Surgery Flashcards
Pre-op, peri-op, post-op care Nutrition and Fluids management. Surgical emergencies
What are the 6 Ps of Acute Limb Ischaemia?
- Pain
- Pulseless
- Pallor
- Perishingly cold
- Parasthesia (which supersedes pain)
- Paralysis
N.o. 5,6 distinguish it from partial limb ischaemia (which can be treated medically first. Complete ischaemia needs revascularisation within 6 hours.
What is reperfusion injury?
Tissue damage as a result of reperfusion (vs ischaemia), due to production of free radicals
Complications of reperfusion (other than reperfusion injury)?
Reperfusion washes out byproducts of anaerobic metabolism - e.g. lactic acid - and cell lysis - e.g. K+, myoglobin. This can cause arrythmias, ARDS and acute renal failure (see below)
Cardiac arrythmias - because metabolic acidosis and hyperkalaemia
Acute renal failure: Rhabdomyolysis -> myoglobin -> acute tubular necrosis
Acute respiratory distress syndrome
Compartment syndrome - increased cap permeability + oedema = muscle swelling. Fascia restrict -> muscle necrosis. Treat with fasciotomy.
Open # Rx
6 A’s
1) Analgesia - M+M
2) Assess NV status, soft tissue, photo. Likely high energy injury, consider [head] CT.
3) Antisepsis - Wound swab, saline sterile gauze to cover
4) Alignment - reduce/splint. Reassess N+V, imaging - orthogonal, + joint above/below.
5) Antitetanus status
6) Abx - Co-amoxiclav
In theatre, debride, clean with wash-out and fixate externally.
When swelling reduced, fixate internally
Complication of an open #
Clostridium perfringens - gas gangrene + Sepsis
Debridement
Clindamycin
Open fractures are associated with high rates of morbidity and mortality
The most common fractures that are open are tibial, phalangeal, forearm, ankle, and metacarpal
Check the overlying area for skin breakdown or tissue loss
All patients with open fractures need antibiotic cover and up-to-date tetanus vaccination
Timely surgical management, with input from plastic and vascular surgery as required, will ensure optimal outcomes
Classification of an open #
Gustillo-Anderson
- <1 cm and clean
- 1-10cm and clean
3a. >10cm but high energy, but soft tissue coverage (Ortho can manage)
3b. ^ but not adequate soft tissue coverage (Need plastics)
3c. All injuries with vascular injury (Need Vascular team as well).
What is compartment syndrome?
inc. pressure in a fascial compartment
due to oedema/bleeding
can lead to muscle necrosis
Rhabdomyolysis -> Acute Tubular Necrosis
Symptoms of Compartment syndrome
Pain - even passive stretch
Parasthesia
Why is it important to remove pus from septic joint?
Pus - neutrophils
Destroy cartilage
Arthritis don’t want
Why intracapsular # matter?
Callus formation in joint not ideal
post-trauma arthritis
Types
Transverse
Oblique
Spiral
Comminuted
Avulsion
Don’t aspirate prosthetic knee joint that looks septic
no idea why
How to distinguish between transient synovitis vs septic arthritis
Kocher’s criteria
Non WB
Febrile
ESR raised >40
WBC raised >12000
Chorda equina red flags
Back pain
Saddle anaesthesia
Faecal incontinence/loss of anal tone
Urinary retention and subsequent stress incontinence
Shoulder trauma types
# Clavicle, prox humeral/humeral shaft # Dislocations - humeral and AC joint
Clavicle important points
FOOSH. Middle 3rd common site. Rx: Broad arm sling 3 weeks
Humeral shaft
Usually FOOSH, oblique and displaced….
Worry about radial nerve damage.
Rx: Collar/cuff
Definition of open #
A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.
Painful arch
Subacromial impingement syndrome refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
Presents with progressive pain in the anterior superior shoulder, typically worsening by abduction and relieved by rest
Diagnosis is a clinical one however MRI imaging can be useful to confirm the diagnosis and assess for further complications of the condition
Mainstay of management is conservative, with limited evidence advocating surgical intervention
Olecranon
Fractures of the olecranon process are relatively common fractures of the upper limb
Will often follow falling on an outstretched hand, with tenderness over the posterior aspect of the elbow and a potential palpable defect
Lateral and AP radiographs remain the mainstay of initial investigations
Management can be either operative or non-operative, heavily influenced by degree of displacement
What leads to mal/non-union
Fragments may have moved Soft tissue got in the way Too much movement Poor blood supply Infection
Rx Compartment Syndrome
Remove all bandages/splints
Lie limb flat (don’t elevate as decreases blood flow)
Monitor pressure in compartment using cathether - if difference between diastolic pressure and osteofacial compartment is less than 30mmHg, immediate decompression.
If you don’t have ^ equipment, then monitor symptoms after removal of bandaging, and if not improved 2 hours, immediate decompression
Fasciotomy. Open and leave for 2 days.
If muscle necrosis, debride
If none, then suture/skin graft
How long does it take for ischaemia to kill off muscle tissue?
4-6 hours
Why can compartment syndrome lead to renal problems?
Muscle death
Rhabdomyolysis
Acute Tubular Necrosis
Proximal humeral #
What nerve are you worried about?
TWO - Radial and (more commonly) Axillary
The axillary nerve is most commonly damaged by trauma to the shoulder or proximal humerus – such as a fracture of the humerus surgical neck.
Motor functions: Paralysis of the deltoid and teres minor muscles. This renders the patient unable to abduct the affected limb.
Sensory functions: The upper lateral cutaneous nerve of arm will be affected, resulting in loss of sensation over the regimental badge area.
Characteristic clinical signs: In long standing cases, the paralysed deltoid muscle rapidly atrophies, and the greater tuberosity can be palpated in that area.
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The radial nerve can be damaged in the axilla region by a dislocation at the shoulder joint, or a fracture of the proximal humerus. Occasionally, it is injured via excessive pressure on the nerve within the axilla (e.g. a badly fitting crutch).
Motor functions – the triceps brachii and muscles in posterior compartment are affected. The patient is unable to extend at the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.
Sensory functions – all four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior arm, posterior forearm, and dorsal surface of the lateral three and a half digits.
Complications of #s
CNS ‘n’ VIV
Compartment Syndrome Nerve damage Sores - pressure and plaster Non-union Vascular injury Infection Visceral injury
Rx of anteromedial shoulder dislocation
! Axillary N injury
Analgesia Assess Radiograph Reduce Reassess Radiograph
Reduction is either traction/countertraction or modified kocker’s (ext. rota, adducted)
What are the types of non-union, and what can be done to treat?
Hypertrophic - Bone ends enlarged, so osteogenesis IS taking place, but not enough.
Functional bracing, Pulsed EM fields, Pulsed USS to stimulate along with rigid fixation
OR
Atrophic - Bone ends rounded and sclerosis present. No more osteogenesis will take place without intervention. Need to excise fibrous tissue and sclerotic edge of the bone + bone graft.
Clostridium perfringens infection symptoms
Pain
Brown discharge
Tachycardia
SMELL
Rx: Fluid resuscitation, decompress wound/debride
+/- hyperbaric O2 chambers
At what point after a fracture and delayed reunion would you intervene ?
If there is point tenderness and pain after 6months, internal fixation and bone grafts
Methods to immobilise #s
External and Internal. Non-op and Op.
External - Splints (relieve pain + prevent further damage); Slings/Collar and cuff; Casts, Traction (gravity, skin, skeletal); cast bracing (plaster cast on thigh and calf, joined by brace). Operative external: Ring fixators for tibia.
Internal - ORIF: Plates and screws (articular/comminuted); IM nails (#s of long bones - femur, tibia, humerus); K-wires (foot, wrist, hand #s)
How do bones heal?
1) Inflammatory phase
2) Reparative phase
3) Remodelling
Torn tissue + blood vessels = haematoma. Lack of blood supply so bone regresses a bit.
Inflammation + soft callus (temporary join + stability, we don’t want this in joints (!) and fixation reduces the need for a callous).
Consolidation: Soft callus becomes woven bone and is mineralised. This is then replaced with lamellar bone.
Over time this is remodelled.
Osteoarthritis ttmt
Advice, Exercise, Weight loss, pain relief
1st line: Paracetamol/topical NSAID
2nd Line: Weak opioid
3rd line: Oral NSAIDs + PPi
4th line: Corticosteriod IA
Surgery
Locking/poor QoL - TKR, THR
Septic Arthritis organisms
Staph aureus/Strep epid (prosthetics)
Prosthetics
Inarticular injection - e.g. for OA
IVDUs
UTIs
Septic Arthritis diagnosis
Kocker's Criteria Fever Non-weightbearing ESR WBC
Septic Arthritis rx
Aspirate under USS - mcs, polarised light microscopy, WCC, gram stain
blood culture
blood test - esr, wcc, crp, lfts, electrolytes
x-ray
Pseudogout
Positively bifringent
Crystals
Calcium pyrophosphate
Gout
Negatively bifringent needles
Sodium monourate
Septic Arthritis Abx
6 week initially IV Flucloxacillin, then oral
Spondyloarthropathies
PAIR
Psoriatic
Enteropathic
Ankylosing spondylitis
Reactive arthritis
Ank Spond
NSAIDs
Reactive Arthritis
Strep A
Chlamydia
Salmonella, shigella, campylobacter
Reiter’s syndrome - conjunctivitis, urethritis, and arthritis
Can’t see, can’t pee, can’t bend your knee
Reactive Arthritis rx
NSAIDs
Gout causes
Monoarthritis
Diuretics Alcohol Starvation Surgery Infection Trauma
Gout ttmt
NSAIDs
if contraindicated: colchicine
Steroids
Wait two weeks, then give Allopurinol - inhibits xanthine oxidase.
!Caution! Azathioprine interacts because xanthine oxidase is involved in breaking down azathi. Reduce dose.
Gout ttmt
NSAIDs
if contraindicated: colchicine
if not getting better
Steroids
Wait two weeks, then give Allopurinol - inhibits xanthine oxidase. Titrate to urate levels.
!Caution! Azathioprine interacts because xanthine oxidase is involved in breaking down azathi. Reduce dose.
Gout extraarticular manifestations
Tophi
Pseudogout - calcinosis in tendons in x-ray
Rest, Icepacks, NSAIDs, Colchizine
Kocher’s criteria for septic arthritis
Non wb
temp 38.5
ESR>40
WBC>12000
Risks of surgery
Bleeding, infection, DVT/PE, anaesthetic risks, damage to nerves/muscles
Where does crohn’s start?
Terminal ileum
Where does ulcerative colitis start?
Rectum
Which has skip lesions Crohns or UC?
Crohn’s
Crohn’s - how deep does it go ?
Transmural - therefore fistulas
Types of fistulas in Crohns
Colovesical
Enterocutaneous
Colovaginal
Defnition of fistulas, strictures, adhesions
fistula = abnormal connection between two epithelial surfaces
stricture = abnormal luminal narrowing
adhesions =
Crypt abscesses are a feature of…
Ulcerative colitis
UC hx
most common manifestation of ulcerative colitis is proctitis, whereby the inflammation is confined to the rectum. Patients will complain of PR bleeding and mucus discharge, increased frequency, urgency of defecation, and tenesmus.
Test to differentiate IBS from IBD
Faecal calprotein
Tests if someone presents with IBD symptoms
Routine bloods* (FBC, U&Es, CRP, LFTs, and clotting) are required to examine for anaemia, low albumin (secondary to malabsorption), and raised CRP and WCC.
In the UK, NICE guidelines recommend that faecal calprotectin testing is carried out in patents with recent onset lower gastrointestinal symptoms; it is raised in inflammatory bowel disease, but unchanged in irritable bowel syndrome. A stool sample should be sent for microscopy and culture.
*Liver function tests may become deranged in patients on medical treatment and clotting can become deranged in severe attacks due to the large inflammatory response affecting the coagulation cascade.
Extra-articular manifestations of Crohns
Musculoskeletal
Enteropathic arthritis (typically affecting sacroiliac and other large joints) or nail clubbing
Metabolic bone disease (secondary to malabsorption)
Skin
Erythema nodosum – tender red/purple subcutaneous nodules, typically found on the patient’s shins
Pyoderma gangrenosum – erythematous papules/pustules that develop into deep ulcers and can occur anywhere (yet typically affect the shins)
Eyes – Episcleritis, anterior uvetitis, or iritis
Hepatobiliary – Primary sclerosing cholangitis (more associated with UC),
cholangiocarcinoma (due to association with primary sclerosing cholangitis), and gallstones
Renal: Renal stones (reduced absorption of bile salts which leads to increased free oxalate)
Mucus in poop
suspect UC
Diarrhoea definition
> 3 loose stool/wk
Rota virus Norovirus Capylobacter Shigella Salmonella E.coli C dif
…
Diverticulosis
Diverticular disease
Diverticulitis
A diverticulum is an outpouching of the bowel wall that is composed of mucosa. The are most commonly found in the sigmoid colon yet can be present throughout the large bowel and (less commonly) small bowel.
There are three different manifestations of diverticiulum:
Diverticulosis – the presence of diverticulum
Diverticular disease – symptomatic diverticulum
Diverticulitis – inflammation of the diverticulum
Diverticulosis is present in around 50% of >50yrs and 70% of >80yrs, yet only 25% of these cases become symptomatic. The disease affects more men than women (1.6:1) and is most prevalent in developed countries.
GI Symptom red flags
ALARM
Anaemia Loss of weight Anorexia Recent onset Malaena
Achalasia
Achalasia is a serious condition that affects your esophagus. The lower esophageal sphincter (LES) is a muscular ring that closes off the esophagus from the stomach. If you have achalasia, your LES fails to open up during swallowing, which it’s supposed to do. This leads to a backup of food within your esophagus.
What neurological syndrome is associated with lower oesophagel..f.dfmlksnkfsjbgn
CREST ??
Calcinosis Raynauds Esophageal dismotiliy Schlerodactyly Telangictasia??????????????
Oropharyngeal dysphagia
Barium swallow
Endoscopy - Abx co-amox prophylaxis
Referral for OGD
New-onset dysphagia
Aged >55 years with weight loss and either upper abdominal pain, reflux, or dyspepsia
New onset dyspepsia not responding to PPI treatment
What is whipple’s procedure
Remove bile duct gallbladder
head of pancreas
duodenum
anatamose everything
rx for pancreatic ca
Hartmann’s procedure
Hartmann’s Procedure
This procedure is used in emergency bowel surgery, such as bowel obstruction or perforation. This involves a complete resection of the recto-sigmoid colon with the formation of an end-colostomy and the closure of the rectal stump.
