Surgery Flashcards
When assessing a trauma for airway, what criteria are used to determine if the airway is patent?
Pt speaks full sentences, doesn’t use accessory muscles for breathing, has bilateral breath sounds
When assessing a trauma for airway, what criteria are used to determine if the airway is Urgent?
Expanding hematoma or cutaneous emphysema is present
When assessing a trauma for airway, what criteria are used to determine if the airway is emergent?
Pt has apnea, GCS<8, gurgling or gasping with breathing
When assessing a trauma for breathing, what parameters are used to determine ventilation and oxygenation status?
Ventilation=CO2=pCO2
Oxygenation=O2=pO2 & SpO2
When assessing a trauma for circulation, what criteria are used to determine if the patient is in shock?
- SysBP<90
- Urinary output<0.5cc/kg/hr
- Pt is pale, cool, and diaphoretic
In hypotensive patients, what is the difference between cool and warm patients?
MAP=COxSVR
- Warm patients have some decrease in SVR (think sepsis, anaphylaxis, anesthesia, spinal trauma)
- Cold patients have some problem with CO (think tension pneumo, pericardial tamponade, hemorrhage)
A patient comes into the trauma bay with JVD, normal heart, decrease breath sounds with hyperresonance and tracheal deviation, what is the next best step in management?
Needle decompression!
-This is a scenario that represents tension pneumothorax. This is a clinical Dx urgently and requires no further diagnostic workup, jump straight to treatment!
A patient comes into the tauma bay with normal lung sounds, JVD, distant heart sounds, distant heart sounds, and pulsus paradoxus >10mmHg. What is the the most likely Dx?
Pericardial tamponade!
- To definitively diagnose get a FAST u/s and
- To Tx perform a pericardiocentesis.
A patient comes to the trauma bay with flat jugular veins, normal heart and lung sounds, decreased Hgb, increased HR. Massive hemorrhaging is noted from the left lower extremity. What should be done on the way to the OR?
Apply pressure to the wound, give IV fluids, type and cross the patient’s blood, gain IV access via 2 large bore IVs, and give blood.
A patient presents to the trauma bay w/ racoon eyes and battle sign with clear otorhea and rhinorrhea following head trauma. What is the next best step in management?
Get a CT scan!
This patient is concerning for a basilar skull fracture. Racoon eyes and battle sign are indicative of hematomas, battle sign is a hematoma behind the ears.
A patient comes in to the trauma bay following massive head trauma. The patient lost consciousness during the ambulance ride but has now regained consciousness. Non-contrast CT scan shows a lens shaped bleed. What is the most likely diagnosis?
Epidural hematoma!
Next step is to treat this patient via craniotomy as untreated, this patient will likely slip into coma due to increased ICP. Epidural hematoma is one of few things that can cause loss of consciousness–>lucid interval–>coma–>death. Epidural hematoma is between skull and dura.
A young patient comes to the trauma bay following massive head trauma and is unconscious. Head CT shows crescent shaped hematoma. What is the prognosis of this patient’s condition?
Poor!
This patient with a crescent shaped hematoma has a acute subdural hematoma. Treatment options are focused on relieving ICP and include hyperventilation, giving mannitol diuresis, and raising the bed angle to 30 degrees. Subdural hematomas are between the brain and the dura.
An elderly patient is brought to the ED by her husband who reports strange behavior changes in the patient over the last few weeks. The patient had a minor fall and hit her head a few weeks ago but was fine at the time. Head CT shows a crescent shaped hematoma. What is the next best step in managing this patient’s condition?
Craniotomy!
This patient presents with features of chronic subdural hematoma. Chronic subdural hematoma is one of the few reversible causes of dementia and can be seen in elderly and alcoholic patients who undergo minor head trauma. Their brains are more vacuolated and are thus more likely to tear bridging veins that run between the cortex and venous sinuses.
A patient comes into the trauma center unconscious after a rolling MVC and appears to have endured head trauma. CT scan shows blurring of the grey/white junctions. What is the prognosis for this patient’s condition?
Poor!
Grey white junctional blurring is indicative of diffuse axonal injury and essentially these patients will slip into a coma and die. Not much can be done.
A 16 year old male loses consciousness during a particularly brutal hit during a football scrimage. On route to the trauma center he regains consciousness and his GCS is 15. He cannot remember the events immediately preceding the loss of consciousness. CT scan at the hospital shows no abnormalities. What is the most likely diagnosis?
Concussion!
This patient can likely go home if he has someone to observe him for mental status changes and keep him awake.
A man gets hit over the head with a blunt object. He comes to the ED because of head trauma and has not had loss of consciousness. There is no scalp wound over the area. A CT scan shows a linear skull fracture with no sign of intracranial hematomas. What is the best next step in management?
Send him home!
Linear skull fractures are left alone if they are closed. If they are open they require wound closure. If they are comminuted of depressed, they have to be treated in the OR.
What are the three zones of the neck?
Zone 2=middle of the neck
Zone 3=posterior to the mandible
Zone 1=below the middle of the neck to the level of the clavicles
What are the hard signs when concerning neck trauma?
What are their significance?
- Airway-gurgling, stridor, loss of airway
- Vascular-Expanding hematoma, pulsatile bleeding, stroke, shock
- Hard signs indicate that the patient is unstable and needs to go to the OR immediately
What are the soft signs when concerning neck trauma?
What are their significance?
Dysphonia, subcutaneous air/crepitance, any of the hard signs but milder
-In the abscence of hard signs, a patient with hard signs should undergo CT angio to determine the need for surgery or if we can just observe the patient.
A pt is transported to the trauma center following a blunt neck trauma. The patient has signs of focal neurological deficit, erectile dysfunction, urinary and bowel incontinence as well as edema at the trauma site. What is the next best step in management of this patient?
IV Dexamethasone!
-This patient is likely experiencing cord compression. The compression isn’t caused by the trauma itself but rather the edema compressing upon the cord. IV steroids to limit the inflammation should help such a patient.
A patient comes to the ED with a stab wound to the posterior neck and now has loss of proprioception and vibratory sensation throughout the body. What is the most likely diagnosis?
This patient likely has a posterior cord syndrome as the dorsal columns controlling proprioception and vibratory sensation were likely injured.
A patient comes to the trauma center following a stab wound to the neck. He has ipsilateral loss of vibration and proprioception and motor function and contralateral loss of pain and temperature throughout the body. Upper limbs are areflexic and lower limbs are hyperreflexic. What is the most likely diagnosis?
Brown Sequard syndrome/hemisection through the cord
- Remember that the ALS decusates at the level of the cord, so spinal damage will always cause contralateral loss of pain and temp.
- Likewise, in cord lesions motor function is completely lost at the level of the lesion but hyperreflexia remains below the lesion.
A patient comes to the ED due to sudden loss of motor functions throughout the body as well as loss of pain and temperature sensations. Hyperreflexia is noted in the lower extremities. Vibratory and proprioception remain intact. What is the most likely cause of this patient’s condition?
Spinal artery occlusion!
-This patient presents with an anterior cord syndrome, the most common cause of which are spinal artery occlusions.
An elderly patient comes to the trauma bay with symptoms of paralysis and loss of pain and temperature sensation of her upper extremities. Her lower extremities are not involved. What likely caused these symptoms if they developed slowly over time causing loss of pain and temp before motor involvement? What is the likely cause if the onset of symptoms was sudden?
This patient presents with a central cord syndrome! The deficits are similar to anterior cord syndrome, however it typically involves only 1 dermatome, so a common presentation is deficit of the upper extemities sparing the lower extremity.
- If this progressed slowly with pain and temp sensatory involvement first, than we think about syringomyelia. The ALS is closer to the central canal, so we expect ALS involvement before motor involvement.
- If this progressed quickly, think about a fall with hyperextension of the neck, often seen with the elderly.
A patient comes in to the trauma center following blunt chest trauma and has chest pain and shallow breathing. CXR shows evidence of multiple rib fractures. Pain control is begun to improve the patient’s breathing. What potential complications are likely given this patient’s history?
Complications associated with secondary penetrating trauma!
-In the setting of rib fracture, the open ribs are basically little daggers open in the chest. Potential complications could be things like tension pneumo or hemothorax. Pain control is warranted as rib fractures themselves cause patients not to breath normally due to pain.
A patient comes to the trauma center with dyspnea, hyperresonance, decreased breath sounds, decreased tactile fremitus and decreased whispered pectoriloquay following a penetrating trauma to the chest. CXR shows vertical lung shadow. Where should the physician place the thoracostamy?
Near the top of the lung!
-This patient with a vertical lung shadow likely has a pneumothorax. Air doesn’t respect gravity, so we see a vertical chest shadow, since air will rise, a superior thoracostamy placement is warranted to treat this condition.
A patient comes to the trauma bay following penetrating trauma. The patient is dyspneic, has dullness to percussion, decreased breath sounds, and decreased tactile fremitus in the right lung. CXR shows a horizontal air fluid level in the right lung. A thoracostomy is performed at the lower lung borders. What should follow up for this patient consist of?
-This patient with a horizontal air fluid level in her right lung most likely has hemothorax. The treatment of hemothorax consists of placing a thoracostamy at the lower lung to drain the accumulated blood.
-Follow up of these patients centers around determining if the bleed is from a peripheral artery, which will need surgical intervention, or from pulmonary vasculature, which will likely self resolve.
In terms of thoracostomy blood drainage:
-20cc/kg or 1500cc at once indicates peripheral arterial bleed–>surgery
-Likewise, 3cc/kg/hr or 200cc/hr indicates peripheral arterial bleed–>surgery
A patient comes to the traumabay with penetrating trauma to the right hemithorax. The patient is dyspneic and the wound is noted to suck in air when the patient inspires. What is the next best step in management of this patient?
Drape the wound in an occlusive dressing taped at three sides until thoracostomy is appropriate!
-This patient with a wound that sucks in air on inspiration has a sucking chest wound. The diagnosis can be made upon visual inspection, but CXR can also be used. An occlusive dressing is useful as it stops air from being sucked in with inspiration. However, it is left partially open so that any air trying to escape can. Thoracostomy is often required at a later time.
A patient is transported to the trauma center following massive blunt trauma. The patient has paradoxical chest wall motion-decreased diameter with inspiration and increased diameter with exhalation. CXR shows multiple rib fractures. What is the most appropriate treatment for this patient’s condition?
Place the patient in binders with weights/plates!
-This patient with paradoxical chest wall motion has flail chest. Diagnosis can be made with visual inspection and CXR showing multiple fractures in multiple locations. Tx is placing the patient in binders with weights/plates
A patient is transported to the trauma center following massive blunt trauma to the chest. CXR on admission shows no abnormalities. However, 24 hours later, the patient complains of dyspnea and CXR shows massive white out of her left lung field. The patient is begun on PEEP and diuresis with furosemide. The patient is on fluid resuscitation with normal saline at 100cc/hr. What is the best next step in management of this patient?
Stop normal saline infusion!
-This patient with white out of a lung field a day after blunt chest trauma is likely suffering from pulmonary contusion as a result of leaky capilaries subsequent to trauma. Daignosis is made based on visualization of “white out” on CXR a day or so following admission. These patients should be placed on PEEP, diuresis, and should be given colloids (blood, albumin) for fluid resuscitation instead of crystalloids (D5W, NS)
A patient comes to the trauma center following massive blunt chest trauma. EKG shows abnormalities and troponins are elevated. What complication should be ruled out in this patient?
Pericardial tamponade!
-A patient with EKG abnormalities and elevated troponins following chest trauma likely has myocardial contusion. Pericardial contusion is often a comorbid condition that is highly lethal and should be determined by doing a FAST u/s. Once acute complications are ruled out we essentially manage these people as if they had CHF and arrythmia with MONA-BASH (morphine, oxygen, nitrates, aspirin, beta blockers, ace-i, statin, heparin)
A patient comes in to the trauma center following massive chest trauma. The patient has unequal pulses between the left and right arms and her mediastinum is widened on CXR. She has stage II renal failure. What should be done to diagnose her likely condition?
MRI or TEE!
-This patient with massive chest trauma and widened mediastinum most likely has an aortic dissection, or atleast aortic dissection should be ruled out. CT angiogram is the usual mode of diagnosis, however, in patients with renal failure, contrast will cause further harm to the kidneys. MRI or TEE are alternative modes of reaching the same diagnosis. Most patients with aortic dissection will be dead on arrival as the ligamentum arteriosum dissects the aorta. In ones who aren’t fully dissected but rather have an adventitial hematoma, surgery is required with IV beta blockers en route to surgery.
A patient is transported to the trauma center following a gunshot wound to his right upper quadrant. The patient is hemodynamically stable. What is the next best step in management of this patient?
Close follow up of clinical signs and serial abdominal CTs!
-This is a bit of a trick question. Gunshot wounds to the abdomen (anything below the nipple line) are usually managed with exploratory laparotomy. However, in select cases of low caliber gunshot wound to the R upper quadrant that are hemodynamically stable, we may suffice to just monitor them closely and get serial CTs.
A patient undergoing abdominal surgery for multiple trauma requiring multiple transfusions develops coagulopathy (bleeding from any open surface). What should be done at this point? What conditions would temporarily shut down the surgery?
This patient should be treated with platelet packs and fresh frozen plasma. If in addition this patient develops hypothermia and acidosis, surgery should be terminated with packing of bleeding surfaces and temporary closure of any wounds.
In patients with circumferential burns, what complications can be expected if the burn occurred on an extremity? The chest? What is the treatment of such complications?
- Circumferential burns of an extremity can lead to loss of distal blood supply of the extremity due to edema accumulating underneath the eschar. Therefore, these patients will need compulsive monitoring of peripheral pulses and capillary refill.
- Similarly, circumferential burns of the chest can lead to difficulty breathing as the edema limits chest wall expansion.
- The treatment of these complications is an escharotomy
How does bone remodeling in children differ from adult bone remodeling following a fracture?
- Degrees of angulation that would be unacceptable in the adult may be okay in children following reduction and fixation.
- Areas where children have special problems include supracondylar fractures of the humerus and fractures of any bone involving growth plates.
What are clues that a penetrating abdominal trauma needs to go to the OR? What about a blunt abdominal trauma?
- Penetrating-Any gunshot wound below the nipple line (T4), pts with peritoneal signs, shock, bowel evisceration, or a probe that goes into the peritoneum.
- Blunt-Blood on a FAST exam or blood or air on a CT scan.
What 5 areas can hide enough blood that can cause a patient to exsanguinate(die by losing too much blood)?
Thighs, pelvis, abdomen, thorax, the floor
A pt is brought to the trauma center following blunt abdominal trauma and is found to have blood and air in his abdomen following CT scan. Exploratory laparotomy is begun in the OR. Signs of a ruptured liver is present. What maneuver can the surgeon do to clear the field of blood while she repairs the liver?
Pringle maneuver, the temporary cutoff of the blood supply to the liver!
-Lobectomy may be part of the repair of a ruptured liver. Liver rupture is the most common cause of abdominal bleed following trauma. The liver ruptures similarly to the aorta via dissection caused by the ligamentum teres (aortic dissection=ligamentum arteriosum)
A pt is brought to the trauma center following abdominal trauma. The patient has several stab wounds, is in shock, and has areas of bowel evisceration. She is brought to the OR for ex lap and is found to have massive intrabdominal trauma to include a ruptured liver and spleen as well as stab wounds to small and large intestine. How should spleen injury be handled?
Splenectomy!
-In a patient with massive trauma requiring multiple repairs to include spleen injuries, just chuck the spleen to save time as it isn’t a vital organ. Post-op these patients will need vaccination against encapsulated organisms to include H. flu, S. pneumo, and N meningitides
How should suspected rectal injury in a trauma be diagnosed? Suspected ureter injury?
- Rectal-proctoscope
- Ureter-IV pyelogram
A patient comes in to the trauma center with a stab wound under the chest. Bowel sounds are heard at the level of the clavicle. CT scan shows loops of bowel in the chest. The patient is brought to the OR for ex lap and repair, what is the most likely diagnosis?
Ruptured diaphragm!
Tx with ex lap and repair
A patient comes to the trauma center with a stab wound to the abdomen. Upright KUB shows air under the diaphragm. The patient is brought to the OR so that ex lap and repair can be done. Given the most likely diagnosis, what would CT scan most likely show?
Air at the apex of the belly!
-This patient most likely has perforation of hollow viscera within the abdomen. Upright KUB will not usually be done, but it would show air under the diaphragm as the air rises to the top. CT scan will show air at the apex of the belly as the patient will be lying down. Tx is ex lap and repair.
A pt is brought to the trauma center following being hit by a car while walking on the sidewalk. Hip rock produces diffuse pain and his hips move in differenct directions with pushing. CT scan shows a pelvic fracture. What is the best tx option for this patient?
External fixation!
-Pelvic fracture rarely requires surgery, believe it or not. The clinical signs and Dx are as outlined in the question.
A patient comes to the trauma center with high riding prostate and blood at the penile meatus. A retrograde urethrogram shows evidence of urethral trauma. If this patient needs to pee, what should be done until his urethra is able to tolerate urination?
Use a suprapubic catheter!
-Signs and dx or urethral trauma are as outlined in the question. Never use a urinary catheter in such patients as this will likely cause further urethral damage.
How should chemical burns caused by ingestion be managed?
Serial CXRs, NPO, watch and wait acutely, later grade via endoscopy
How should chemical burns caused by inhalation be managed? What are signs of more severe damage?
- Monitor these patients via ABGs, spO2, peak flow, bronchoscopy and intubate prophylactically as if their airway closes they will need a cric/trach.
- Worse signs include stridor/soot or singing in the nares.
What is the feared complication of electrical burns and how should is be managed?
Rhabdomyolysis!
-Rhabdo is common as the bones conduct electricity so they heat up and cook the surrounding muscle. Monitor for rhabdo by checking CK, and creatinine. Tx rhabdo (no treatment for the electrical burn itself) with IV fluids and mannitol.
A 70kg patient comes in to the trauma center with 3rd degree burns over 20% of his body, 1st degree burns over 15%, and 2nd degree burns over 30% of his body. How much fluids will this patient need over the next 24 hours?
4x70x50%=14,000mL=14L over the next 24 hours!
-You split this up, giving 50% over the first 8 hours, and the rest over the next 16 hours. 1st degree burns don’t count, so only use the 2nd and 3rd degree burns in the calculation.
What are the s/s of a black widow bite and how would you treat it?
Abdominal pain that mimicks pancreatitis following a bite. Tx with IV calcium
What are the s/s of a brown recluse bite and how would you treat it?
Bite–>ulcer–>necrosis
Tx with debridement and grafting
What is the management and follow up of either a domesticated animal or human bite?
Irrigation, leave the wound open and give amox clav (augmentin). F/u with tetanus IG and tetanus toxoid vaccine if their last vaccination was atleast 5 years ago.
What laboratory clue hints at possible alcohol intoxication?
Elevated olmolar gap in the face of normal sodium, glucose, and BUN levels!
-remember that olmolal gap=2xNa+(glucose/18)+(BUN/2.8) and shouldn’t be over 15. If you have an elevated gap but these parameters are normal, you likely have alcohol toxicity
What is the treatment for an alcohol intoxication that doesn’t cause an elevated anion gap? What about one that does?
- supportive treatment
- Fonepizole or EtOH
What can be used to reverse acetiminophen toxicity?
N-acetyl cysteine
What is the treatment of salicylate toxity?
Urine alkalinization and forced diuresis
What is the treatment of cyanide toxicity caused by smoke inhalation? What is an option viable for cyanide toxicity caused by nitroprusside ingestion?
- Thiosulfate
- Amyl nitrate
What agent treats the symptoms of organophosphate toxicity? What agent reverses organophosphate acetylcholinesterase inhibition?
- atropine
- pralidoxime
Describe the following hand deformities: Duputyren contracture Felon Jersey finger Mallet finger
- Duputyren contracture-Norwegians, contracture of the palm of the hand and palmar fascial nodules
- Felon-abscess in the pulp of a fingertip, pt will have fever and this requires urgent surgical drainage
- Jersey finger-Distal fingertip won’t flex when making fist (patient always pointing), caused by injury to flexor tendon
- Mallet finger-Extensor tendon ruptured, patient can’t extend affected digit.
A patient recovering from a subtotal gastrectomy for gastric cancer with a gastroduodenal anastamosis begins draining 2 liters per day of green fluid. The patient has no abdominal pain, fever, or signs of peritoneal irritation. What is the most likely diagnosis?
The patient has developed a GI fistula!
-Given the setting of surgery and spouting out green fluid, GI fistula is the most likely Dx in this patient. Management should include fluid replacement and nutritional support, and protection of the abdominal wall (suction tubes, ostomy bags) until the fistula heals on its own.
When should you get a gastrograffin swallow?
Whenever you suspect esophageal full thickness perforation. This is most likely in cases of Boerhaave syndome. These patients will have fever & leukocytosis.
A patient presents with colicky abdominal pain, protracted vomiting and no pasage of gas or feces in 3 days. Abdominal exam reveals a prior laparotomy scar from a prior gunshot wound, high pitched bowel sounds coinciding with the pain, and obvious distension. X rays show distended loops of small bowel with multiple air fluid levels. What is the next best step in management?
NPO, NG suction, and IV fluids
-This patient likely has mechanical intestinal obstruction caused by adhesions from her previous laparotomy. Clinical course and treatment are as outlined. The goal with treatment is to watch and wait to see if it will resolve spontaneously and to see if there are any signs of strangulation. Surgery is done if such conservative management fails to relieve symptoms-within 24 hours in cases of complete obstruction, and within a few days in cases of partial obstruction.
What parameters of CHF and MIs confer an increased risk for surgery?
Ejection fraction and timing since the MI!
-An EF<35% confers a 75% chance of death. Likewise, MI within 3 mos of surgery confers a 40% chance of mortality, but waiting until 6 mos post MI reduces this risk to 6%. The Goldman Index is an indicator of cardiac risk (the more points, up to 53, the greater the risk of complication)
Why is ventilation more important than oxygenation during surgery?
Ventilation is useful to relove acidosis during surgery. Oxygenation is relatively well controlled in the OR with oxygen masks etc.
What lab values should be ordered in the preop evaluation of a patient with lung disease?
PFTs and ABGs to check for increased CO2 or decreased O2 indicating poor pulmonary status
How long should patients stop smoking before surgery?
8 weeks
What parameters should be checked preop for a patient with liver pathology?
Albumin (dec=bad) PT/PTT (inc) Total bilirubin (inc) ascites encephalopathy -1 of these raises surgical mortality rate to 40%, all of these means 100% mortality chance. Childs pugh score is an indicator of cirrhosis severity with 15=bad and 5=good
When should prealbumin and CRP be checked preop?
In suspected cases of nutritional deficiency!
-Think of patients who’ve lose 20% of their body weight in the last 3 months, albumin <3, skin anergy. Give these patients oral nutrition for atleast 10 days.
What is a metabolic absolute contraindication to surgery?
DKA!
Give them IVF and insulin until anion gap resolves, these patients will die if they go to the OR.
During surgery a patient develops fever. What treatment should be initiated?
O2, IVF, Dantrolene, and cooling!
-Sudden fever after anesthesia is most likely to be malignant hyperthermia. This is why you ask about family history of anesthesia complications.
What is the most likely diagnosis in a patient with fever immediately after a surgery?
Bacteremia!
-Get a blood Cx and start them on broad spectrum Abx. Prophylaxis would’ve been better sterility in the OR
On POD 1 a patient develops fever. CXR is negative. What is the most likely diagnosis?
Atelectasis!
Prophylaxis would be incentive spirometry and getting these folks out of bed.
On POD 2 a patient develops fever. CXR confirms a diagnosis of pneumonia. What is the next best step?
Start broad spectrum Abx with vanc zosyn!
Prophylaxis would’ve been incentive spirometry and getting these folks out of bed.
POD 3 a patient develops fever. The patient’s urine looks relatively cloudy and he’s had a foley in since the operation. What is the next best step?
Get urine culture, urinalysis, and begin appropriate antibiotics!
-This patient most likely has a UTI. This situation could’ve been prevented by removing the foley earlier.
POD 5 a patient has a swollen tender leg and has developed fever. Lower extremity US shows evidence of DVT. What could have prevented this situation?
LMWH postop and getting out of bed!
-This patient likely has DVT. Tx with a heparin-warfarin bridge
POD 5 a patient has hypoxia, hypercapnic respiratory alkalosis and fever. CXR shows evidence of plueral effusion. What treatment should be initiated?
Heparin to warfarin bridge!
-This patient likely had a PE. This situation could have been prevented with LMWH postop and getting out of bed.
POD 7 a patient develops fever and tenderness around the suture site. What is the next best step in management?
US the wound to check for abscess!
-US will be negative in a case of cellulitis and positive showing for the abscess in a case of abscess. For both you should start Abx, but incision and drainage should be done for abscess. Additionally abscess happen POD 7-14 and may be mistakenly thought of as unrelated to the surgery. These can be prophylaxed with OR sterility and patient hygiene around the surgical site.
What labs/imaging should be used to rule out postop MI or PE in a chest pain patient?
MI-EKG troponins
PE-US spiral CT
What are 4 causes of altered mental status during the postop period?
Delirium tremens-give benzos
Electrolytes-dx with BMP
Hypoxemia-give PEEP for ARDS
Sundowning-give atypical antipsychotics
What would KUB show for a case of postop ileus?
small AND large bowel dilation-give fluids, potassium, and make patient move
What would KUB show for a case of postop obstruction?
Small OR large bowel dilation-get an NG tube, perform surgery
What would KUB show for a case of Ogilvie syndrome?
Colonic dilation-get a rectal tube, stigmine, colonoscopy
POD 10 a patient returns with a hernia and serosanguinous salmon colored drainage. What is the most likely Dx?
Dehiscence!
-Tx with binders, less straining, and reoperate electively
POD 10 a patient returns with loops of bowel out of her open incision site. What is the best next step in management?
Go to the OR emergently and apply warm saline dressings!
-This is a case of exisceration. Never push the bowel back into the peritoneum! This will only make things worse.
What are the most common causes of fistula?
Foreign body Epithelialization Tumor Irradiation/Inflammation/IBD (Crohn's) Distal obstruction You will need to resect or divert the fistula.
How can you easily distinguish between obstruction and renal failure in a oliguric postop patient?
Ask them is they have the urge to pee!
- If they have urge-obstruction, get in and out cath and a bladder scan
- If not-renal failure-after 500 cc bolus if they start producing urine they were just volume down, give fluids, if they don’t then it’s intrinsic renal disease.
- If there is literally 0 output, it might be a mechanical kink in the foley, unkink it!
A patient comes to your clinic complaining of retrosternal burning chest pain made worse with lying flat and eating spicey food. She states the pain is made better when she sits up and uses antacids. She describes episodes of “nocturnal asthma” some nights. What is the best test for diagnosis of this patient’s condition and what would be the appropriate diagnostic workup if such a patient came in with concurrent nausea, vomiting weight loss or anemia?
Best test is 24 hour pH monitoring, if the patient came in with “alarm symptoms” (nausea, vomiting, weight loss, anemia) do EGD +Bx to rule out more severe pathology!
-This patient has GERD, caused by a weakened LES–>acid reflux. Simply treat with a PPI. IF an EGD discovers metaplasia-high dose PPI; dysplasia-ablation; adenocarcinoma-resection. Severe GERD can be surgically managed via Nissen fundoplication.
A patient comes in with postprandial N/V and a feeling of food being stuck in his throat after meals. What is the diagnostic workup and tx of this patient’s condition?
Get a barium swallow (bird’s beak), monometry (diagnostic), EGD+Bx (rule out psuedoachalasia) and tx with myotomy!
-This patient likely has achalasia, caused by a failure of the LES to relax.
A patient comes to your clinic complaining of dysphagia that has progressively gotten worse over the last 6 months. Barium swallow shows an area of esophageal stricture and EGD+Bx are concerning for malignancy. What is the most likely malignancy if the stricture is in the upper 1/3rd or the esophagus vs the lower 1/3rd of the esophagus?
Upper 1/3rd=squamous cell carcinoma(SCC); lower 1/3rd=adenocarcinoma!
-SCC is most likely to be caused by smoking and drinking hot drinks whereas adenocarcinoma is most likely to be caused by GERD.
A 20 year college student is brought to the ED by his roommate after he was found retching and vomiting blood. The patient had been to a large party that night and does not typically drink as much as he does this night. 2 large bore IVs are placed, IVFs are given, the patient is typed and crossed for potential transfusion, PPIs are given and GI is consulted. Shortly after arriving to the ED the patient stops vomiting blood. What is the most likely Dx?
Mallory Weiss tear!
-These are superficial esophageal tears more common in “weekend warriors”. Diagnostic workup is unnecessary, however you’re going to treat this as a more severe incident until you confirm that the patient doesn’t have something much more serious like Boorhaave’s.
A known bulimic patient comes to the ED with chest pain that began after an episode of vomiting. On examination, crepitance is heard throughout the entire chest, a “Hammond’s Crunch” is heard with every heart beat and the patient has fever, leukocytosis and nonproductive cough. What is the next best step in management of this patient?
Get a gastrograffin swallow!
-This patient has Boorhaave’s syndrome caused by a transmural esophageal tear. This is most likely in “career vomiters” like bulimics, alcoholics. Gastrograffin swallow is the first diagnostic test, if this is negative get a barium swallow, if this is negative get an endoscopy. Remember that gastrograffin is caustic to the lungs.
On POD 5 following C-section, a woman comes to the ED with colicky abdominal pain. Physical exam shows abdominal distension. She is admitted and over the next 2 days she becomes obstipated and no longer has bowel sounds on physical exam. She remains distended. What is the next best step in management of this patient?
Get and upright KUB or CT scan with contrast!
-This is a case of small bowel obstruction most likely caused by adhesions (non-surgical cause is hernia). CT scan is particulary helpful here as it can be used to determine if the obstruction is complete or partial. Partial obstruction can be managed conservatively with NG tube and IVFs for three days, after which we go to surgery or unless the pain becomes peritoneal before then. The point is to wait and see if the incomplete obstruction will self resolve. Complete obstruction needs to be managed with surgery.
Describe the patients and locations of these hernias:
- Direct
- Indirect
- Femoral
- Ventral
- Direct-Adults, an inguinal hernia that passes through the transversalis muscle
- Indirect-Babies-an inguinal hernia that passes through the inguinal ring
- Femoral-Females, herniation under the inguinal ligament
- Ventral-Iatrogenic, common in the post-op period
What are the surgical indications for these hernia characteristics:
- Reducible
- Incarcerated
- Strangulated
- Reducible-elective surgery
- Incarcerated-urgent surgery
- Strangulated-emergent surgery
A patient comes in with intolerable lower abdominal pain with radiation to the left lower quadrant (mcburney’s point), anorexia, nausea and vomiting. What is the next best step in management?
-Surgery
This patient has appendicitis. No further workup is needed, Dx is clinical. In practice, practitioners typically get a CT scan to confirm the Dx while the OR is prepped.
A patient recently diagnosed with lung cancer comes to the ED looking flushed, with wheezing and diarrhea. KUB shows evidence of cardiac fibrosis and new metastasis to the liver. What laboratory test will confirm the Dx?
Urinary 5-HIAA!
-This patient likely has carcinoid syndrome. Pathology is by the new mets outside of the liver producing serotonin. Metastasis must come from a primary lung or GI malignancy as these areas typically mask excess serotonin production by deactivating it. Once the malignancy mets outside these areas, the serotonin isn’t dealth with properly and builds up–>serotonin syndrome. Treatment is by IDing the lesions with CT scan and resecting the tumors.
A patient comes to the ED with abdominal pain that radiates to the back. The pain is positional and eases when she leans forward and gets worse when she lays back. She has associated nausea and vomiting. What are the best diagnostic steps to determine the most likely diagnosis and what tests can be used to determine the etiology of this condition?
This is most likely pancreatitis!
- Get a lipase and amylase, if these are negative but pancreatitis is still heavy on the differential get a CT scan. Amylase is often negative so lipase is always better
- To determine the etiology of pancreatitis, get a RUQ US and triglyceride panel (think stones, alcohol, hyperlipidemia in terms of etiology)
A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after elevations in lipase and US confirms stones at the Ampula of Vater. What is the appropriate management of this patient during this admission?
NPO, IVFs, IV pain control until symptoms of pancreatitis resolve!
A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after negative amylase and lipase but a positive abdominal scan. Abnormal lipid panel confirms the etiology as hyperlipidemia. She is started on NPO, IVFs, IV pain control. 1 day after admission this patient develops a sick as shit appearance and hypotension. What is the next appropriate step in management?
Send this patient to ICU, plan for a necrosectomy, and perform FNA to determine if the patient has developed a pancreatic infection necessitating carbapenems!
-In a patient with confirmed pancreatitis who develops such a clinical appearance, you must have a high degree of suspicion of necrotizing pancreatitis. Necrotizing pancreatitis develops within hours to day.
A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after negative amylase and lipase but a positive abdominal scan. Abnormal lipid panel confirms the etiology as hyperlipidemia. She is started on NPO, IVFs, IV pain control. At an unspecified time after admission admission, this patient develops early satiety, weight loss, and increased abdominal pain. A CT scan is ordered and is concerning for psuedocyst. What is the management of this condition?
- If the cyst has been present <6 weeks AND is <6cm in size, it is uncomplicated, watch and wait
- If the cyst has been present for >6 weeks OR is >6cm in size, it is complicated, drain that mofo
A patient that came to the ED with positional epigastric pain that radiates to the back, especially when leaning back, and nausea vomiting is diagnosed with pancreatitis after elevations in lipase and US confirms stones at the Ampula of Vater. He is started on NPO, IVFs, IV pain control. 1 week after admission this patient’s still haven’t fully resolved and he develops fevers, leukocytosis, and is septic. What is the most likely Dx?
This patient most likely has a pancreatic abscess!
-The next best step is to start antibiotics and perform an incision and drainage
What antibiotic regimens are appropriate for biliary tract infections?
You need gram - and anaerobic coverage
- Ciprofloxacin+Metronidazole
- Gentamycin+Metronidazole
- Zosyin (pip-tazo) will work, but is poor antibiotic stewardship as it also convers gram +s, so it will be wrong on the test.
A patient comes in colicky RUP pain that radiates to the shoulder and is worse with fatty meals. What is the best step in diagnosis?
Get a RUQ abdominal US!
-This patient with colicky RUQ pain likely has cholelithiasis. Etiology is a mixed cholesterol (fat female fertile forty) or pigmented stone (hemolyisis). Tx includes elective cholecystectomy or ursodeoxycholic acid for poor surgical candidates
A patient comes in with constant RUQ abdominal pain, positive murphy’s sign, fever, and leukocytosis. RUQ US is negative, but HIDA scan shows a filing defect of the gallbladder distal to the cystic duct. What tx should be given to the patient?
NPO, IVFs, IV abx (gent+MTZ, cipro+MTZ) urgent cholecystectomy or cholecystotomy is this is a poor surgical candidate.
-This patient has cholecystitis. Typically, these patients will have pericholycystic fluid, thickened gallbladder wall and visible gallstones on US, but in cases with high suscpiscion and a negative US, a HIDA scan will show a filling defect of the gallbladder at the level of the cystic duct.
A patient has painful jaundice with a positive murphy sign, fever and leukocytosis. RUQ US shows dilation of the common bile duct. What is the most likely diagnosis in this patient?
Choleydocolithiasis!
-Caused by stone in the common bile duct, these patients will have jaundice +/- hepatitis and pancreatitis
(depends on the level of the stone). If the US is negative, MRCP is the next best diagnostic tool. Tx with NPO, IVFs, Abx (cipro+MTZ, Gent+MTZ), get urgent ERCP, and elective cholecystectomy.
What is the ball valve effect in cases of choleydocolithiasis?
The stone is obstructing one day and not the next leading to up and down labs/symptoms that seems confusing!
-Just remember that shit gets bad when they’re obstructed, but better the next day when their not and the cycle repeats until you get that urgent ERCP. Same management as choledocolithiasis, don’t be fooled.
What are Charcot’s triad and Renold’s pentad for cholangitis?
- Charcot’s-RUQ pain, jaundice, fever
- Reynold’s-Charcot’s+hypotension and altered mental status
A patient comes in with RUQ pain, jaundice, fever, hypotension and altered mental status. RUQ US confirms the presence of common bile duct dilation and obstruction via stone. What is the treatment algorithm for this patient?
Emergent ERCP followed by urgent/elective cholecystectomy, give IVFs, IV Abx (cipro+MTZ, Gent+MTZ0
-This patient likely has cholangitis, the infected version of choledocolithiasis. Caused by gallstone in the common bile duct, but the occlusion has gone on long enough to lead to infection.
What kind of findings should prompt you to get a colonoscopy?
- Iron deficiency bleeding in a postmenopausal woman or any man.
- Change in stool caliber, weight loss, alternating bowel habits
Describe the difference between “good” and “bad” colon polyps
- Good polyps are pedunculated, small, tubular, and have a stalk
- Bad polyps are sessile, have no stalk, are large and villous.
How would you treat familial adenomatous polyposis colon cancer?
Prophylactic colectomy!
-These patients will have 1000s of polyps on colonoscopy
How often should a patient receive repeat colonoscopies given:
- 1-2 polyps
- Carcinoma in situ
- frank dysplasia
- 1-2 polyps-q5 years
- Carcinoma in situ-q 3 years
- frank dysplasia-yearly
What are the pt findings and treatments of internal and external hemorrhoids?
- Internal-bleeding but painless-get these banded
- External-painful but bleedless-resect these.
- Preparation H and sitz bath are first line treatments before those outlined above. Dx is made by visual inspection/anoscopy.
How is the Dx of anal cancer made?
Anal pap smear showing evidence of HPV–>squamous cell carcinoma.
-Be mindful of this in homosexual males, those with prior STD, anoreceptive sex. These patients need chemo and radiation.
Wth is a pilonidal cyst?
Bruh, is that an abscessed hair follicle on your hair ass?
-More likely with family history, hairy ass. Clinical Dx, get incision and drainage.
What are the 5 types of visceral abdominal pain?
- Obstructive
- Inflammatory
- Perforation
- Ischemic
- Referred
Describe obstructive abdominal pain (visceral)
- Colicky pain, patient can’t get comfortable.
- Negative for leukocytosis, or fever
- Think cholelithiasis, nephrolithiasis
Describe inflammatory abdominal pain (visceral)
- Constant pain where patient can’t get into a comfy position.
- Positive for leukocytosis and fever
- Think cholecystitis, pyelonephritis
Describe abdominal pain due to perforation (visceral)
- Patient appears sick as shit, pain is constant and patient remains motionless
- X-ray will be concerning for free air
- Think PUD, Cancer, penetrating trauma
Describe ischemic abdominal pain (visceral)
- Pain out of proportion to appearance, bloody bowel movements
- S/s of sepsis
- Think CAD, Afib, Mesenteric ischemia
