surgery- cardio + radiology Flashcards
aortic aneurysm: ___-___X measured at level of ______?
1-1.5X, at level of renal arteries
> ___cm is considered an aortic aneurysm, MC in what location?
> 3cm is an aneurysm. MC infraRenal.
connective tissue d/o (marfans, ehlers danlos) are at risk for what cardiac abnormality?
aortic aneursym and aortic dissection
what is Laplaces law?
Laplaces law: in short- larger aneurysms expand quicker and all expanding ones will eventually rupture
> ___cm increases rupture risk of aortic aneurysm?
>___cm NEEDS immediate Sx? (or expanding how quickly?)
> 5cm
5.5cm = Sx
(or >0.5cm expansion over 6 months)
MC symptom aortic aneurysm
asymptomatic till rupture
what is a chronic-contained aortic aneurysm/rupture?
uncommon, rupture may be tamponaded by surrounding retroperitoneum
what is an aortoenteric fistula?
presents as acute GI bleed in pts who underwent prior aortic grafting
Dx of aortic aneurysm? what about for monitoring expansion? what about thoracic?
Angiography is gold standard, US for monitoring expansion, CT for thoracic
Txt for aortic aneurysm/rupture
endovasc stent graft or open repair. + BBs to reduces shearing forces
aortic aneurysm: \_\_\_-\_\_\_cm: monitor by US annually \_\_\_-\_\_\_\_cm: monitor by US Q6mo >\_\_\_cm: vascular surgeon referall >\_\_\_cm: immediated Sx
3-4cm: monitor by US annually
4-4.5cm: monitor by US q6mo
>4.5cm: vasc surgeon referral
>5.5cm immediate Sx
what is an aortic dissection and what is the MC type?
tear in innermost layer of aorta (intima)
65% ascending (high mortality)
what is the MOST important risk factor for aortic dissection?
HTN
turner syndrome pts are most at risk for what cardiac abnormality?
aortic dissection
aortic aneursym vs aortic dissection presentation:
BOTH pain, hypotension
dissection- SUDDEN tearing/ripping, decr. peripheral pusles, new onset aortic regurg
Sx txt for aortic dissection is used for what types?
Sx for acute proximal (stanford A, debakey I+II), or acute distal (type III) w/ complications.
conservative txt for aortic dissection is used for what types? what is the target BP and HR to acheive w/in ___min?
for descending and NO complications (stanford B/debakey III) = esmolol, labetolol.
Target SBP 100-120 mmHg and pulse <60bpm within 20min.
mesenteric ischemia is MC at what location?
splenic flexure b/c least collateral blood supply
MC cause of mesenteric ischemia
sudden decr blood supply to bowel:
MC from occlusion (embolus, thrombus). Nonocclusive (shock- decr blood, cocaine,)
severe abd pain out of proportion to PE. N/V/diarrhea, peritonitis - what is a likely cardiovascular cause?
mesenteric ischemia
Txt for mesenteric ischemia
bowel rest (chronic), both - Sx revascularization (angioplasty w/ stenting or bypass), bowel resection if not salvageable
colonoscopy of chronic mesenteric ischemia shows what?
muscle atrophy w/ loss of villi
S+S chronic mesenteric ischemia
chronic, dull abd pain worse after meals. Intestinal angina, weight loss anorexia
what is carotid Dz?
when fat deposits (plague) clog the carotids → stroke
after lifestyle changes, BP and statins, what is the Txt for carotid Dz?
Sx- carotid endarterectomy (removal of plaques), or if unable to reach the plaque - Carotid angioplasty/stenting (balloon + mesh stent)
pericardial tamponade - pathophys?
pericardial effusion causing significant strain on heart → restriction of ventricular filling → decreased cardiac output.
pericardial tamponade acute vs chronic ?
Acute: small, rapidly developing effusions can cause tamponade
Chronic: (i.e. CA), pericardium can stretch to accommodate 1 L without hemodynamic compromise.
3 characteristic S+S of pericardial tamponade
Becks Triad- distant/muffled heart sounds, incr JVP, systemic hypotension. + pulsus parodoxus
what is pulsus parodoxus?
(>10mmHg decrease in systolic BP and decreased pulses with inspiration) [incr right heart filling = decr left heart filling].
echocardiogram = effusion + diastolic collapse of cardiac chambers
pericardial tamponade
MC symptom of peripheral arterial Dz?
intermittent claudication
intermittent claudication of aortic bifurcation / common iliac causes what symptoms?
buttock/hip/groin.
Leriche’s syndrome (triad claudication- butt/thigh pain, impotence, decr femoral pulses)
intermittent claudication of femoral and popliteal arteries causes pain where?
femoral: thigh/upper calf
popliteal: lower calf/ankle/foot
+ ABI for peripheral arterial Dz is what? what is normal?
+ if <0.9. Normal ABI is 1-1.2)
if plt inhibitors dont help intermittent claudication from PAD, what is a Sx txt?
Revascularization: percutaneous transluminal angioplasty. Bypass grafts (fem-pop bypass), endarterectomy
prostate cancer symptoms
asymptomatic till bladder invasion, urethral obstruction or bone involvement.
txt for prostate cancer
local dz = active surveillance/observation if low grade. → radical prostatectomy
Advanced dz: external beam radiation therapy, androgen deprivation (orchioectomy/GnRH agonists). Chemotherapy. If bone/other METS = localized radiation/cryotherapy.
MC type of prostate CA, most important risk factor
adenocarcinoma. Most important risk factor - age >40yo,
MC location for breast CA? MC places for METs?
upper outer quadrant, METS to lung, liver, bone, brain.
what is paget’s dz and peau d’orange?
paget’s disease (scaly nipple), peau d’orange (lymphatic obstruction, poor prognosis)
neoadjuvant endocrine therapy for breast CA: 3 med types
Neoadjucant endocrine therapy (hormone) if CA is estrogen receptor positive or progesterone receptor positive, HER2 positive
- anti-estrogen (tamoxifen), aromatase inhibitors, monoclonal Ab txt
mammogram screening guidelines
ACS: >45yo annually, >55yo Q2yrs. ACOG: >40yo annually, USPTF: >50 Q 2yrs, of >40 if risk factors, 10yrs prior to age of 1st degree relative.
MC type of breast CA
infiltrative ductal carcinoma or lobular carcinoma
when should self breast exam be done?
after menstruation or on days 5-7 of cycle. (least hormone influence)
preventative meds for breast CA
SERM - tamoxifen or raloxifene in post-menopausal women (or those >35yo with high risk). Or aromatase inhibitors
symptoms of thyroid CA
MC -euthyroid (asymptomatic), thyroid nodule- rapid growth, fixed, no movement with swallowing, difficulty swallowing/hoarseness.
besides subtotal or total thyroidectomy, what txts are there for thyroid CA?
+/- radioiodine therapy +/- thyroid suppression drugs
how long do you monitor for residual cells after thyroidectomy? how do you do this?
. Monitor Thyroglobulin levels 6mo after for residual cells. (give recombinant TSH and check levels)
MC type of thyroid CA
papillary (least aggressive)
S+S colon CA right vs left sided
Right-sided: lesions bleed- anemia/fecal occult blood, diarrhea
Left-sided: bowel obstruction, changes in stool diameter, hematochezia
txt for colon cancer, what stages require surgical resection vs chemo?
stage I-III = surgical resection. Stage III-metastatic = chemo (5FU)
colon cancer screening: Avg risk vs 1st degree relative >60yo, vs first degree relative <60yo
Avg risk: fecal occult annually @50yo, colonoscopyQ 10yrs or flex sigmoid Q5yrs
1st degree relative >60yo: fecal occult annually @40yo, colonoscopy Q10yrs
1st degree relative <60yo: fecal occult annually @40yo (or 10yrs b4 dx), colonoscopy Q 5yrs
colon CA: MC type and MC area of METS
adenocarcinoma . MC METS to liver
MC cause of CA deaths is what type of CA ?
lung
what is trousseau’s syndrome?
recurrent thrombophlebitis - sign of malignancy
what are the two types of nonsmall cell lung cancer? is nonsmall or small/oat cell more aggressive?
nonsmall (adenocarcinoma, squamous cell, large anaplastic)
small/oat cell (aggressive)
txt for lung CA nonsmall vs small cell?
nonsmall : surgical resection
small: chemo/radiation
preventative screening for lung CA
CT annually for smoking w/in 15yrs and 55-80yo
MC type lung CA?
nonsmall- adenocarcinoma
5 METS “signs” of gastric cancer?
supraclavicular node (virchows), umbilical node (sister mary josephs), ovarian (krukenburg), rectal (Blumer’s shelf), left axillary lymph (irish sign)
adenocarcinoma is the MC type of all cancers besides which two?
breast and thyroid
when is surgical resection an option for liver CA txt?
if confined to a lobe and not assoc. w/ cirrhosis
preventative screening for liver CA
US q 6months in someone with cirrhosis.
MC type of live CA
usually METS from other cancer, primary liver neoplasm = hepatocellular carcinoma
courvoiser’s sign
: palpable nontender distended gallbladder assoc with jaundice (common bile duct obstruction). - occurs in pancreatic CA
Sx txt for pancreatic cancer, what if its the tail only?
whipple: radical pancreatic/duodenal resection (done if CA is confined to head or duodenal area)
Tail: distal resection
txt for advanced/inoperative pancreatic CA
ERCP w/ stent placement as palliative txt for intractable itching
MC type of pancreatic CA. what are the 3 most important risk factors?
adenocarcinoma - ductal. Most important risk factor (in order) - smoking, age, chronic pancreatitis
radiology- what imaging studies are contraindicated for pregnancy?
absolute: IVP, MRI, nuclear bone scan
relative: Xray, CT, colonoscopy
what are relative contraindications to contrast CT?
renal impairment, hyperthyroidism, pheochromocytoma, myasthenia gravis
indication for HIDA scan
problems of liver, gallbladder and bial ducts. (radioactive tracer into vein)
Tests function of hepatocytes, patency, and integrity of the biliary ducts, gallbladder contractility, and sphincter of Oddi function.
what are the limitations of a HIDA scan?
falsely positive when the gallbladder is not filling in the absence of cholecystitis. (severe liver disease,total parenteral nutrition, hyperbilirubinemia, inadequate fasting, and alcohol and opiate abuse.
what are the indications for ERCP? ( endoscopic retrograde cholangiopancreatography)
treat stones, tumors or narrowed areas of the bile ducts
amylase or lipase more specific?
lipase
braided absorbable vs monofilament absorbable
braided: vicryl
monofilament: monocryl, chromic gut
non-abs sutures: braided vs monofilament
braided: ethibond, silk
monofilament: ethilon
what is the most important predictor of postop complication?
Surgical site is most important predictor. (aortic, thoracic and upper abdominal)
post-op wound infection is w/in ___days of surgery. what are the bugs and drugs?
30 days
staph , strep, pseudomonas
Cefazolin, vancomycin, IV FQs
causes of post-op fever: 5 Ws
wind (PNA, sinusitis)
wound (surgical incision, decubitus ulcers, lines)
walk (DVT, PE)
water (UTI, prostatitis, epididymitis)
wonder drugs (drug fever- abx, malignant hyperthermia, neuroleptic malignant syndrome)
fever __-___days postop is MOST likely an infection
5-30
general anesthesia: inhalation vs Total IV anesthetics
Inhalational Anesthetics – aka volatile anesthetics (Sevoflurane, Isoflurane, Desflurane, Nitrous Oxide*)
TIVA – Propofol, Dexmetatomadine, Remifentanyl
three classes of thyromental distance for airway assessment
class A (maui), B (jaw lines up), C (kerin)
what causes malignant hyperthermia and what are the effects from it?
Paralytics and Volatile Agents are the triggers → Hypermetabolic Crisis
- Elevated temp is a late sign!
- HUGE influx of Calcium!
reversal agents for malignant hyperthermia: anticholinesterase (aka cholinergic) + anticholinergic
Neostigmine – anticholinesterase; reversal of NMB with glyco
Glycopyrolate – anticholinergic;
what is the earliest, most specific and sensitive finding for malignant hyperthermia
incr end tidal CO2
txt protocol for malignant hyperthermia
Txt: STOP volatile agent, flood with oxygen, cool down . Administer Dantrolene-Sodium (or Ryanodex)
