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Surgery Flashcards

1
Q

Pre-op Assessment

A

Cardioresp function: CXR, ECG/echo, PFT, exercise
bloods: FBC, UE, BM, XM/GS
MRSA/infection screen, current illness
DH and allergies, esp. steroids
PMH and comorbidities, pregnancy!
previous anaesthesia, intubation (neck, teeth)
special tests (e.g. bowel prep)

cannula, VTE PPx, drug chart, consent, marked, NBM

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2
Q

Vascular Imaging/Ix

A

Doppler: venous reflux, pulses (triple), ABPI
Duplex: doppler + flow direction
CT/MR angiography: non-fempop

ABPI: lying; highest arm + highest foor (each leg); 0.8/0.6/0.3
Beurger’s: reactive hyperaemia; 25 = CLI, 45 = severe
Allens: pre-ABG
Tourniquet/Trendelenburg: venous incompetence (from above)

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3
Q

SSI risk

A

Clean (hernia): not entering viscus/cavity; no ABx needed

Clean-contaminated (lap chole/appe): elective viscus/cavity; ?ABx

Contaminated (intestinal spillage/inflamm): contaminated but not infected; ?ABx

Dirty (abscess, peritonitis): active infection; ABx

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4
Q

Post-op review

A

End of the bed: well = read notes first
R/V notes: test results, fluids/tubes/drains, NEWS, meds

Hx: operation, symptoms, E+D, BO/wind, mobilise, ICE/Qs
Ex: AtoE, vitals, fluid status (incl. IV, catheter, drains), chest2, abdo, wound, legs
*wound: dressing (?leak), pain, ?infection, d/c
*drains: location, working, fluid type, volume

document: ID, summary (op, days), latest results, SOAP, sign
* plan: Ix, Tx, other (TTO, chase, d/w etc.)

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5
Q

Amputation

A 
gangrene/CLI
severe infection
massive trauma
malignancy
intractable pain/malformation

toes/transmeta/transmall (Syme’s)/transtib/throughknee/transfem

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6
Q

HTN stages

A

stage I: >140/90 (135/85 ABPM)
stage II: >160/100 (150/95)
stage III: >180/110

isolated systolic:
grade I: 140-159 (DBP <90)
grade II: >160 (DBP <90)

Malignant/accel: >200/120 + retinal hge
*headache, SOB, palp, CP, PVD, LOC

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7
Q

Secondary HTN (5%)

A

renovascular disease: RAAS; surgery
Renal disease: PCKD, DM, GN, pyelo
Coarctation: proximal HTN; rad-fem delay, CXR
Endocrine: Phaeo, Conn’s, Cushing’s, hyperPTH, acro, thy
Neurogenic (ICP)
drugs: OCP, alc, CST, NSAID, ADD, MAOI
pregnancy/pre-eclampsia

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8
Q

HTN complications

A

CVS: CAD/IHD, PVD, AAA, dissection, HF
Brain: ICH, CVA, vasc. dementia
Renal: sclerosis, nephritic, nephrotic, CKD
eyes: silver-wiring, AV nipping, hge/CWS, papilloedema

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9
Q

HTN Ix

A

first line: diagnose, ?2nd, damage/risk

UA, MSU, FBC, U&E, LFT, Ca, lipids, glucose, CXR and ECG

second line (<45yo - ?2nd)
abdo US, 24h catechole, renin, cortisol, aldosterone, echo, MRA (?coarctation)
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10
Q

HTN Mx

A

treat if stage III, high CV risk, vascular disease, organ damage

lifestyle + RF: incl. DM and lipids, antiplatelet

A/C rules: A/C, A+C, A+C+D, ACD +other

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11
Q

Primary Cardiac Prevention

A

lifestyle: weight, diet, exercise, alc, smoke

regular risk review for >40yo
QRISK: DM, HTN, BMI, demo, chole, PMH/FH, smoking

atorvastatin 20mg if >10% risk, or DMT1, or CKD

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12
Q

Secondary Cardiac Prevention (in PVD)

A

lifestyle and DM
anti-plt: aspirin
anti-lipids: statin (atorva 80)
anti-HTN: ACEI (caution in PVD)

*statin: LFTs (3x)/CK (5x) + Sx = stop + restart lower

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13
Q

Hyperlipidaemia

A

primary: apoproteins/enzymes
secondary: DM, obesity, alc, nephro/nephritic, hypothy

VLDL/TAG: atheroma risk
apolipoA: IHD/CVD

Statins (aim <4-5, LDL <3), fibrates (ppar-a; TAG), ezetimide (absorption)

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14
Q

Statins

A

anti-thrombo, anti-inflam
stabilise plaques
reduced cholesterol
take ON

SE: myalgia, abdo pain, LFTs, CK, rhabdo

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15
Q

Atherosclerotic Aneurysm

A

> 150% normal diameter (>4cm aorta)

RF: age, male, FHx, CTD, athero, mycotic, injury, Takayasu aortitis

sites: abdo, asc/arch, cerebral, mycotic wall (Any)
effect: mass effect (pain, Fx), rupture, thrombosis/emboli

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16
Q

True vs. false aneurysm

A

true: all wall layers; sacular/fusiform;
* aorta > iliac > popliteal > femoral > thoracic

false/pseudo: surrounding tissue; trauma + pulsing haematoma
*firm, enlarged, pulseless vessel

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17
Q 
AAA presentation
(always rule out if abdo pain)
A

infra > juxta or suprarenal

aSx until expanding/leaking/rupture
epigastric/back/groin pain
pulsatile expansile mass
HD instability, anaemia, haematemesis
trash feet: dusky toes (emboli)
sudden death
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18
Q

Popliteal aneurysm

A

present in 40% of AAA; also check femoral
pulsatile fossa mass

acute ischaemia (T/E clot), chronic isch (thrombus),
‘DVT’/compression (swelling, cyanosis)
rupture (pain, swelling, ischaemia)

Mx: thrombolysis + surgery

19
Q

thoracic aneurysm pathology

A

intimal tear; false lumen between media/intima

external rupture: lower aorta; fatal haemothorax
retrograde spread to heart: pericardial rupture - tamponade
internal rupture: double channelled aorta (rare)

RF: HTN, pregnancy, degeneration, atheroma, FHx, Marfan’s/ED

20
Q

Thoracic aneurysm: presentation

A

severe central CP, ‘tearing’
radiates to back/arms
can mimic MI

shock, unequal arm pulse/BP
neurology: brain/SC e.g. CVA
AKI, MI, fistulae,
acute ischaemia: lower limb, visceral

21
Q

Thoracic aneurysm management

A

CXR: wide m’stinum/knuckle
MRI: gold standard
TOE/CT: confirms Dx
ECG: rule out MI

XM 10U + urgent cardiothoracic consult
permissive hypotension (100-110 SBP) - labetalol
type A: surgery (stent/replace)
type B: medical unless comlpications
22
Q

EVAR vs. open

A 
mortality: 1.7% vs. 5%
shorter stay: 2-4 vs. 7-10 days
ITU less likely
more expensive
anatomy important: 15cm normal infrarenal
more f/u: CT and USS lifelong
re-intervention likely: endo leak

*open F/u: d/c at 3/12, re-scan at 5-7y

23
Q

PAD - Fontaine classification

A

1) aSx
2) intermittent claudication
3) rest pain:
a/b: ankle >/<50mmHg
c/d: DM, ankle >/<30mmHg
4) CLI: tissue damage (gangrene, ulceration)

24
Q

PAD - Rutherford classification

A

0) aSx
1) mild IC
2) mod IC
3) severe IC
4) rest pain
5) ulceration (toes only)
6) severe ulceration/gangrene

25
Intermittent Claudication
common, progression unlikely angina of the legs; consistent distance Leriche: ileal aa; erectile dysfunction + thigh/buttock pain calf = fempop; thigh = iliac DDx: spinal claudication, OA, neuropathy, venous claudication, aneurysm, pop aa entrapment *pulses*
26
Buerger's disease
lifestyle/other RF (e.g. DM) antiplatelets (all), ACEI (HTN), statins (all), ?iloprost Percut Transluminal Angioplasty (PTA) Bypass/reconstruction Amputation (pain, gangrene, sepsis)
27
Rest pain (vs. neuropathic)
burning pain at night (lying down), gravity eases forefoot; cold, pale, and pulseless neuro: red, warm, pulses; glove/stocking, paraesthesia hyperalgesia, allodynia
28
PAD signs | +RF for progression
absent pulses, postural colour change cold white legs, atrophic skin, hair loss painful 'punched-out' ulcers Buerger's angle <20 + reactive hyperaemia CRT >15s 6Ps if acute; may have bruit RF: smoking, DM, HTN, lipids, FHx
29
Gangrene DM vs. non-DM
drys vs. wet vs. gas (clostridium) sensation, contracture, hge, focal gangrene DM: wet more likely; single toes/heels (smaller aa)
30
PAD - Mx
FBC, U&E, CRP/ESR, lipids, ECG, clotting + G&S (arteriography) ABPI, arteriography (e.g. duplex) lifestyle/other RF (e.g. DM) antiplatelets (all), ACEI (HTN), statins (all), ?iloprost Percut Transluminal Angioplasty (PTA) Bypass/reconstruction Amputation (pain, gangrene, sepsis)
31
Mesenteric ischaemia
arterial/venous/trauma/vasculitis/strangulation ACUTE TRIAD: pain, shock, no abdo signs chronic: atheroma + low flow CHRONIC TRIAD: pain (post-prandial), weight loss, bruit/N&V ischaemic colitis: chronic IMA; LIF pain +/- bloody dd; 'thumb print' enema
32
Ulcers
arterial: painfull, small and deep, dry, ABPI, pulseless * toes, heel, foot, lateral, tibia venous: painless, large and shallow, wet, pulses * medial malleolus; NOT foot/leg neuro: painless, pressure areas, pulses, wet, deep * other: vasculitic, SCD, infection, cancer, pyoderma, trauma (pressure ulcers)
33
Acute PAD (6Ps)
RF: dehydration, hypoTN, posture, cancer, hypervisc, IVDU, thrombophilia aetio: thrombo, embo, iatro (graft), trauma, dissection, pop aneurysm thrombo: Virchow's, acute-on-chronic, abn pulses, bruit, calcified embo: AF/AAA thrombus; acute, normal pulses, no PMH
34
Acute PAD: Mx
non-viable: stained, blanches, rigor mortis *amputate threatened: anaesthesia, passive pain/calf squeeze * revasc <6h: embolectomy, tPa, amputation non-threatened: normal fx *RF/meds + LMWH + semi-elective revasc
35
Raynauds Syndrome (secondary)
CTD: SSc, mixed, SLE, Sjogrens, myositis CVD: atheroma, Buerger's, thoracic outlet occupational: vibration, chemical, cold, compression drugs: cytotoxic, BB, ergotamine other: Ca/paraneo; causalgia, livedo 3 phases (white, blue, red) reperfusion pain/burn/numb severe: infarction and emboli Ix: FBC, U&E, PT/APTT, glucose, TFT, specials Tx: warm, smoking, nifedipine, ARB/AB/SSRI/iloprost
36
thoracic outlet syndrome (TOO)
cervical rib, clav#, muscle, fibrous bands neuro T1 root: hand mm + inner arm sensory arterial: claudication, aneurysm, emboli/ischaemia Ix: BP (lower), arteriography, CXR (rib), bruit
37
Varicose veins
1: DTSI (deep to superfical incompetence) 2: obstruction (DVT), inflam/destruction (AVF), RF: standing, pregnancy, obesity, FHx, OCP ache, worse on ex, pain, eczema, thrombophleb ('cords'), ulcers decreased capps, increased wcc trapping and fibrin
38
Venous disease - VVV LAPS
``` varicose veins: great/small saph venous stars/spider veins venous ulcers lipodermatosclerosis, eczema, atrophy blanches, haemosiderin pitting oedema and skin thickening scars/fibrosis - champagne legs ```
39
venous Ix
doppler: flow direction; DTSI at SFJ/Pop fossa * compression = upflow, release stops (compentent valve) duplex: direction + anatomy; blue forward, red reflux/back trendelenburg/tourniquet: SLR to empty veins, tourniquet, test refilling *fillinf from above = incompetent, below = problem lower down
40
venous ulcer Mx
nutrition and RF compression bandages (ABPI >0.8) * I: 'tired legs', mild VV/oedema * II: severe VV/oedema, prevent ulcers * III: ulcers, 'itis', lymphoedema cellulitis: ABx, debride, soak, cressing
41
varicose veins Mx (pain, bleed, ulcer, thrombopleb, QoL)
education, weight, exercise, support/bandage endovascular surgery: RFA, endovenous ablation/coag, injection sclerotherapy open: ligation, avulsion, stripping post-op: tight bandages + 24h elevation, then reg walking
42
Lymphoedema
swelling, non-pitting, cobblestone skin primary: young, inherited secondary: obstruction (Ca, post-op), tumour, RDT (fibrosis), injury/inflam Mx: compression, massage, ABx (cellulitis), avoid surgery
43
Arterial Injury Sx
pulsatile bleed, bruit/thrill, distal ischaemia, haematoma Ix: doppler, angio, ABPI, visualistion (theatre) beware reperfusion injury/compartment syndrome
44
Arterial Injury types
dissection, aneurysm (T/F), transection, AVF transection Mx: pressure + gauze; image + repair (may need graft) AVF: trauma, erosion, or iatro (dialysis); heavy + pain support stocking, sclerotherapy, surgery (embolise)

Key Points (20 decks)

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