Surgery Flashcards
Anesthesiologist
MD or DO
Chooses and applies correct meds
Monitors physicologic function during surgery
In charge of fluids
Anesthesia assistant
AKA an anesthetist such as CRNA
works up the anesthesiologist
Edu: RN + BSN+ 2 years extra school + 1 year on the job experience
Surgeon
MD, DO
Board certifed in their surgical field
In charge of surgical procedure
1st Assist
Can be PA or MD
Person standing directly across from surgeon
Maintains visibility of surgical site with suction
Holds retractors, control bleeding
Apply dressing etc
Scrub tech
Can be RN or LPN
Maintains integrity and safety of the sterile field throughout the procedure
XR/fluoroscopy tech
Fluoroscopy = continuous XR image on monitor
Intern/resident/student
There to learn how to cut
Residents can do surgeries by themselves
Circulating nurse
RN
Monitor and coordinate all actvities within the room
Manage care required for the patient
Perfusionist
Makes sure the heart-lung machine is efficienctly managing the lungs and heart
Delivers the drug that stops a patients heart in cardiac surgery
American society of anesthesiology
Risk assessment
ASA 1 Normal healthy
ASA 2 mild systemic disease
ASA 3 Severe systemic disease
ASA 4 Severe systemic with constant threat to live
ASA 5 Moribund, not expect to survive without operation
ASA 6 declared brain dead
Upper airway exam
ROM of cervical spine Thyroid cartilage to mentum dis: >6cm Mouth opening greater than 3 cm Look at dentition, dentures loos teeth Jaw protrusion Presence of beard Mallampati score
Mallampati score
Grade1: easy intubation
2: see tonsilar pillars and part of uvula
3: only hard and soft palate visable
4: hard palate only visable
G tube
gastrostomy tube, surgical access
tube inserted thru abdomen directly into stomach
Indicated when patient needs long term access
Also used for decompression
Can bolus feed
J tube
jejunostomy tube
same as g tube but placed more distally
Reduced risk of aspiration
Continuous drip w pump required
PEG tube
percutaneous endoscopic gastrostomy
specific technique
Done with endoscope
Most common use if for head and neck cancer
Pre surgery diabetes glucose level
300 = reevaluate surgery
Phases of wound healing 1
Coagulation:
Fibrin plug form
Main cell type: platelets
Platelets aggregate, release fibrinogen fragments
Phase 2 of wound healing
Inflammatory
Cell recruitment and chemotaxis
Cell types: neutrophils, monocytes/macrophages
Phase 3 of wound healing
Migratory/proliferative
Epidermal resurfacing, angiogenesis
Keratinocytes, fibroblasts, endothelial cells
Phase 4 of wound healing
Remodeling
Scar formation
Myofibroblasts
Phenotypic switch to myofibroblasts from fibroblasts
Suture size on face
5-0 and 6-0
Most common surgical site infection
Staph aureus
Staph epidermidis: worry for immunocomp
Pathogens in sites involving intestines
E.coli
K. pneumo
Enerobacter
Bacteroides species
Dirty wound number of bugs
10^5
Furuncle
Boil
Caused by S aureus, can also be strep
Tx: most often resolve, can I&D
Carbuncle
Collection of furuncles
Extend to subQ
RF: DM, immunoComp, chronic steroid use
Manage: I&D, often excision
Cellulitis
Eti: strep, staph, MRSA in hospital
Mangement: Abx: keflex, amox, dicloxacilin
(TMP-SMX if MRSA)
Severe: IV PCN G, naficillin (+vanco if MRSA)
drain abcess
Pyomyositis
Bact infx of skeletal muscles due to hematogenous spread, leads to abcess formation and sepsis
Most common in the tropics
Gas gangrene
Eti: Trauma, IVDU. One of clostridia
Crepitus, gas in tissue on palpation and CT/XR
Manage: surg debridement, IV abx
Necrotizing fascitis
Strep, Kleb, Clostrid, E.coli, Staph Infection of fascia Type 1: polymicrob Type 2: group a strep Type 3: gas gangrene Marked systemic toxicity and pain out of proportion to local findings
Post surgical pneumonia
Most common pulmonary comp for pt. who die after surgery
Usually 2/2 aspiration of gram - bact.
Sx/s: fever, tachyP, increased secretions, consolidation on PE
Dehiscence
Surgical complication when wound ruptures along a surgical incision
Often result from using too few sutures
Evisceration
Rupture of all layers of the abdominal wall and extrustion of abdominal viscera
Most common on 5-8th day PostOpp
Atelectasis
Complete or partial collapse of a lung or a lobe
Most common surgical pulmonary complication 25%
Most freq: old, OW, smokers,
Sx/s: vent/profusion mismatch, low O2
Ileus
disruption of normal propulsive ability of the GI tract
Caused by failure of peristalsis rather than mechanical obstruction
Fecal impaction
Most common in elderly and with opioid use
Post op anemia
Result of gastric operation
Iron absorption in proximal tract
Intrinsic factor needed for B12 absorption
IV phlebitis
Inflammation of IV site entry
One of the most common causes of post op fever
Day 3ish
Tx: removal of IV at first sign of it
Post op fever
Occurs in about 40% of pt. post major surgery
48 hours: IV phleb, Pneumonia, UTI
>5 days: wound infection
Post op DVT
Surgery increases risk 21 times
DVT most common source of PE
Upper abdominal pain
Fore gut: esophagus liver gallbladder pancreas stomach duodenum
Midline periumblicial pain
Midgut pain: small intestine cecum appendix ascending colon
Lower abdominal pain
Hindgut:
descending colon
sigmoid colon
rectum
Ruptured spleen
Eti: commonly blunt trauma
S/s: Kehr’s sign: (blood leaking->abd pain radiates to left shoulder/neck
Tenderness with palp of LUQ 9-10th rib
Splenomegaly
Perforated bowel
Eti: commonly: diverticulitis & colonoscopies
S/s: Sudden onset of severe agonizing mid/low abd pain
Abdomen is rigid and tender
Choelithiasis/Cholecystitis
4F's: Fat, female, forty, fertile s/s: biliary colic, RUQ pain. episodes of pain Pain may refer to scapula Murphy's sign. Ultra sound
Peritonitis
Eti: Preexisting large-volume ascites
- 2nd: appendicitis, perf bowel/ulcer divertic, trauma
Positive peritoneal sign
Dx: CBC, blood cult, abd paraC for gram stain
Bowel obstruction etiology
Small bowel 3 most common:
Adhesion (65-75%), hernias, neoplasm
Large bowel: 15%
Bowel obstruction s/s
High pitched bowel sounds or absence of them
Crampy pain, occurs in cycles
Classic: vomiting, distention, obstipation (severe constipation)
Colon cancer
3rd most common men and women
Majority asymptomatic
Subclinical bleeding-> asymptomatic iron deficiency anemia
Dx: colonoscopy
Diverticulitis
More common in colon
Remains asymptomatic in 80%, incidentally found
Mild tenderness in LLQ
Volvulus
Rotation of a segment of intestine Surgical emergency S/s: Severe intermittent colicky pain that begins in the right abdomen and becomes continous Dx: Coffee bean sign in cecum Barium enema - > Bird beak sign
Appendicitis
Gangrene and perforation can occur in about 24 hours
Progression of symptoms is key
Begin: vague midabdominal/ periumbilical discomfort
N/V/indigestion
Pain continuous but not severe with mild cramping
Pain shifts to RLQ, causing discomfort on moving, walking etc.
Localized tenderness (McBurney), guarding, rebound tenderness
Pilonidal disease
Chronic gland infection of the gluteal cleft 3 types - Acute, chronic, recurrent S/s: pain and swelling Tx: I&D
Hemorrhoids, internal
Bleeding, pressure-like pain, prolapse
Can have sig blood loss and show symptoms of anemia
Dx: DRE to rule out mass lesions or malignancy
Tx: grade 1: fiber, fluid, possible laxitive
grade 2-3: rubber band ligation
grade 4: excisional hemorrhoidectomy
Hemorrhoid internal grades
Grade 1: no prolapse
Grade 2: prolapse that spontaneously reduces
Grade 3: prolapse that requires manual reduction
Grade 4: prolapse that is not reducible
Anorectal fistulas
Chronic drainage of mucus and blood, typically a history of anorectal abcess. Occur in 50% of anal abcesses
Image: MRI choice
Tx: fistulotomy, lays flat the tract
Perirectal abcess
Acute pain, swelling, possible fever
Occasional leakage of pus and mucus
Dx: may have elevated WBC, history and physical usually all that is needed. MRI if necessary
Tx: I&D
Carcinoma of the breast
s/s: single, nontender, firm to hard mass with ill-defined margins
Later s/s: skin or nipple retraction, axillary lymphA, breast enlargement, erythema, edema, pain, fixation of the mass
Simple mastectomy
removal of entire breast, leaving pectoralis muscle not all the lymphnodes
Modified radical mstectomy
Removal of breast, leaving pectoral muscle, taking axillary lymphnodes
Fibroadenoma
Most frequent in young women within 20 years of puberty
Typically: round or ovoid, rubber, discrete, relatively mobile, non-tender 1-5 cm
Mitral regurgitation
Associated with pulmonary congestion and low cardiac output
S/s: dyspnea, poor exercise tolerance, fatigue
PE: displaced PMI, S3 gallop over apex
XR: shows cardiomegally
Echo is the mainstay of diagnosis
Mitral valve stenosis
Eti: most common cause: rheumatic fever
s/s: mid diastolic rumble best heard over apex
opening snap can be heard in beginning of disease
Aortic stenosis
Eti: most common senile calcific aortic stenosis
s/s: gradual decrease in exercise tolerance, syncopy, angina, dyspnea on exertion
Ausc: harsh ejection murmur (heard best base of heart)
Aortic insufficiency
S/s: most pt. don’t develop symp until LV dialation
PE: water hammer pulse (head bob with heart beat)
Ausc: High-pitched blowing diastolic murmur immediately after S2
Thoracic aortic aneurysm
Abrupt tearing sensation in chest radiating to the back
UE pulse deficit and possible regurg murmur
AAA
AA: greater than 3 cm, surgical if greater than 5 cm
Think old smokers
s/s: sudden abdominal or flank pain with pulsatile mass and hypertension
Dx: FAST or Ct if patient is stable
Tx: reduce HTN with BB and nitroprusside, vascular surgery
Mesenteric ischemia
patients > 60 (afib, CHF, recent MI)
Abdominal pain out of proportion with clinical presentation
Intestinal pain after eating, relieved by vomiting
Progression: N?V, bloody diarrhea, peritonitis.
