Surgery Flashcards
If O2 sats are below 90, do
ABG
Normal bicarb =
24
Cardiac output =
Stroke volume x Heart rate
Stroke volume =
End Diastolic Volume - End Systolic Volume
Total peripheral resistance =
Mean arterial pressure - Mean venous pressure
Blood pressure =
Cardiac Output x Total Peripheral Resistance
Immediately perform __ in pericardial tamponade
pericardiocentesis
In preparation for immediate exploratory laparotomy, do a bunch of things simultaneously:
2 large bore IV lines Type and cross Give fluids and blood Insert foley Administer IV antibiotics
Surgery is always done for ___ head injuries, even if the patient is asymptomatic!
comminuted or depressed skull fracture
All patients with open skull fractures should receive
tetanus toxoid and prophylactic antibiotics
Management of basal skull fracture =
CT scan of head/nec
CSF leak sill stop by itself
Facial palsy may occur 2-3 days later
All epidermal hematomas require
emergency craniotomy
Epidural hematoma = injury to
middle meningeal artery
Subdural hematoma = injury to
bridging veins
Only do an emergency craniotomy in case of subdural hematoma if
there are lateralizing signs and midline displacement
Surgery cannot help in this head injury that is caused by acceleration-deceleration injuries to the head
diffuse axonal injury
Gradual dilatation of one pupil and a decreasing responsiveness to light is an important sign of
elevating intracranial pressure
DO NOT EVER DO THIS
perform an LP before getting a head CT. If you perform a lumbar puncture on a person with increased intracranial pressure, you will HERNIATE THE BRAIN, KILL THE PATIENT, GET CHLAMYDIA AND DIE.
Hyperventilation causes vaso___ and decreased blood volume in the brain, causing ICP to ___
constriction; lower ICP
First line measures for high ICP are
elevated head of bed
hyperventilation
avoid fluid overload
second line: mannitol, sedation/hypothermia
Anisocoria =
unequal size of pupils
When is surgery the answer for acute abdomen?
Peritonitis
Abdominal pain/tenderness plus sepsis signs
Pneumoperitoneum
Acute intestinal ischemia
rule out pancreatitis first
Treatment for spontaneous bacterial peritonitis is
immediate paracentesis; diagnosis is made when fluid contains neutrophils greater than 250 cells per cubed mm
Treat SBP with
ceftriaxone and albumin at 1.5g/kg on day 1 and day 3 of hospitalization
First study of choice for esophageal perforation is
gastrografin contrast esophagram
Most accurate test for adult with GI obstruction is
CT scan of abdomen and pelvis with contrast
When diagnosing acute diverticulitis, don’t forget to order
a pregnancy test in women of reproductive age!
___ is absolutely contraindicated in acute diverticulitis
Colonoscopy
When palpation of the LLQ causes pain n the RLQ, think
acute appendicitis (Rovsing’s sign)
It’s important to administer ___ before appendectomy
IV antibiotics:
- cipro and metronidazole
- ampicillin/sulbactam
- levofloxacin and clinda
- cefoxitin or cefotetan
If chronic UC has been present for more than 20 years, ___ is indicated
elective surgery
also if high dose chronic steroids are needed or toxic megacolon is present
What three major GI arteries arising from the abd aorta supply the gut?
celiac axis, the SMA, and the IMA
SMA is most commonly affected by ischemia
The best initial and most accurate test for ischemic colitis is
CT abdomen showing thickening of the bowel in a segmental pattern
Therapy for ischemia colitis
IV fluid hydration and bowel rest
In chronic mesenteric ischemia, ___ is both therapeutic and diagnostic
computed tomography angiography
Development of symptoms (postprandial abd pain, unrelenting nausea, anorexia, weight loss) after a recent dramatic weight loss
Median Arcuate Ligament Syndrome
treat by surgical decompression of the celiac artery
Always do what to an intra-abdominal abscess?
Drain it!
Which two ducts merge to form the common bile duct?
Common hepatic duct and Cystic duct
CT scan of obstructive jaundice caused by a tumor will show
double duct sign (aka simultaneous dilatation of both the common bile duct and the pancreatic duct)
Treat acute cholecystitis is
NG suction NPO IV fluids antibiotics then cholecystectomy after 6-12 weeks
Reynold’s pentad:
jaundice RUQ pain fever AMS shock
Treat acute ascending cholangitis with
IV antibiotics
Emergency decompression of the common duct
ERCP or percutaneous transhepatic cholangiogram
Surgery isn’t often necessary
The most accurate test for fecal incontinence is
anorectal manometry
Do not perform surgery in patients with multiple
derangements in hepatic risk factors
The most lethal cause of post-op disorientation if not recognized and treated early is
hypoxia, so order an ABG
The leakage of fecal, gastric, or duodenal contents to the outside opstoperatively is ___
not an indication for emergency surgery! observe stable patients
Manage malignant hyperthermia by
IV dantrolene, 100% O2, acidosis correction, cooling blankets
watching for development of myoglobinuria
Manage bacteremia and fever >104 with
blood cultures x3 and empiric abx
The most important step before surgery at birth is
check for congenital anomalies and look for VACTERL constellation
If excessive salivation or chocking spells are noted shortly after birth, it could be
esophageal atresia
What causes esophageal atresia?
Ventrally displaced location of the notochord in an embryo
Confirm diagnosis of esophageal atresia with
NG tube, which becomes coiled in the upper chest on x-ray
If anal atresia is suspected, look for
a fistula nearby; if no fistula present, perform a colostomy
The primary abnormality of congenital diaphragmatic hernia is
hypoplastic lung with fetal type circulation
Treat CDH with
endotracheal intubation
low pressure ventilation
sedation
NG suction
Where is the defect in gastroschisis?
To the right of the umbilical cord
due to failure of neural crest cells to migrate
Incomplete fusion during the fourth week of development results in
omphalocele
Which trisomies are a/w omphalocele?
Edwards syndrome and Patau syndrome
Exstrophy of the urinary bladder requires
Surgical repair in the first 1-2 days of life! Transfer to a specialized center
What can present with double bubble sign?
Annular pancreas
malrotation
duodenal atresia
Intestinal atresia is not associated with
other congenital abnormalities
A sign of sepsis in newborns is
rapidly dropping platelet count
The most common pathogens in necrotizing enterocolitis are
E. coli and Klebsiella pneumonia
Feeding intolerance + bilious vomiting + CF =
meconium ileus
In meconium ileus, ___ is both diagnostic and therapeutic
gastrografin enema
Diagnose hypertrophic pyloric stenosis with
sonogram showing target sign
Treat pyloric stenosis by
first correcting metabolic abnormalities and dehydration, then performing a pyloromyotomy
Persistent progressively increasing jaundice in 6-8 week old babies =
biliary atresia
Treat biliary atresia with
HIDA scan after 1 week of phenobarbital, then surgery if that doesn’t work
diagnose Hirschsprung Disease with
full-thickness biopsy of rectal mucosa
When does intussusception show up?
6-12 months of age, chubby healthy looking kids with brief episodes of colicky abdominal pain
Lower GI bleeding in a child of pediatric age =
Meckel diverticulum
When a fracture is suspected, order
2 views at 90 degrees to one another and always include the joints above and below the broken bone
When a fracture is displaced severely or angulated or cannot be aligned, what should you do?
Open reduction and internal fixation
When does an open fracture need to be reduced?
within 6 hours from time of injury
Neuro dysfunction, petechial rash, respiratory distress, fracture =
fat embolism
Fixing a long-bone fracture within ___ reduces the incidence of respiratory distress from embolic phenomena
24 hours
Which type of shoulder dislocation is possible in a patient with a recent seizure?
Posterior shoulder dislocations.
Otherwise, anterior shoulder dislocations are the most common
What type of xray should you order in a patient with a recent seizure and shoulder pain?
axillary or scapular views of the affected shoulder
Painful wrist + dinner fork deformity =
Colle’s fracture
Direct blow to the ulna or radius results in a combo __ and __ fracture
diaphyseal and displaced dislocation. Treat w/ ORIF
Suspected scaphoid fracture, treat w/
thumb spica cast
Treat femoral neck fractures with
femoral head replacement
Intertrochanteric fractures are treated with
open reduction and pinning
Femoral shaft fractures are treated with
intramedullary rod fixation
Posterior dislocation of the hip (knees hit dashboard in MVA) =
orthopedic emergency! Leg is internally rotated and shortened
Symptoms caused by tapping the nerve over the flexor retinaculum and awaiting parasthesias =
Tinel’s sign for CTS
Flexing the wrist gently and holding the position =
Phalen’s test for CTS
Signs of a __ injury include inability to dorsiflex (extend) the wrist
oblique distal humerus, complicated by radial nerve paralysis
The most important intervention for a urologic obstruction is
a ureteral stent or percutaneous nephrostomy
A child who has hematuria from a trivial trauma has ___ until proven otherwise
undiagnosed congenital urologic anomaly
A teenager drinks large volumes of beer and develops colicky flank pain
Ureteropelvic Junction Obstruction
-only symptomatic with diuretics
Treat subclavian steal syndrome with
bypass surgery
Classic symptoms of subclavian steal syndrome are
visual symptoms, equilibrium problems, and claudication in the arm during arm exercises
