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Surgery > Surgery - Cardiopulmonary > Flashcards

Surgery - Cardiopulmonary Flashcards

1
Q

S/p CABG a few days

+ fever, tachy, CP, leukocytosis, purulent wound discharge

A

Acute mediastinitis
- complication of cardiac surgery

Need drainage/debridement + prolonged abx

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2
Q

What post op days is atelectasis most common?

A

day 2 and 3

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3
Q

Preventing atelectasis…

A

pain control
deep breathing exercises
early mobilization
incentive spirometry

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4
Q

Reason for atelectasis post-op

A

Pain and changes in lung compliance post op can cause impaired cough and shallow breathing

Shallow breaths:
decrease recruitment of alveoli at lung bases

Weak cough:
causes small airway mucous plugging

Results in hypoxia –> increase RR –> blow off CO2

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5
Q

How do you get hematuria with AAA?

A

hematuria in AA rupture –> aortocaval fistula w/ IVC –> venous congesion in retroperiteoneal structures (eg bladder) –> fragile and distended veins in bladder can rupture –> gross hematuria

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6
Q

Which diaphragm is more prone to injury?

A

Left

  • congenital weakness in diaphragm’s left posterolateral region
  • also liver protective effects on R side

Can have late presentation of diaphragm injury

Use CT to diagnose diaphragmatic injury

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7
Q

How much circulating blood vol can a hemithorax hold?

How much blood is a massive hemothorax?

A

50% of circulating blood vol

Massive > 1.5 L

Will have FLAT NECK VEINS

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8
Q

Characteristics of hemothorax

A

tracheal deviation
Reduced breath sounds
dullness to percussion over involved side
flat neck veins (if hypovolemic)

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9
Q

Takotsubo’s cardiomyopathy

A

is a type of non-ischaemic cardiomyopathy in which there is a sudden temporary weakening of the myocardium (the muscle of the heart). Because this weakening can be triggered by emotional stress, such as the death of a loved one, a break-up, or constant anxiety, it is also known as broken heart syndrome

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10
Q

What kind of heart attack is perioperative MI?

A

NSTEMI

O2 demand > delivery

Will have increased HR w/ pain, anxiety and also increased contractility –> need more O2 demand but not enough delivery

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11
Q

How do you handle MI sx post-op?

A

EKG before, 1 day post op, 2 day post op, 7 day post op

Troponins day 1, 2, 7

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12
Q

How can you try and ppx against NSTEMI peri-op?

A

+ Beta blocker

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13
Q

How do you avoid pulm complications post-op?

A

Incentive spirometer before and after surgery

DO NOT need PFTs

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14
Q

Cardiac cath MAJOR complications

A

MDS

MI
Death
Stroke/TIA

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15
Q

Cardiac cath MINOR complications

A

CHHAAP

Contrast allergy
Hemostasis @ access site
Hematoma formation (retroperitoneal)
AV fistula
Arterial thrombosis
AKI
Pseudoaneurysm
Perforation of heart or great vessels
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16
Q

Which bronchus is more commonly injured w/ tracheobronchial perforation 2/2 to blunt thoracic trauma?

A

Right main bronchus

Confirm w/ CT scan or surgical exploration

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17
Q

Pneumomediastinum causes

A

Tracheal rupture

Esophageal rupture

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18
Q

ARDS vs. pulmonary contusion

A

Pulmonary contusion usually within first 24 hrs

ARDS usually 24-48 hrs from trauma
- also, b/l lung involvement usually

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19
Q

Tension pnsumothorax

A

Life threatening

Air w/in pleural space displacing mediastinal structures
- air can enter pleural space but cannot excape naturally

Findings:

  • SOB
  • tachycardia
  • tachypnea
  • HYPOtn
  • distension of neck veins (b/c SVC compression)

1/4 of these in hospital caused by placement of subclavian central venous catheters

Tx: needle thoracostomy + emergency tube thoracostomy

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20
Q

When ok to give heparin for aortic dissection?

A

DO NOT GIVE if it’s ruptured

Give if not ruptured

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21
Q

How high can diaphragm be?

A

4th thoracic dermatome on R

5th thoracic dermatome on L (nipples)

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22
Q

Cx negative infective endocarditis

A

HACEK

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
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23
Q

UTI associated endocarditis

A

Enterococci (esp fecalis)

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24
Q

How much blood needed to cause sudden rise in intrapericardial pressure that compresses cardiac chambers and compromises both venous return and CO?

A

100-200mL

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25
Q

Respiratory quotient

  • what is it?
  • different values = what?
A

= Steady state CO2 produced : O2 consumed / unit time

Can be used to make assessments of metabolism in particular organs or in body as whole

RQ = 1 = carbs major nutrient oxidized
RW = 0.8 = protein metabolism only
RW = 0.7 = fatty acid metabolism only
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26
Q

Ppx for bacterial endocarditis for these procedures:

  • dental/oral
  • GI/GU
A

Dental/oral/resp/esoph: - give 1 hr before procedure

  • amoxicillin
  • clindamycin / cephalosporin / clarithromycin

GI/GU high risk

  • ampicillin + gentamicin before and after
  • vanco + gentamicin before ONLY

GI/GU mod risk

  • amoxicillin / ampicillin before ONLY
  • Vanco before ONLY
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27
Q

Cardiac index =

A

CO / body surface area

CO = SV x HR

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28
Q

What does PCWP via swann ganz catheter represent?

A

L atrial P
L ventricular EDP

Pulm vasc disease can increase PCWP independent of LAP or LVEDP

Mitral stenosis and regug increase LAP and PCWP and falsely elevated LVEDP in swann ganz catheter reading

PEEP/CAP can alter PCWP on SG catheter

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29
Q

Tx gastric aspiration into tracheal tree

A

Tracheal intubation and suctioning

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30
Q

Tracheostomy - tips

A

Trachea should be entered at 2nd or 3rd cartilaginous ring

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31
Q

Central venous pressure

  • increasors
  • decreasors
A

Increase

  • vasoconstrictor
  • PEEP
  • mediastinal compression
  • hypervolemia
  • acute PE (RV overload –> increase RAP0

Decrease
- sepsis

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32
Q

1st branch of ascending aorta

A

Coronary A

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33
Q

1st branch off internal carotid A

A

Ophthalmic A

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34
Q

Internal and external carotid relationship

A

Internal carotid is always posterior

Internal carotid is lower resistance b/c it perfuses the brain

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35
Q

A-a gradient

A

= PAO2 - PaO2

PAO2 = 150 - PaCO2 / 0.8

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36
Q

Tx hemothorax

A

Chest tube

Don’t need surgery to stop bleeding usually - will stop by itself if it is the lung bleeding

Need thoracotomy if systemic vessel (intercostal A) is bleeding

Surgery if:

  • > 1500 mL blood when chest tube put in
  • > 600 mL blood / 6 hrs with CT
37
Q

Danger of pulmonary contusion and how that plays for tx

A

Very sensitive to fluid overload

Tx = fluid restriction + diuretics

Can happen from flail chest

38
Q

Tx myocardial contusion

A

Troponins are specific - get when sternal fracture

Tx focuses on complications (like arrhythmias)

39
Q

Ddx subQ emphysema

A

Rupture of trachea
Rupture of esophagus (usually w/ endoscopy or vomiting)
Tension pneumo

40
Q

Sudden death in chest trauma pt who is intubated + on respirator

Tx?

Prevent?

A

Air embolism

also happens when subclavian opened to air (eg central line placement, supraclavicular node bx)

Tx:
- cardiac massage w/ pt L side down

Prevent:
- Trendenlenburg if putting in central line

41
Q

Vascular ring

A

congenital defect in which there is an abnormal formation of the aorta and/or its surrounding blood vessels.

The trachea and esophagus are completely encircled and sometimes compressed by a “ring” formed by these vessels, which can lead to breathing and digestive difficulties.

42
Q

1d old child w/ cyanosis - what do they have? What do you do next? what keeps them alive?

A

Transposition of great vessels

Echo next

ASD, VSD, or PDA keeps them alive

43
Q

When do you do a valve replacement for aortic stenosis?

A

Gradient > 50 mm Hg

1st indication of CHF, angina or syncope

44
Q

Repair for chronic vs acute aortic regurg?

A

Chronic - repair when see signs of LV dilatation

Acute - immediate repair! Long term abx needed. Usually 2/2 endocarditis via drugs

45
Q

What’s the best surgery for mitral regurg?

A

Valve annuloplasty (preferred over prosthetic replacement)

46
Q

CAD intervention indication?

A

If >=1 vessles have > 70% stenosis and the distal vessel is still ok
–> do angioplasty + stent

Triple vessel disease - best to use bypass via internal mammary

47
Q

Post op care of cardiac pt - if the CO is low, what do you do next?

A

Find out the PCWP

If it is low, then need more IVF
If it is high, then you have ventricular failure

48
Q

1st thing you do after pt has a coin lesion on CXR?

A

Find old xray and compare to see if it was there before, got bigger, etc

49
Q

Tx central vs peripheral lung cancer.

Indications?

A

Central = pneumectomy

Peripheral = lobectomy

A minimum of FEV1 = 800 mL is needed post op. Tx w/ chemo and radiation if pt is not a surgical candidate

50
Q

Subclavian steal syndrome

  • pathophys
  • signs
  • dx
  • tx
A

Arteriosclerosis plaque at origin of subclavian (before vertebrals branch off) lets arm have enough blood at rest but not w/ activity

Arm will try to steal enough to meet higher demands
–> arm will steal blood from brain by reversing flow in vertebral

Signs:

  • claudication of arm
  • posterior neuro signs (visual sx, equilibrium problems) when arm exercised

Dx:
Duplex scanning when it shows reversal of flow

Tx:
Bypass

51
Q

When repair AAA?

A

> 5-6 cm –> elective repair

If grow 1cm/year or faster –> elective repair

Tender AAA (impending rupture)

Back pain in AAA pt (aneurysm is already leaking, rupture is imminent)

52
Q

Best way to dx thoracic aortic dissection

A

spiral CT scan

Will have wide mediastinum on CXR

Manage ascending surgically
Descending –> medically w/ HTN control in ICU

53
Q

Pulmonary contusion

A

Can be caused by severe blunt chest trauma

Dyspnea
Tachypnea
Chest pain
Hypoxemia WORSENED by intravascular volume explansion

Patchy, irregular alveolar infiltrates in CXR

54
Q

Square root sign

A

Constrictive pericarditis

Equalization of pressures in RA, RV, LA, LV

55
Q

The deep sulcus sign

A

is when one costophrenic angle appears much ‘deeper’ and more lucent than the other. Additionally, that hemidiaphragm or the adjacent cardiac border may appear much crisper (clearly defined) than the other. It can be confirmed by performing a decubitus film on which air should ascend to the abnormal side.

When a patient is supine, the air rises to the highest part of the thorax, namely the anterior costophrenic sulcus. Instead of seeing the typical lucency around the lung apex, as with an upright CXR, you see it at the base.

56
Q

Pt has a fall and suspected rib fx. What imaging do you get?

A

You can just get CXR to r/o any hemithorax, pneumothorax.

You will most likely know it is rib fx so no need for imaging

ONly get rib fractures in:

  • children w/ suspected hcild abuse + possible posterior rib fx
  • patients w/ cancer
57
Q

Pneumomediastinum causes

A

Spontaneous - usually young, fit, skinny men

Related to high inspiratory or expiratory pressures - asthma, intubated patients (often with high PEEP settings such as acute respiratory distress syndrome)

Secondary to a pneumothorax or pneumoperitoneum (e.g. laparoscopy)

Secondary to esophageal perforation (vomiting, instrumentation, tumor)

Traumatic from a tracheal or bronchial rupture

Complication of free basing cocaine

58
Q

Coin lesions on CXR in lung common in…

A

areas where fungal disease is prevalent

Coccidio, histo

59
Q

CXR has coin lesion - what is next step?

A

CT

  • defines lesion
  • examines if lymph nodes present

Needle aspiration w/ CT

60
Q

If CT guided needle aspiration of coin lesion is malignant or indeterminate on needle bx, what do you do?

What is complicatino of needle bx

A

Resection

complication - PTX

61
Q

Use of the following in examining lung lesions:

  • bronchoscopy
  • mediastinoscopy
A

Bronch = obtain tissue diagnosis and determine location of lesion

Mediastinoscopy = determines state of mediastinal lymph nodes

62
Q

Tx small cell carcinoma of lung

A

Chemo b/c usually systemic spread

63
Q

Most common non-small cell carcinomas

Tx

A

adenocarcionma
SCC

Stage 1 + 2:
Should resect + radiation + chemo
 - exploratory thoracotomy
- lobectomy OR
- pneumonectomy (removal of all of lung)

Stage 3
- chemo + radiation

64
Q

How can you assess percentage of functioning lung tissue pre-pneumectomy?

How about mechanics of respiration?

A

Percentage - V/Q perfusion scan

Mechanics - spirometry

65
Q

Suspect pancoast tumor - workup?

A

CT
Bronchoscopy
Mediastinoscopy
Needle bx of mass

66
Q

Pancoast tumor

A

lung cancer in extreme apex of lung in the groove produced by subclavian artery

Invades:

  • chest wall
  • lower cords of brachial plexus
  • subclavian A
  • sympathetic ganglia

Results:

  • brachial plexopathy
  • horner’s syndrome
67
Q

Tx pancoast tumor

A

Irradiation for 6 weeks
Surgical resection of invlved chest wall and lung

Pts usually do pretty well

68
Q

Bronchial adenomas

A

Types:

  • carcionid tumor
  • adenocystic carcionmas

Can be malignant!
Often cause atelectasis b/c blcok bronchus

Bronch for definitive diagnosis

Tx: lobectomy

69
Q

Pleural effusion in older person - work up?

A

Thoracentesis + pleural bx

Suspicious for malignancy/mesothelioma!

70
Q

Tx mesothelioma

A

Very bad prognosis

Extrapleural pneumonectomy

71
Q

What does it mean when you see air bubbles in the water or PleurVac fo PTX?

A

There is still an air leak in the patient / the patient still has air in his pleura.

72
Q

Tx spontaneous ptx

A

Thorascopic excision of blebs adn pleural abrasion (pleurodesis)

73
Q

Tx empyema

A

Abx
Evacuate pus via cehst tube drainage - otherwise risk empyema to become loculated and thoracotomy and decortication is needed to reexpand lung
Reexpand lung

74
Q

Iatrogenic causes of afib

A

hypokalemia

fluid overload

75
Q

esophageal cancer tx

  • cervical +upper 1/3
  • middle 1/3
  • distal 1/3
A

Cervical - chemo + radiation, resection

Middle - chemo + radiation, resection

Distal - esophagectomy + proximal gastrectomy

76
Q

Why would someone with suspected esophageal cancer cough constantly?

A

Could be 2/2 to chronic aspiration from tracheoesophageal fistula b/c tumor erodes into trachea

77
Q

Anterior mediastinum masses

A

Teratoma
Thymoma
Thyroid cancer
Hodgkin’s lymphoma

78
Q

Middle mediastinum masses

A 
Lymphatic tumors
Various cysts (Bronchiogenic)
79
Q

Posterior mediastinum masses

A 
Neurogenic tumos (from nerves and nerve sheaths in the area)
- ex: neurilemoma
80
Q

Who benefits the most from CABG?

A

3 vessel disease + reduced EF

81
Q

Best gract patency rate for CABG

A

Internal mammary A graf

82
Q

1st step in management for massive hemoptysis

A

Worry about asphyxiation, not exsanguination

Patent airway asap!

Bronchoscopy is initial procedure b/c can localize bleeding site

83
Q

Pt w/ recent MI –> EKG later on shows persisten ST elevation and deep Q waves in same leads

SOB – what happened?

A

LV aneurysm

84
Q

Systolic diastolic abdominal bruit + HTN + atherosclerosis - what is it?

A

Renal artery stenosis

NOT ab aorta aneurysm (would maybe have systolic bruit, but not systolic, diastolic)

85
Q

Tx symptomatic sinus bradycardia

A

IV atropine + transcutaneous pacing

86
Q

Pneumonitis (patchy diffuse infiltrates) + colitis in post-bone marrow transplant pt - what is organism?

A

CMV

Diarrhea suggests CMV! Can be P jiroveci but does not cause diarrhea

87
Q

Dx pericardial tamponade

A

US

88
Q

Tx torsades de pointes

A

Stop offending agents

+ Mg SO4

Surgery (12 decks)

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