Surgery Flashcards
most common cause of LE edema
venous insufficiency (valvular incompetence)…NOT arterial occlusion
Sxs of arterial occlusion
6 P's of PVD: Pallor Pain Pulselessness Paresthesias Poikolothermia (cold) Paralysis
How to test for PVD?
ABI via Doppler studies: Ankle-Brachial Index:
Normal = 0.9-1.3
1.3 = calcified incompressible vessels, needs more studies
Unilateral LE edema that worsens in dependent position (moving around) and better with elevation (sleeping)
Venous insufficiency secondary to valvular incompetence
Findings suggestive of aortic injury after MVC
Widened mediastinum, left-sided hemothorax, rightward mediastinum deviation, disruption of normal aortic contour. Sxs = Anxiety, HYPERtension, TACHYcardia
Tx of aortic injury after MVC
beta-blockers (anti-hypertensive) and immediate operative repair
widened mediastinum and left-side hemothorax
Aortic injury post high force blunt trauma (MVC)
T/F: High energy, blunt, rapid deceleration injury i.e. MVC commonly results in aortic injury, which usually results in death unless contained
True
Shock characterized by:
Increased/upper normal PCWP
Cardiogenic –> Myocardial contusion
Infusion of saline increases patients PCWP, does not increase SBP. Type of shock?
Cardiogenic –> Myocardial contusion
Who gets screened for AAA?
Men 65-75 with a hx of smoking get a one time screening. Not surgically repaired until >5cm or >1cm growth/year.
common peripheral artery aneurysms
Popliteal and then femoral. Commonly associated with AAA. Cause ischemia and pain (compression of nerve)
Aortoiliac artery occlusion (Leriche syndrome) triad
- thigh/hip/buttock claudication
- impotence
- symmetric atrophy b/l LE
Hemodynamic instability/ipsilateral flank or back pain after cardiac catheterization
Retroperitoneal hematoma –> need to get a non-contrast CT abdomen/pelvis or US
*note: will have flat jugular veins (vs tamponade will have distended)
Where is ischemic colitis most likely to occur?
Watershed areas: Splenic flexure and rectosigmoid. Is Non-Occlusive, so either due to hypotension or underlying atherosclerotic disease
What is a watershed area?
area between the territory of two arteries, i.e. splenic flexure (SMA and IMA) and rectosigmoid (Sigmoid and superior rectal). This is where ischemic colitis is most likely to occur
Whats the difference between ischemic colitis and mesenteric ischemia?
Ischemic colitis: Colon. Usually occurs due to hypotension in watershed areas (splenic flexure/rectosigmoid)
Mesenteric Ischemia: Due to thromboembolic (afib) or atheroembolic (endovascular procedures) events, pain is severe but is poorly localized and OUT OF PROPORTION
Management of ischemic colitis
Occurs in watershed after hypotension or atherosclerotic disease
- immediate CT with contrast to identify need for surgical intervention –> colectomy (perf/extensive damage).
- IV fluids + ABx + Colonoscopy to confirm dx
T/F: Patient with classic signs of appendicitis (pain over McBurneys point, +Rovsing’s sign, leukocytosis and fever) needs CT before appe
False. If signs are classic then go to OR to avoid complications like perforation. Only need imaging if not convinced clinically
Patients with appendicitis for >5 days have probably developed what?
An phlegmon with an abscess that has walled off. Mnage with IV Abx, bowel rest and a delayed appendectomy weeks later
RUQ pain, fever, nausea/vomiting and gas in the gallbladder wall/crepitus
Emphysematous cholecystitis…life-threatening form of actue chole due to infection with Clostridium or e coli. Risk factors = Diabetes, vascular compromise, immunosuppression
Imaging for patient with blunt genitourinary trauma (i.e renal lac)
- All get UA
- Hematuria –> Contrast-enhanced CT (most common)
- Gross hematuria, difficulty urinating, and blood @ meatus (urethral injury)/suprapubic pain (bladder rupture) –> Retrograde Cystourethrograms (so not most common test to get)
CT scan findings in ischemic colitis
bowel wall thickening
partial vs complete SBO (imaging)
Partial: air in colon
Complete: transition point, no air in colon
colicky abdominal pain, vomiting, inability to pass flatus or stool, abdominal distension and diffuse tenderness
SBO
Mgmt of SBO (small bowel obstruction)
- Normal: Bowel rest, NG tube, correct metabolic deragnements
- Complicated (fever, hypotension/tachycardia, guarding, keukocytosis, metabolic acidosis (low bicarb): Urgent ex lap before perforation n
T/F: Atelectasis is a common post-op pulmonary complication, esp after abdominal
True…pain and changes in lung compliance can cause impaired cough and shallow breathing, limiting recruitment of alveoli @lung bases and weak cough predisposes o small-airway mucus plugging. Get hypoxia, which increase resp rate = low CO2
Why is there respiratory alkalosis during atelectasis?
Get small airway mucus plugging/shallow breathing…results in low pO2, which stimulates respiratory drive = hyperventilation = low pCO2
How do we decrease risk of atelectasis post-op?
Incentive spirometry! Also, pain control and early mobilization
T/F: We use prophylactic antibiotics to reduce risk of post-op pneumonia
- False, these are only used if pre-existing infection. -INCENTIVE SPIROMETRY = BEST
- can use deep breathing exercises, CPAP, and intermittent positive pressure breathing
define flail chest
> 3 contiguous ribs fractured in 2 or more location. Will see paradoxical chest wall motion with inspiration (i.e. moves inward) + chest pain/rapid shallow breaths
lower GI bleed + abdominal tenderness
highly suggestive of colitis (IBD, ischemic colitis, infectious diarrhea)
lower GI bleed + iron deficiency anemia
suggestive of malignancy (CRC)
left side abdominal pain and bloody diarrhea in old person with dehydration/heart failure/shock/trauma
ischemic colitis
most common cause of lower GI bleed
diverticulosis
T/F: Left colonic diverticula are more likely to be source of lower GI bleed than right
False. Most diverticula are left sided, but most that bleed are from the right side
T/F: 60% of people over 60 have diverticula
true
most common site of diverticula
95% in sigmoid colon (b/c harder stool b/c water reabsorbed and dec lumen diameter)
T/F: Diverticulosis and diverticulitis both bleed
False, typically diverticulosis bleeds.
CT scan findings of mesenteric ischemia
small bowel thickening, occlusion of SMA and gas in bowel wall (pneumatosis)
Initial steps in management of a lower GI bleed
- Place 2 large-bore IV
- send lab tests for cross and match, CBC, INR
- if sig blood loss, resusc with crystalloid and possibly PRBCs
- place NG tube (to r/o upper GI bleed…NG aspirates bile without blood)
first diagnostic step of choice in hemodynamically unstable patient with lower GI bleed (NG already done)?
- Colonoscopy done urgently w/o bowel prep (unless they can wait a day)
-if this doesnt help localize bleeding, 2 more options:
2A. Diagnostic arteriography
2B. Nuclear scintography (tagged rbc scan, nuclear med)
What are the two types of spontaneous pneumothorax?
Primary (thin young men)
Secondary (to underlying lung dz…COPD)
signs and sxs of spontaneous vs tension pneumo
Spontaneous: chest pain, dyspnea, dec breath sounds/chest movement, ipsi hyper resonance
Tension= all of that + hemodynamic instability + tracheal deviation across from normal side
management of pneumothorax
Spontaneous: Small (<2cm) = observe and O2
rest = needle aspiration or chest tube
Tension: urgent needle decompression or chest tube
where is needle placed from decompressiong a large pneumothorax?
2nd-3rd MCL or “%th interfost space
hx of blunt trauma/MVC, abnormal CXR and lower lung , mediastinal shift
diaphragmatic rupture. get a CT
NG tube in the pleural cavity
diaphragmatic hernia
blunt abdominal trauma, i.e. MVC, leading to respiratory distress and decreased breath sounds on the left side
Diaphragmatic hernia…sudden increase in intra-abdominal P leads to tear in diaphragmatic musculature…left more susceptible b/c not protected by liver…compression of lungs and mediastinal shift
T/F: Mediastinal shift and respiratory distress after MVC = pneumothorax always
False. Blunt abdominal trauma = diaphgramatic rupture = diaphragmatic hernia
Adducted and internally rotated leg following trauma suggests:
Acetabular fracture with posterior dislocation
high-riding prostate after trauma on DRE
worry about urethral/bladder injury. If blood at urethral meatus, need retrograde urethrogram, and then retrograde cystogram (esp if hematuria/not voiding)
Initial hematuria vs terminal hematuria vs total hematuria
Initial: Urethra (Urethritis, injury/trauma)
Terminal: Bladder (cystitis, urothelial cancer), Stone or Prostate (cancer or BPH)
Total: Kidney (stone, mass, GN, PKD, pyelo, cancer, trauma)
Risk of mechanical ventilation in hypovolemic shock
Already have low CVP. Vent causes increase in intrathoracic P which = collapse of venous capacitance vessels = no venous return to RA = no CO = cardiac arrest
Trauma patient with hypotension, tachycardia and tracheal deviation: decreased breath sounds, hyperresonance to percussion
Tension pneumo
Trauma patient hypotension, tachycardia and tracheal deviation: absent breath sounds, dullness to percussion
Hemothorax
T/F: All burn victims should initially get tx with high flow O2 via non-rebreather mask
True! And low threshold for intubation, because can get supraglottic airway compromise (it exchanges heat with air and susceptible to thermal injury…edema = resp block). ABCs!!
tx if you suspect tension pneumothorax
immediate needle thoracostomy in hemodynamically unstable pt (2nd intercostal space in MCL. alt: 5th intercostal in midaxillary). Followed by emergency tube thoracostomy
Rapid onset of tachycardia, hypotension, tachypnea, distention of neck veins due to compression of _____ = _____
superior vena cava. Tension pneumothorax
most common cause of urethral injury
Iatrogenic –> during abdominal surgery
T/F: Ability to pass a foley catheter makes urethral injury unlikely
True
tachypnea, tachycardia and hypoxia <24 hours after blunt trauma/MVC
Pulmonary contusion
hypoxia and CXR/CT showing patchy, alveolar infiltrate following MVC/blunt trauma with decreased breath sounds on one side
- Pulmonary contusion within 24 hours
- ARDS = complication of PC, 24-48 hour out and bilateral patchy alveolar infiltrates
Mgmt of pulmonary contusion (occurs <24 hours after trauma)
Pain control
Pulm toilet (nebs, PT)
Oxygen
Bladder injury causing chemical peritonitis (spillage of urine causing guarding/pain and referred pain to shoulder)
Bladder dome rupture!
Note: anterior bladder wall and bladder neck = extraperitoneal…usually injured from pelvic fracture…get extraperitoneal leakage of urine = localized lower abdominal pain
In the trauma setting, subcutaneous emphysema (crepitus) is caused by ________ until proven otherwise
Pneumothorax
Cushings reflex that indicates elevated ICP (3)
hypertension, bradycardia, respiratory depression
loss of pain and temp in UE following whiplash MVC
syringomyelia ( can have delayed presentation years later)
5 or 6 yo kid who is cyanotic, small for his age, clubbing
Tetralogy of Fallot
R->L shunts = cyanosis, 5 T’s…Tet is most common and children can grow into infancy
1 or 2 day old child with cyanosis who is in deep trouble
Get an ECHO…most likely Transposition of the Great Vessels. Req ASD, VSD, or PDA to survive but will die soon if not corrected.
Harsh mid-systolic murmur, angina and exertional syncope
Aortic Stenosis
Blowing, high pitched diastolic heart murmur best heard at 2nd lower LSB
Aortic Regurg
Why would a young person develop acute aortic regurg?
Drug addict gets endocarditis. Will develop CHF and new, loud diastolic murmur @ right 2nd intercostal space
Mitral stenosis is caused by:
Rheumatic fever
Sxs of mitral stenosis
Dyspnea on exertion Orthopnea PND Cough Hemoptysis Afib
First thing to do in a patient with hx of smoking that shows Coin Lesion on CXR
find an old xray to compare
most common intracranial tumor
metastatic from Lung>Breast>Melanoma
most common primary brain tumor
Gliomas and then meningiomas
most malignant brain tumor
GBM
how can you tell if a stroke/vascular problem is ischemic vs hemorrhagic
+HA: Hemorrhagic
-HA: Occlusive/Ischemic
Patient is awaiting surgical removal of brain tumor. What do you use to treat the increased ICP?
High-dose steroids (dexamethasone)
Testicular Torsion vs Acute Epididymitis: surgical emergency?
Torsion
Testicular Torsion vs Acute Epididymitis: Fever and pyuria
Epididymitis only
Testicular Torsion vs Acute Epididymitis: Tender cord
Epididymitis only
Testicular Torsion vs Acute Epididymitis: Ages
Torsion: young adolescent
Epidy: young man, sexually active age
Testicular Torsion vs Acute Epididymitis: Acute onset severe testicular pain
both!
How do you tx acute epididymitis?
First get an US to r/o testicular torsion (surg emergency). Then antibiotics
Patient is being allowed to pass ureteral stone but develops high fevers, chills and flank pain. Dx?
Obstruction and infection of the urinary tract –> Dire emergency!!!
Why is a combined obstruction and infection of the urinary tract a dire emergency?
Can lead to destruction of kidney in few hours and death from sepsis. Give IV antibiotics and immediate decompression (ureteral stent or percutaneous nephrostomy)
Urologic workup: Sonogram, CT scan, Cystoscopy. When are these used?
US: Dilation/obstruction
CT: Renal tumors
Cystoscopy: Bladder cancer
IV pyelogram is the probs wrong answer (nephrotoxic, allergic)
old man with chills, fever, dysuria, frequency, low back pain and tender prostate
Acute bacterial prostatitis. Give IV antibiotics, avoid doing any more rectal exams (sepsis risk)
who gets bladder cancer?
Smokers
