud popping sound and no more pain when pulled
Trigger finger
Cause of trigger finger
Stenosis of tendon sheath
Rx trigger finger
Steroids
Surgery if fails
Who gets dupuytren’s
Men > 40
Rx dupuytren’s
Surgery
MC bone implicated in fat embolism
Femur
Onset of fat embolism sx
Within 5 days of Fx
Presentation of fat embolism
Confusion
Petechial rash
SOB
Dx tests for fat embolism
PO2
Rx fat embolism
Keep PO2 > 95
6 signs of compartment syndrome
Pain Pale Paresthesia Paralysis Pulselessness Poikilothermia
Rx compartment syndrome
Fasciotomy
Dx torn ACL
MRI
Most definitive rx of ACL tear
Arthroscopic repair followed by rehabilitation
Anterior drawer sign is for
ACL
Posterior drawer sign is for
PCL
Rx knee injuries
MRI
Rx MCL/LCL
Surgical repair
Which knee injuries are repaired arthroscopically
ACL
PCL
Meniscus
Knee injury w/ popping sound on flexion and extension
Meniscus
Unhappy Triad
ACL
MCL
Medial meniscus
Done for all pts under 50 presenting for acute onset back pain
MRI to r/o slipped disk or lumbar disk herniation
Most appropriate next step after MRI in acute back pain
Antiinflammtory agents
MC sites of lumbar herniation
L4-5
L5-S1
Hallmark signs of AAA
Bruit
Pulsatile abdominal mass
Syncope in setting of AAA
Rupture until proven otherwise
Diagnostic tests in AAA
CT/MRI - relation of AAA to surrounding structures
U/S for size and monitoring
Surgery when AAA reaches 5cm
Who gets screened for AAA
Former or current smokers over 65
POD 1-2 fever cause
Atelectasis
Post-op PN
POD 3-5 fever cause
UTI
POD 5-7 fever cause
DVT, thrombophlebitis of IV
PE
POD 7 fever cause
Wound infections and cellulitis
POD 8-15 fever cause
Drug fever
Deep abscess
Dx test for POD 1-2 fever
CXR and sputum Cx
Prevent POD 1-2 fever
Incentive spirometry
Rx POD 1-2 fever
Vanco, tazobactam-pipercillin for HCAP
Dx POD 3-5 fever
UA showing +nitrates and leukocyte esterase
UCx for species and sensitivity
Dx POD 5-7 fever
Doppler U/S
Change IV access
Cx IV tips
Rx POD 5-7 fever
Heparin for 5 days as bridge to coumadin
Dx POD 8-15 fever
CT
Rx POD 8-15 fever
CT guided percutaneous drainage or surgery
Post-op confusion
Likely hypoxis or sepsis
- ABG
- CXR
- Blood Cx
- UCx
- CBC
Causes of post-op hypoxia
PE
Atelectasis
PN
Signs of post-op ARDS
Severe hypoxia
Tachypnea
Accessory muscle use
Hypercapnia
Dx post-op ARDS
CXR - B/L infiltrates w/o JVD
Rx post-op ARDS
Positive end expiratory pressure
Signs of post-op PE
Acute onset PE w/ clear lungs
Best initial dx test for post-op PE
EKG (No ST changes)
Confirm with troponins and cardiac enzymes
Then do CT angio
Rx post-op PE
Heparin as bridge for coumadin
Second PE while on coumadin for post-op PE
Place IVC filter
