Surgery Flashcards
1
Q
The number one limiting factor prior to surgery is:
A
a hx of cardiovascular disease
Ejection fraction below 35%: increased risk for noncardiovascular surgery
Recent MI: must defer the surgery 6 months and stress the pt at that interval
Congestive heart failure (JVD, le edema): medically optimize the pt with ACE Inhibitors, bblockers, and spironolactone to decrease mortality.
2
Q
Surgery risk factors
A
Male over 45
CAD
Diabetes (same as CAD)
htn
high cholesterol
3
Q
If the pt is under the age of 35 and has no hx of cardiac disease
A
EKG is only thing needed
4
Q
Pt with a hx of cardiac disease, regardless of age must have
A
EKG
stress testing to evaluate for ischemic coronary lesions
Echocardiogram for structural disease and to assess ejection fraction
5
Q
Pulmonary Disease Risk Assessment
A
pts with known lung disease or those who have a smoking hx pft is necessary to evaluate for vital capacities.
have pt quit smoking for 6-8 weeks? prior to surgery and use a nicotine patch in the meantime
6
Q
Renal disease risk assessment
A
pts with known renal disease must be kept adequately hydrated: otherwise, hypoperfusion of the kidneys can lead to increased mortality.
if a preexisting renal disease is present, volume loss during surgery will adversely and acutely affect renal function.
subsequent raas activation will lead to further constriction of renal vasculature and make the creatinine clearance even lower.
7
Q
To ensure adequate kidney perfusion
A
give fluids before and during surgery
if the pt is on dialysis, dialyze the pt 24 hours prior to surgery
8
Q
age > 70
A
significant risk factor for a cardiac event
9
Q
when do you do a thallium stress test?
A
when the pt cannot do an exercise one
pad
10
Q
ABC
A
A
Airway, primary step to assess and secure the airway
orotracheal tubes are the best way to maintain an airway in pts with no facial trauma
patients with facial trauma require a cricothyroidotomy
patients with cervical spine injury still need an orotracheal tube intubation. this should be performed with flexible bronchoscopy to reduce risk of further cervical spine injury.
11
Q
ABC
B
A
breathing: proper ventilation is necessary to maintain oxygen saturation. the routin goal in management is to keep oxygen saturation above 90%.
12
Q
ABC
C
A
Circulation: insert 2 large bore IVs into the patient and begin aggressive fluid reusucitation to prevent hypovolemic shock
13
Q
Interpretation of SIRS Criteria
SIRS
A
2 criteria
14
Q
Interpretation of SIRS Criteria
Sepsis
A
2 criteria and source of infection
15
Q
Interpretation of SIRS Criteria
severe sepsis
A
2 criteria and source of infection and organ dysfunction
16
Q
Interpretation of SIRS Criteria
septic shock
A
2 criteria and source of infection and organ dysfunction and hypotension
17
Q
SIRS
A
a global inflammatory state that yeileds a particular set of symptoms and objective finding before sepsis and shock set in. there are 4 SIRS criteria
18
Q
SIRS Criteria
A
need 2 or more to indicate SIRS:
body temperatrure <36 or >38
heart rate >90BPM
tachypnea >20 BPM or PCO2<32mmhg
WBC <4000 cells/mm or >12000 cells/mm
19
Q
Hypovolemic schock
Signs and symptoms -
CVP -
SVR -
HR -
CO -
LVEDP or PCWP -
Treatment -
Most common cause -
A
Signs and symptoms - pale and cool
CVP - dec
SVR - inc
HR - inc
CO - dec
LVEDP or PCWP - dec
Treatment - fluids and pressors
Most common cause - massive hemorrhage
20
Q
Cardiogenic shock
Signs and symptoms -
CVP -
SVR -
HR -
CO -
LVEDP or PCWP -
Treatment -
Most common cause -
A
Signs and symptoms - pale and cool
CVP - inc
SVR - inc
HR - inc
CO - dec
LVEDP or PCWP - inc
Treatment - treat cardiac problem
Most common cause - myocardial infarction
21
Q
Neurogenic Shock
Signs and symptoms -
CVP -
SVR -
HR -
CO -
LVEDP or PCWP -
Treatment -
Most common cause -
A
Signs and symptoms - warm
CVP - dec
SVR - dec
HR - pos
CO - ded
LVEDP or PCWP - dec
Treatment - fluids and pressors
Most common cause - spinal cord injury (cervical or thoracic)
22
Q
Septic shock
Signs and symptoms -
CVP -
SVR -
HR -
CO -
LVEDP or PCWP -
Treatment -
Most common cause -
A
Signs and symptoms - warm and faint
CVP - dec
SVR - dec
HR - inc
CO - inc
LVEDP or PCWP - no change
Treatment - fluids, antibiotics, and pressors
Most common cause - e. coli and s. aureus
23
Q
two pictures
A
study them
24
Q
Cullen sign
A
bruising around the umbilicus
hemorrhagtic pancraetitis, ruptured abdominal aortic anuerysm
25
grey turner sign
bruising in the flank
retroperitoneal hemorrhage
26
kehr sign
pain in the left shoulder
splenic rupture
27
balance sign
dull percussion on the left and shifting dullness on the right
splenic rupture
28
seatbelt sign
bruising where a seatbelt was
deceleration injury
29
between 10-50% of pts with acute pancreatitis will have ?
bruising in the flanks
30
Abdominal trauma
diagnose with FAST scan to evaluate for intraabdominal bleeding. add Ct scan to evaluate retroperitoneal bleed or if you suspect splenic rupture in spite of negative FAST. manage hemodynamically stable pts with close monitoring, serial abdominal exams, and IV fluids. hemodynamically unstable pts need exploratory laparotomy.
31
upright cxr is the best initial test to
evaluate free air under the diaphragm. free air under the diaphragm indicates a perforation of the bowel.
32
the abdominal x ray is also useful for evaluation of
ileus, which is a nonmechanical etiology for lack of peristalsis in the GI tract
33
Pericardial Tamponade
etiology
trauma with penetration to the pericardium, secondary to broken ribs knives or bullet wounds
34
Pericardial Tamponade
signs and symptoms
jvd, hypotenstion, muffles heart sounds, electrical alternans on EKG
35
Pericardial Tamponade
diagnostic tests
cardiac echogram
36
Pericardial Tamponade
treatment
pericardiocentesis, is most effective
37
Pneumothorax
etiology
air in the pleural space
38
Pneumothorax
signs and symptoms
chest pain
hyperresonance
decreased breath sounds
39
Pneumothorax
diagnostic tests
cxr
40
Pneumothorax
treatment
chest tube
41
Tension Pneumothorax
etiology
air in the pleural space thorugh a one way leak
42
Tension Pneumothorax
signs and symptoms
chest pain
hyperresonance
decreased breath sounds
tracheal deviation away for the involved lung
43
Tension Pneumothorax
diagnostic tests
cxr
44
Tension Pneumothorax
treatment
immediate needle decompression followed by chest tube placement
45
Hemothorax
etiology
blood in the pleural space
46
Hemothorax
signs and symptoms
absent breath sounds and dull percussion
47
Hemothorax
diagnostic tests
blunting of costophrenic angle on chest xray and ct scan
48
Hemothorax
treatment
chest tube drainage and possible thoracotomy
49
atelectasis pulls the trachea
toward the involved lung
50
urethral disruption evaluation
kidney ureters and bladder x ray (KUB)
then a retrograde urethrogram before any other tests
don't place a foley before these steps, but you can after if it is possible
51
acute mesenteric ischemia
severe abdominal pain that is out of proportion to physical findings
worse with eating
no peritoneal signs
increased neutros and decreased bicarb
angiography so you don't perforate, surgery
52
severe abdominal pain that is out of proportion to physical exam findings
10/10 pain
no guarding
soft abdomen
no rebound tenderness
53
ischemic bowel disease
due to a lcak of blood flow to the mesentery of the bowel
progressive disease that begins with mild ischemia and progresses to full occlusion of blood flow
analogous to angina, occurs shortly after eating as the muscular contraction of the bowel increases its oxygen requirements
54
ischemic bowel disease
most common symptoms
abdominal pain after eating
bloody diarrhea
55
ischemic bowel disease
diagnostic tests
best initial test a ct scan of the abdomen
most accurate test is angiography
colonoscopy with biopsy can also show ischemic mucosa but it takes time to get pathology back
56
ischemic bowel disease
treatment
IV normal saline followed by surgical intervention to remove necrotic bowel
57
Mesenteric ischemia
overviews
the acute occlusion of mesenteric arteries, most commonly the sma.
number one risk factor is afib which can cause emboli to occlude the vessel
58
Mesenteric ischemia
presentation
excruciating pain that is out of proportion of the physical exam
labs may show increased lactic acid and leukocytosis
59
Mesenteric ischemia
diagnosis
best initial test is abdominal xray showing air in the bowel wall.
the most accurate test is angiography
60
Mesenteric ischemia
treatment
emergent laparotomy with resection of necrotic bowel is the most appropriate therapy
endovascular therapy is indicated only if there is a clear reason to avoid surgery
61
causes of abdominal pain that do not require surgery
mi
gerd
lower lobe pneumonias
acute porphyria
62
most common locations for infarction are the 2 watershed areas
splenic and hepatic flexures
63
RUQ pain
cholecytitis
biliary colic
cholangitis
perforated duodenal ulcer
64
LUQ pain
splenic rupture
| IBS-splenic flexure syndrome
65
RLQ pain
appendicitis
ovarian torsion
ectopic pregnancy
cecal diverticulitis
66
LLQ pain
sigmoid volvulus
sigmoid diverticulitis
ovarian torsion
ectopic pregnancy
67
MI
Site of referred pain
left chest, jaw, and left arm
68
Cold foods such as ice cream
Site of referred pain
brain freeze secondary to rapid tem change of the sinuses
69
Gallbladder
Site of referred pain
R shoulder/scapula
70
pancreas
Site of referred pain
back pain
71
pharynx
Site of referred pain
ears
72
prostate
Site of referred pain
tip of penis/perineum
73
appendix
Site of referred pain
RLQ
74
esophagus
Site of referred pain
substernal chest pain
75
pyelonephritis, nephrolithiasis
Site of referred pain
CVA
76
Boorhaave syndrome
full thickness tear of the esophagus secondary to retching
severe incessant vomiting usually from alcoholism
air in subq space, snap crackle pop
most commonly in the posterolateral aspect of the distal esophagus
25% mortality even with surgery
77
esophageal perforation
etiology
due to the rapid increase in intraesophageal pressure combined with negative intrathoracic pressure caused by vomiting
78
esophageal perforation
presents with
severe and acute onset of excrutiating retrosternal chest pain
odynophagia
positive hamman sign, a crunching heard upon palpation of the thorax due to subcutaneous emphysema
pain that can radiate to the left shoulder
79
esophageal perforation
diagnostic test
most accurate test is an esophogram using diatrizoate meglumine and diatrizoate sodium solution (gastrografin; braxxo diagnostics, Princeton, new jersey); it will show leakage of contrast outside of the esophagus
do not use barium bc it is caustic to the tissues
80
esophageal perforation
treatment
surgical exploration with debridement of the mediastinum and closure of the perforation is an absolute emergency
mediastinitis is a compicatoin that caries a very high mortality rate.
81
most common cuse of esophageal perforation is
iatrogenic, most common procedure that causes this is upper endoscopy
82
the most comon procedure that causes an esophageal perforation is
upper endoscopy
83
Mucosal Tear:
Mallory Weiss Syndrome
Cause -
Symptoms-
Location -
Diagnosis -
Treatment -
Complications -
Cause - vomiting/retching in alcoholics
Symptoms- hematemesis, odynophagia
Location - gastroesophageal junction
Diagnosis - gastrografin esophagogram, no leakage
Treatment - supportive, cauterization if necessary
Complications - rare
84
Esophageal Perforation:
Boerhaave Syndrome
Cause -
Symptoms-
Location -
Diagnosis -
Treatment -
Complications -
Cause - iatrogenic is #1 (endoscopy)
Symptoms-tetrosternal chest pain, severe acute onset, radiates to l shoulder, subcutaneous emphysema
Location - distal esophagus, left posterolateral aspect
Diagnosis - gastrografin esophagogram, leakage
Treatment - emergent surgery (25% mortality)
Complications - acute mediastinitis, very high mortality
85
hemorrhagic ulcers
coffee ground hematemesis
86
Gastric perforation
etiology
most commonly seen secondary to ulcer disease
risk factors include: h pylori, nsaid abuse, burns, head injury, trauma, and cancer. these either diminish the stomachs barrier against acid, or create increased levels of gastric acid
alcohol and smloking prevent ulcer healing.
once the ulcer erodes deep enough into the stomach, allows for leakage og gasric acid into the abdominal cavity and causes peritonitis
can cause pancreatitis if the ulcer is in the posterio part of the sotmach
87
Gastric perforation
presentation
acute, progressive worsening abdominal pain that radiates to the right shoulder due to acid irritation of the phrenic nerve
likely signs of peritonitis by the time the pt comes to the ED including
guarding
rebound tenderness
abdominal rigidity
88
Gastric perforation
diagnostic tests
best initial test is an upright cxr which shows free air under the diaphragm
most accurate test is a CT scan
89
Gastric perforation
Treatment
make pt npo- prevents further extrusion of gastric contents into preitoneal cavity
place ng tube - suctions gastric contents, mitigates risk from newly formed acid
medical management - broad spectrum abs to combat infection, iv fluids in preparation for surgery
emergent surgery - exploratory laparatomy and repair of the perforation
90
RLQ pain in a female of childbearing age
ectopic pregnancy, cysts, and torions must be considered
get a beta hcg and pelvic sonogram
avoid radiation in a pt who may be pregnant
emergent surgery if ectopic
91
acute diverticulitis
acute onset of severe abdominal pain most likely in the LLQ,
treat medically if not complications
recurrent will need resection of the affected loop of bowel
most common complication is abscess formation
highly associated with constipation
92
barium enema and colonoscopy are contraindicated in
diverticulitis due to an increased incidence of perforation
93
RLQ pain algorithm
picture
94
Abdominal abscess
occur after invasive procedure, inflammatory conditions and traumatic events
diagnosed by Ct
incision and drainage is only therapy
percutaneous drainage can be done by Ct or ultrasound guidance
abs to prevent bacteremia
95
abdominal pain that radiates to the back has 2 emergent origin
pancreatitis and aortic dissection
96
acute cholecystitis
inflammatory condition that occurs often in obese women in their 40's
gallstone occludes the lumen of the cystic duct
peritoneal signs and positive murphy sign
on us it will have perisholecystic fluid and a thickened gallbladder wall
97
sonoraphic murphys sign
is when the us probe causes a cessation of breathing when it presses against the abdominal wall
98
Appendicitis
Etiology -
Signs and sx -
diagnostic tests -
treatment -
complications -
Etiology - fecolith obsturctint he appendiceal orifice, causing inflammation
Signs and sx - anorexia, fever, periumbilical pain with RLQ tenderness. elevated white count with left shift
diagnostic tests - ct scan is the most accurate test
treatment - laparoscopic surgery
complications - abscess formation and gangrenous perforation
99
Acute Pancreatitis
Etiology -
Signs and sx -
diagnostic tests -
treatment -
complications -
Etiology - alcohol or gallstone obstruction of the duct, causing inflammation
Signs and sx - fever, severe midabdominal pain radiating to the back, nausea and vomiting
diagnostic tests - Ct scan is the best test. amylase is sensitive and lipase is specific
treatment - aggressive IV fluids and npo until sx resolve
complications - hemorrhagic pancreatitis and pseudocyst formation
100
Diverticulitis
Etiology -
Signs and sx -
diagnostic tests -
treatment -
complications -
Etiology - fecal impaction into pseudodiverticula, causing inflammation
Signs and sx - fever, nausea, most commonly LLQ pain, and peritonitis
diagnostic tests - ct scan is the best and most accurate test
treatment - antibiotics for the first attack, surgical resection if it recurs or perforates
complications - abscess formation, no endoscopy due to risk of perforation
101
Cholecystitis
Etiology -
Signs and sx -
diagnostic tests -
treatment -
complications -
Etiology - gallstones occluding the lumen of the cystic duct, causing inflammation of the gallbaldder
Signs and sx - fever, severe RUQ tnederness, murphy sign, pain on inspiration causing a cesation of breathing, nausea, and vomiting
diagnostic tests - us will reveal pericholecystic fluid, gallbaldder wall thickening, and stones in the gallbladder. HIDA scan is the most accurate test
treatment - laparoscopic surgery, or open surgery if there is perforation of the gallbladder
complications - perforation of the gallbladder
102
Acute cholecystitis HIDA Scan
shows delayed empyting oft he gallbladder by failure to visulaize the gallbladder from istotope accumulation
103
Signs of appendicitis
Rovsing sign - palpation of the LLQ cause pain int he RLQ
psoas sign - pain with extension of the hip
obturator sign - pain with internal rotation of the right thigh
104
hallmarks of small bowel obstruction
failure to pass stool
flatus
hyperactive bowel sounds
nausea
vomiting
abdominal pain
105
significant risk factor for small bowel obstruction
prior abdominal surgery
106
bowel obstruction
a mechanical of runctional obstructiono f the intestines due to various causes
upon occlusion gas and gluid build up and incrase the pressure within the lumen leading to decreased perfusion of the bowel and necrosis
most common cause is prior abdominal surgery
107
2 types of bowel obstruction
partial: a small amount of GI contents can pass
Complete: no GI contents can pass
108
bowel obstruction
signs and symptoms
severe waves of intermittent crampy abdominal pain
nausea and vomiting
fever
hyperactive bowel sounds
high pitched tinkling sounds indicate that the intestinal fluid and air are under high pressure in the bowel
hypovolemia due third spacing
109
bowel obstruction
etiology
adhesions from pervious abdominal surgery (MCC)
hernias
crohn disease
neoplasms
intussusception
volvulus
foreign bodies
intestinal atresia
carcinoid
110
what alleviates obstruction from stool impaction in pts on chronic opiods
methylnatrexone (relistor)
111
bowel obstruction
diagnostic tests
an elevated white count is sensitive but not specific
an elevated lactate with marked acidosis is a hallmark sign
the best initial test is abdominal xray which will show multiple air fluid levels with dilated loops of small bowel
most accurate test is ct of the abdomen. it will show a transition zone from dilated loops of bowel with contrast to an area of bowel with no cotrast
112
bowel obstruction
treatment
make pt npo - prevents further increase in bowel pressure
place ng tube with suction - lowers bowel pressure proximal to obstruction
medical management - iv fluids to replace volume lost via third spacing
surgical decompression indicated if - complete obstruction (emergent), lack of improvement with medical management
113
Fecal incontinence
definition
defined as the continuous or recurrent uncontrolled passage of fecal material (>10ml) for at least 1 month in an individual >age3
114
bowel obstruction
diagnostic testing
diagnosed by clinical hx combined with flexible sigmoidoscopy or anoscopy as the best initial test
most accurate test is anorectal manometry
if there is a hx of anatomic injury then the best itest is endorectal manometry
115
bowel obstruction
treatment
medical therapy includes bulking agents such as fiber
biofeedback includes control exercises and muscle strengthening exercises
injection of dextranomer/hyaluronic acid (solesta) has been shown to decrease incontinence episodes by 50%
if this all fails colorectal surgery is needed
116
fractures are always diagnosed with
xray
117
general rules of fracture therapy
closed reduction: mild fractures without replacement
open reduction and internal fixation: severe fractures with displacement or misalignment of bone pieces
open fractures: skin must be lcosed and the bone must be set int eh operating room with debridement
118
fractures present with
pain, swelling, and deformity
119
5 types of fractures
comminuted fractures
stress fractures
compression fractures
pathologic fracture
open fracture
120
comminuted fracture
a fracture in which the bone gets broken into multiple pieces
most commonly caused by crush injuries
121
stress fractures
a complrete fracture from repetitive insults to the bone in question
most common stress fracture is in the metatarsals
think athlete with persistent pain
do not see on xray so do a ct or mri
treat with rehab, reduced physical activity, and casting, if persistent then surgery
122
compression fractures
specific fracture of the vertebra in the setting of osteoporosis
approximately one-third of osteoporotic vertebral injuries are lumbar, 1/3 are thoracic, and 1/3 are thoracolumbar
123
pathologic fracture
occurs from minimal trauma to bone that is weakened by disease
metastatic carcinoma (breast or colon), multiple myeloma, and paget disease
older person fractures rib from coughing
must surgically realign bone and treat underlying disease
124
open fracture
when injury causes a broken bone to pierce the skin
associated with high rates of bacterial infection
SURGERY
125
Anterior Shoulder Dislocation
Etiology -
signs and sx -
diagnosis -
treatment -
Etiology - any injury that cause strain on the glenohumoral ligaments, most common type more than 95%
signs and sx - arm held to the side with externally rotated forearm with severe pain
diagnosis - xray is the best initial test and mri si the most accurate test. must rule out axillary artery or nerve injury
treatment - shoulder relocation and immobilization
126
Posterior shoulder dislocation
Etiology -
signs and sx -
diagnosis -
treatment -
Etiology - seizure or electrical burn
signs and sx - arm is medially rotated and held to the side
diagnosis - xray is the best initial test and mri is the most accurate
treatment - traction and surgery if pulses or senation are diminished during physical exam
127
Clavicular fracture
Etiology -
signs and sx -
diagnosis -
treatment -
Etiology - trauma
signs and sx - pain over location
diagnosis - xray is the best test. must rule out subclavian artery/brachial plexus injury
treatment - simple arm sling
128
Scaphoid fracture
Etiology -
signs and sx -
diagnosis -
treatment -
Etiology - falling on an outstretched hand
signs and sx - persistent pain in the anatomical snuffbox
diagnosis - xray wont show results for 3 weeks
treatment - thumb spica cast
129
figure 8 slings for a clavicular fracture
no longer used bc outcomes are not better than a simple arm sling
130
trigger finger
acutley flexed and painful finger
steroid injection first
then surery
caused by a stenosis of the tendon sheath
131
dupuytrens contracture
more common in men over 40
the palmar fascia becomes contracted and the hand can no longer be properly extended open
surgery is only effective therapy
132
fat embolism syndrome
confusion, petechial rash, dyspnea and tachypnea
fracture of long bones causes fat to escape as little vesicle and occlude vasculateru throughout the body
femur is most common bone
w/in 5 days of fracture
133
fat embolism diagnostic tests
abg will show p02 under 60 mm hg
cxr will show infiltrates
ua may show fat droplets
134
fat embolism treatment
oxygen to keep P02 over 95%
intubation and mechanical ventilation if pt becomes severely hypoxic
135
Spinal stenosis
arthritic changes narrow the spinal canal at L1 and C2
neck and back pain, bilateral leg/buttock pain and numbness, and psuedoclaudication
sx are worse with walking but improve with spinal flexion
136
herniated disk disease
intervertebral disk herniates, compressing the spinal nerve root
seen in the elderly and is associated with a lifting injury
electrical pain following a dermatomal distribution
straight leg raise, MRI
nsaids and activity modification
137
Compartment syndrome
compression of nerves blood vessels and muscle insided a closed space
can happen from trauma or from a cast after setting a fracture
medical emergency and immediate fasciotoy must be done before necrosis occurs
138
6 signs of compartment syndrome
1. pain - usually first sx
2. pallor - lack of blood flow causes pale skin
3. paresthesia - Pins and needles sensation
4. paralysis - inability to move the limb
5. pulselessness - lack of distal pulses
6. poikilothermia - cold to the touch
139
Early findings in compartment syndrome
pain pallor parethesias
140
late findings in compartment syndrome
poikilothermia paralysis pulselessness
141
what is the most common knee ligament injury
ACL
142
Medial and lateral collateral ligament injury
etiology -
signs and sx -
diagnosis -
treatment -
etiology - trauma to the opposite side of the injury
signs and sx - pain
diagnosis - mri
treatment - surgical repair
143
ACL
etiology -
signs and sx -
diagnosis -
treatment -
etiology - direct trauma to teh knee
signs and sx - pain and positive anterior drawer sign
diagnosis - mri
treatment - arthroscopic repair
144
PCL
etiology -
signs and sx -
diagnosis -
treatment -
etiology - direct trauma tot he knee
signs and sx - pain and positive posterior drawer sign
diagnosis - mri
treatment - arthroscopic repair
145
Meniscal injury
etiology -
signs and sx -
diagnosis -
treatment -
etiology - traumatic injury of the knee
signs and sx - popping sound upon flexion and extension
diagnosis - mri
treatment - arthroscopic repair
146
Terrible triad
acl
mcl
lateral or medial meniscus
147
acute onset of back pain under the age of 50
mri to rule out spinal cord ocmpression due to a slipped disk or herniation
antiinflammtory agetns
l4-l6 and l5-s1 are most common
148
AAA
occurs when theprtion of the arota in abdomen grows to 1.5 times its normal size or exceeds the normal diameter by more than 50
true anuersym bc it involves all layers of the arterial wall
bruit and pulsatile mass are hallmark signs
syncope is rupture until proven otherwise
smoking and age are risk factors
149
ruptured AAA
painful pulsatile mass in abdomen with signs of hypovolemia (hyptension and tachycardia) the ruptured aorta is pouring blood into the retroperitoneal space and it bulges with every heartbeat
150
AAA
diagnostic tests
Ct or MRI will give infor regarding the relationschip of the AAA to surrounding vessels
us must be done bc it gives info on the size and can be sued to monitor the AAA over time
surgery is indicated when it reaches 5 cm
151
Management of AAA
3-4cm, us q 2-3 years
4-5.4 cm, us or ct q 6-12 months
>5.5 cm, asymptomatic, surgical repair
152
Screening for AAA
former or current smokers over 65 should have abdominal ultrasound. this is >95% sensitive and specific
153
Aortic Dissection
definition
occurs when a tear in the intima of the aorta creates a false lumen, this weak spot extends with each beat, extending the tear
154
Aortic Dissection
risk factors
htn is the number one risk factor
age>40
marfans
155
Aortic Dissection
presentation
sudden onset of tearing chest pain that radiates to the back
asymmetric bp in the R and L arms
156
Aortic Dissection
diagnostic tests
magnetic resonance angiogram (MRA), computed tomography angiogragphy (CTA), and transesophageal echocardiogram (TEE) are all equal in sensitivity and specificity. However, TEE is the fastest of the 3 modalities and is used if the pt is clinically unstable. in a stable pt, MRA is the diagnostic test of choice
157
Aortic Dissection
treatment
if imaging demonstrates an ascending dissection, manage the pt with emergent surgery and bp control
for a descending dissection provide medical therapy for bp control
bblockers are best inital antihypertensive therapy. follow with vasodilators such as sodium nitropursside.
vasodilators should never be used alone bc they will cause relfex tachycardia that will increase shearing forces
158
postoperative care
most likely infection
uti
159
POD 1-2
Mnemonic -
possible cause -
diagnostic test -
therapy -
Mnemonic - wind
possible cause - atelectasis or postoperative pneumonia
diagnostic test - cxr followed by sputum cultures
therapy - prevention by incentive spirometry, vancomycin and tazobactam-pipercillin for hospital acquired pneumonia
160
POD 3-5
Mnemonic -
possible cause -
diagnostic test -
therapy -
Mnemonic - water
possible cause - uri
diagnostic test - urine analysis showing pos nitrates and leukocyte esterase. urine culture for species and sensitivity
therapy - antibiotics appopriate for the organism
161
POD 5-7
Mnemonic -
possible cause -
diagnostic test -
therapy -
Mnemonic - walking
possible cause - dvt or thrombophlebitis of the IV access lines
diagnostic test - doppler us of the extremities. changing of iv access lines and culture of the iv tips
therapy - heprain for 5 days as a bridge to coumadin for 3-6 months
162
POD 7
Mnemonic -
possible cause -
diagnostic test -
therapy -
Mnemonic - wound
possible cause - wound infections and cellulitis
diagnostic test - pe of the wound for erythema, purulent discharge, and/or swelling
therapy - incision and drainage if abscess or fluid followed by abs
163
POD 8-15
Mnemonic -
possible cause -
diagnostic test -
therapy -
Mnemonic - weird
possible cause - drug fever or deep abscess
diagnostic test - ct scan for examination of a deep fluid collection
therapy - ct guided peructaneous guided dranage of the abscess, otherwise surgery
164
Postoperative confusion
likely they are hypoxic or septic
get an abg xcr blood cultures urin culture and cbc
treate appropriate organism
if hypoxic consider pe atelectasis or pneumonia as the cause
165
confused pt postop
obtain abg cxr cbc
evidence of infection (abnormal CBC)
culture likely sources
blood (bacteremia)
urine (UTI)
treat with empiric abs
166
confused pt postop
obtain abg cxr cbc
changes on cxr
yes
atelectasis vs pneumonia
incentive spirometry
antibiotics
167
confused pt postop
obtain abg cxr cbc
changes on cxr
no
cosider pe
spiral ct
168
Adult respiratory distress syndrome
ARDS
is seen postop with severe hypoxia, tachypnea, accessory muscle use for ventilation, and hypercapnia.
diagnose with cxr that will show b/l pulmonary infiltrates w/out jvd (rule out chf) and treate with peep
169
PE
presents as an acute onset of chest pain with clear lung exam
best intial diagnostic test is an ekg - shows tachycardia w/out st segment changes. ou can confiem noncardiac ches pain with troponins and cardiac enzymes. then follow with a ct angiogram of the ches
treat with heparin as a bridge to coumadin
if pt has second pe while on coumadin the place an ivc filter via inguinal catheterization
170
The most common finding on ekg for pe is
nonspecific st segment changes
s1q3t3 is not the most common and is seen less than 10% of pts
171
PE testing
ekg
do a spiral ct scan if pt is not allergic to contrast dye
if allergic to dye then do vq mismatching
