Surgery Flashcards
Management of increased ICP due to acute subdural hematoma (7)
- ICP monitoring***
- elevate head
- hyperventilate
- avoid fluid overload
- mannitol or furosemide
- sedation
- hypothermia
tx of rib fracture
**esp impt in elderly
local nerve block + epidural catheter
pulmonary contusion on CXR
white out of lungs
gunshot wound to abdomen management
exploratory laporatomy
management of intraoperative development of coagulopathy
platelet packs + FFP
**if hypothermia and meta acid –> stop laparotomy
penetrating injury of extremities management
** determine if vascular injury based on anatomic location
if no –> tetanus prophylaxis + cleaning
if yes and asym–> Doppler/CT angio +/- surgery
if yes and sx –> surgery
circumferential burns
** edema can cutoff blood supply
tx + escharotomies
GI fistula
if all contents don’t leak outside, can cause sepsis
if draining freely with no fever or peritoneal irritation, can cause 1) fluid and lytes loss, 2) nutritional depletion, 3) erosion/digestion of belly wall **worse the higher the fistula is in GI tract
Tx = fluid/lyte replacement, nutritional support, protect abdominal wall (with suction, ostomy)
Nature will heal the fistula if no FETID (foreign body, epithelialization, tumor, infection/ irradiated tissue/IBD, distal obstruction
int vs ext hemorrhoids
internal - bleed, tx = rubber band ligation (if prolapsed can become itchy and painful)
external - painful, tx = conservative or surgery
workup of SCC of HEENT mucosa
triple (pan) endoscopy to look for primary
biopsy establishes dx
NO open biopsy
acute epididymitis
men old enough to be sexually active
severe sudden onset testicular pain + fever + pyuria
testis is swollen and tender, in normal position, cord is tender
tx = abx (US to rule out testicular torsion)
uretopelvic junction obstrtuction
normal urine flow is fine, but with large diuresis (e.g. after beer binge) the area is too narrow –> colicky flank pain
testicular cancer workup
biopsy with radical orchiectomy
preop serum markers: alpha fetoprotein, beta HCG
platinum based chemo *very radio and chemo sensitive
scaphoid fracture
fall on outstretched hand
wrist pain + tenderness over snuffbox
initial xrays negative but postive 3 weeks later
tx = thumb spica cast (ORIF if displaced)
wound dehiscence
~POD 5
wound looks intact, but there is large amounts of pink/salmon colored fluid soaking dressings (peritoneal fluid)
tx = securely tape and bound abdomen, re-operation for closure
SCC of anus
HIV+, receptive anal sex
fun gating mass grows out of anus, +/- metastatic LNs
Dx = biopsy
Tx = nigro chemoradiation +/- surgery
tx of resectable breast cancer
if small lesion and away from nipple/areola –> lumpectomy + rad
if large tumor or laying below nipple/areola –> mastectomy
chronic constrictive pericarditis
exertion dyspnea + hepatomegaly + ascites
cardiac Cath shows square root sign and equalization of pressures
tx = surgical
morton neuroma
inflammation of common digital nerve of the third interspace between 3rd and 4th toes
palpable tender spot
common cause is pointed high heels or cowboy boots
tx = analgesics, better shoes, +/- surgical excision
zero urinary output?
usually mechanical prob - kicked or blocked catheter
correcting hypernatremia
start with D51/2NS
every 3 meq/L that Na is above 140 equals 1.L of fluid lost
anal fissure
young women with super painful, blood streaked stools
fear of pain causes constipation
exam under anesthesia
cause = tight sphincter
tx = stool softeners, topical nitroglycerin, botox, forceful dilatation, lateral internal spincterectomy , diltiazem ointment
obstructive jaundice caused by tumor
thin walled dilated gallbladder
CA: pancreas head adenocarcinoma, ampulla of vatar adenocarcinoma (jaundice + anemia + occult blood in stool), cholangiocarcinoma
do CT scan then ERCP if necessary, endoscopy of ampullary suspected
full blown renal cell CA
hematuria + flank pain + flank mass
hypercalcemia, erythrocytosis, elevated LFTs
workup = CT –> heterogenic solid tumor (can grow into renal vein or vena cava
tx = surgery
transitional cell cancer of the bladder
*smokers hematuria, irritated voiding dx = CT, cystoscopy tx = surgery, intravesical BCG high rate of local recurrence *lifelong F/U
topicals for burns
silver sulfadiazine
mafenide acetate for deep penetrations (thick eschar, cartilage)
triple abx cream for burns near eye
obstruction AND infection of urinary tract
emergency!! can lead to kidney death, sepsis, death within hours
can happen while someones waits to spontaneously pass ureteral stone
tx = IV abx, immediate decompression of urinary tract (ureteral stent or percutaneous nephrostomy)
Ogilvie syndrome
paralytic ileus of the colon seen in elderly sedentary patients that are further immobilized because of surgery elsewhere
large abdominal distention (tense, not tender), massively dilated colon
tx = fluid and late correction, colonoscopy to suck out air/decompression, place long rectal tube
primary peritonitis
classic: child with ascites and nephrosis or adult with ascites and mild generalized abdomen
+/- fever, leukocytosis
tx = abx
diagnostic and therapeutic enema for meconium ileum
gastrogaffin
management of arterial embolization of extremitiy
doppler to locate site of obstruction
incomplete obstruction –> clot busters
complete –> embolectomy w/ Fogarty catheter (+ fasciotomy if several hrs pass before revascularization)
brachial cleft cyst vs cystic hygroma
brachial cleft cyst: anterior edge of SCM, several cm +/- opening and blind tract
cystic hygroma: base of neck, large and mushy ill defined mass, occupies entire supraclavicular area and extend deeper into chest *CT before surgical removal
penetrating neck trauma
upper zone gunshot: arteriogram
GSW at base of neck: arteriogram + esphagogram + esophagoscopy + bronchoscopy before surgery
surgical exploration if expanding hematoma, deteriorating vital signs, clear signs of esophageal or tracheal injury
dx of intraabdominal bleeding
stable –> CT
unstable –> FAST exam
tx of acute organ rejection
steroid bolus 1st line
antithymocyte serum
anti lymphocyte agents (OKT3) have high toxicity
leg ulcers
-diabetic vs arterial insufficiency vs venous stasis vs marjolin ulcer
diabetic ulcer: pressure points
art insufficiency: tips of toes (as far from heart as possible), look dirty, no granulation tissue, pt with other CAD signs, workup = doppler, angio
venous stasis: chronic edema, indurated and hyperpigmented skin above medial malleolus, painless with granulating bed, varicose veins and cellulitis bouts, workup = duplex scan
marjolin ulcer: SCC develops in chronic leg ulcer *untreated 3rd degree burns or chronic draining sinuses from osteomyelitis, dirty looking deeper ulcer develops with heaped up tissue growth around the edges, biopsy, wide local excision and grafting
