Surgery - Misc (Trauma, Vascular, MS, Repro, Renal) Flashcards
1
Q
Meniscal injuries
- most common when?
- signs/symptoms
- physical exam
- diagnosis?
A
Most often in pts in 30s-40s
Happens when performing activities needing axial loading and rotation
Classic:
- pt feels a pop followed by pain
- joint swelling following 12-24 hrs
PE:
- joint line tenderness
- decreased ROM
- McMurray’s test
MRI to dx
2
Q
Meniscal vs. ligamentous injuries
A
Meniscal injuries joint swelling over 12-24 hrs
Ligamentous injuries are REALLY RAPID swelling b/c hemarthrosis
- ligaments have more blood supply than menisci
- ex: ACL tear
3
Q
Patellar tendonitis
A
From chronic overuse (like strenuous athletic activities)
Point tenderness over proximal patellar tendon
4
Q
Anserine bursitis
A
Anserine bursa = under conjoined tendons of gracilis and semitendinosus muscles
- separates theses muscles from head of tibia
Bursitis –> tenderness over MEDIAL knee
- usually in atheletes and obese middle age –> elderly women
5
Q
Penile fracture
- what happens?
- treatment?
A
Tearing of tunica albuginea which invests the corpus cavernosum
Hematoma rapidly forms at site of injury –> bends shaft of penis at fracture site
Tx:
- emergent urethrogram to look for urethral injury
- then emergent surgery to evacuate hematoma and mend torn albuginea
6
Q
Organs lacerated in blunt abdominal trauma
A
- spleen
2. liver
7
Q
How to evaluate blunt ab trauma
A
Hemodynamilcaly unstable + unresponsive to fluids –> exlap
Responds to fluids: CT scan is next best step
- assess for intraperitoneal free fluid or hemorrhage
- use US
+ eval pericardium = focused assessment w/ sonography for trauma (FAST) exam - Exploratory laprotomy if diagnostic peritoneal lavage or FAST is +
OR
- Ab CT to see if need ex lap if hemodynamically stable and (-) FAST
8
Q
Focused assessment w/ Sonography for trauma (FAST) exam
A
US to detect free intraperitoneal fluid + evaluate pericardium
High sensitivity + specificity to detect hemoperitoneum, pericardial effusion, intraperitoneal fluid
9
Q
Sepsis
A
Response to an infection
= SIRS w/ known infection
10
Q
Systemic inflammatory response syndrome (SIRS)
A
Response to NONinfectious cause
Need at least 2/4 criteria
Temp > 101.3 or < 95
Pulse > 90
Respiration > 90
WBC > 12,000, < 4000, or > 10% bands
11
Q
Major cause of morbidity and mortality in patients w/ total body surface burns?
A
Hypovolemic shock
Usually 2/2 sepsis and septic shock
12
Q
Who do you use the following for?
- orotracheal intubation
- laryngeal mask placement
- nasotracheal intubation
- needle cricothyroidotomy
A
OT intubation = unstable, apneic pts
Laryngeal mask = temporary if OT intubation fails and need to figure out what to do next
NT intubation = blind procedure, pt needs to be breathing SPONTANEOUSLY
Needle CT = good for children in field. Not for adults b/c risk CO2 retention
13
Q
+ psoas sign
no guarding, rigidity, rebound
What could be likely?
A
Psoas abscess
- usually staph aureus
from furuncles on leg, heme spread of bacteria, etc
Not appendicitis b/c - guarding, rigidity, rebound
CT scan to confirm
14
Q
Steps in diagnosing peripheral artery disease
A
Usually due to atherosclerosis
1 is normal
1) Ankle-brachial index via Doppler
- ratio < 0.9 (nl = 1-1.3) is very sensitive and specific for > 50% occlusion in major vessel
2) If normal ABI…
- Exercise test w/ repeat ABI
15
Q
Tx peripheral artery disease
A
Aspirin + cilostazol
Verapamil can improve walking distance but change ABI
Tight glucose control doesn’t have significant impact on PAD
16
Q
Most important goal in management of rib fracture?
A
Ensure proper analgesia
Rib fracture very painful and may cause hypoventilation —> atelectasis or pneumonia
Can use
- NSAIDs
- opaiates
- intercostal nerve block (some risk pneumothorax)
DO NOT NEED TO DO MECH STABILIZATION OF CHEST WALL
17
Q
Acute febrile nonhemolytic transfusion reaction
- how happen?
- tx
A
Happens after blood transfusions
Increase 1C + rigors
Ab bind donor cells –> activate complement –> release inflammatory cytokines
Tx:
- stop blood transfusion
- give antipyretics
18
Q
Thigh abduction at hip
A
Gluteus medius
Gluteus minimus
Superior gluteal N
Palsy: Trendelenburg gait
19
Q
Hip abduction (assists) Knee extension (maintains)
A
Tensor fascia lata
Iliac crest –> fascia lata
20
Q
Flex and laterally rotate thigh
A
Psoas major muscle
Transverse processes of lumbar vertebrae –> lesser trochanter of femur
21
Q
Lateral flexion of trunk
Rib cage fixation
A
Quadratus lumborum
Iliac crest –> 12th rib and transverse processes of L1-L4
22
Q
Leg extension at knee
A
Quadriceps femoris
23
Q
Hip flexor
A
Rectus femoris
24
Q
Most common cause of sepsis in splenectomy patients?
A
S. pneumo
25
If suspect child abuse...
1) Perform thorough PE + skeletal survey to document abuse
2) Report case to child protective services
3) admit pt for safety
26
How do you manage splenic trauma if patient is
- hemodynamically unstable + responds to fluids
- hemodynamically unstable + unresponsive to fluid administration?
If responds to fluids (SBP > 100
- abdmoinal CT scan
Unresponsive..
- ex lap
27
Compartment syndrome signs
Deep pain out of proportion to injury
Pulselessness
Paresthesias
Cyanosis
Pallor
PULSES present DO NOT rule out compartment syndromeage in an unstable trauma patient if FAST exam is inconclusive
28
Eschar
Firm necrotic tissue formed on exposed tissue following burn wounds
If circumferentially on extremity, can restrict outward expansion of compartment as edema builds --> vascular flow compromised --> compartment syndrome
Need to do escharotomy
Also do escharotomy if muscle compartment pressure > 30 mmHg
29
Abdominal bleeding - diagnostics?
Hemodynamically stable --> abdominal CT
Hemodynamically unstable --> FAST US, then DPL
30
Rupture of tendon of long head of biceps
Biceps muscle belly becomes prominent in mid upper arm
Weakness in supination
Forearm flexion OK
31
+ drop arm sign in shoulder injury
Rotator cuff tear
32
Better to dx diffuse axonal injury
MRI
CT will show many minute punctate hemorrhages w/ blurring of grey white interface
33
Nasal septum surgery - complications
Difficult to heal b/c septum poorly perfused cartilage
Can result in septal perforation = whistling noise during repisration
34
Nasal furunculosis
From staph folliculitis
Usually after nose picking or nasal hair plucking
Can be life threatening if spreads to cavernous sinus
Pain, tenderness, erythema in nasal vestibule
35
Best for animal bites
Unasyn (ampicillin + sulbactam)
36
How are hip fractures classified?
By anatomic location and fracture type
Intracapsular
- femoral neck and head
- ----> higher chance of avascular necrosis
Extracapsular
- intertrochanteric and subtrochanteric
- -----> greater need for implant devices (eg nails and rods)
37
Risk factors for VTE
MOIST
Malignancy
Motherhood
Ortho procedures
Oral contraceptives
Immobility
Inflammation (lupus)
Surgery
Trauma
Thrombophilic disorder or previous DVT
38
Can you infuse vanco fast into blood? Why not?
NO!
Will cause thrombophlebitis
39
What to do for hydrocele in newborn?
Nothing!
Most will resolve by age of 12 months
- can be safely observed during that period
Communicating hydrocele needs surgery
40
Kehr sign
L shoulder pain referred from splenic hemorrhage irritating phrenic N and diaphragm
41
Signs of necrotizing infection
Intense pain in wound
Fever, hypotension, tachy
Decreased sensitivity at edges of wound
Cloudy-gray discharge
Tense edema outside involved skin
SubQ gas w/ crepitus
42
Acute pain
Swelling
of midline sacrococcygeal skin + subQ tissues
Infection of pilonidal cyst
Most common in young males w/ larger amts of body hair
Can spread to form abscess
Drain abscess and excise sinus tracts
43
Nerve entrapment features
Radiating pain
Not reproducible usually with palpation
44
Central cord syndrome
Classical w/ hyperextension injuries in elderly w/ degen changes in cervical spine
Selective damage to central portion of anterior spinal cord
Weakness more pronounced in upper extremities than in lower extremities
- arm motor fibers nearer to central part of corticospinal tract
45
Tx scaphoid bone fractures
If nondisplaced, wrist immobilization for 6-10 wks
If displaced (>2mm), open reduction and internal fixation
46
Most common peripheral artery aneurysms
Popliteal > femoral
47
Hemodynamically unstable victim of MVA w/ suspected blunt ab trauma (BAT), management?
C-spine immobilization
IV hydration
FAST
48
Hemodynamically stable victim of MVA w/ suspected BAT, management?
CT scan of abdomen w/ contrast
Quantify amt of blood
Surgeon selects laparotomy or admission and observation based on CT result
49
Drugs increasing cAMP
Increases heart contractility
Relaxes smooth muscle of arteries
Theophylline
PDE-3 inhibitors:
- Millrinone
- Caffeine
- cilostazol
- dipyridamole
50
Drugs increase cGMP
Hydralazine
Nitroprusside
Nitroglycerin
PDE-5 inhibitors:
Sildenafil
51
Next steps in management after a fall showing a hip fracture
1) Stabilization, treatment for pain control, DVT ppx
2) Figure out cause of fall and assess preop risk
In elderly, commonly:
- syncope (arrhythmia, valves)
- ACS
- Heart failure
- CNS pathology (TIA, stroke)
- infection (PNA)
- metabolic (Hypoglycemia)
Get:
- EKG
- trops
- CXR
52
Stasis dermatitis
| - pathology
LE venous valvular incompetence --->
Pooling of venous blood and increased P in postcapillary venules --->
Damages capillaries w/ increased P --->
Lose fluid, plasma proteins, RBC into tissue -->
RBC extravasation causes hemosidering deposition -->
get classic color of stasis dermatitis
Xerosis is most common early finding
53
Preeclampsia
Triad of
HTN
Proteinuria
Edema
54
Todd paralysis
Transient unilateral weakness after tonic-clonic seizure that usually resolves
55
What's a common physical sequelae after grand mal seizure?
Posterior dislocations of shoulder
Pt holds arm addudcted and internally rotated
56
Anterior urethra injuries
- where is the injury?
- how does it happen?
- findings
Injury to urethra distal to urogenital diaphragm
Usually due to blunt trauma to perineum (straddle injuries) OR instrumentation of urethra
Exam:
- perineal tenderness/hematoma
- normal prostate
- bleeding from urethra
Findings:
- may not complain of inability to urinate
- delayed presentation can be complicated by sepsis 2/2 to extravasation of urine into scrotum, abdominal wall
Tx:
- immediate surgical repair
57
Posterior urethra injuries
- where is the injury?
- how does it happen?
- findings
Injury to prostatic and membranous urethra
Usually assoc w/ fractures of pelvis
Exam:
- blood at urethral meatus
- high riding prostate (b/c displaced by pelvic hematoma)
- scrotal hematoma
- pelvic fracture
Findings:
- suprapubic pain
- inability to void following major trauma
Tx step 1:
- retrograde urethrogram
58
Where are most clavicular fractures?
In middle 1/3 of bone
Shoulder of affected side is displaced inferiorly and posteriorly
59
Clavicular fracture ID'd - what do next?
Careful neurovascular exam b/c clavicle close to subclavian A and brachial plexus
Angiogram if hear bruit in clavicle area
60
Fixing clavicle fractures
middle 1/3 --> nonoperative w/ brace, rest, ice
distal 1/3 --> open reduction + internal fixation
61
Thessaly test
Pain or locking w/ internal and external rotation of knee while standing on 1 leg w/ knee flexed to 20 degrees
62
McMurray test
Painful clock w/ passive flexion and extension of knee w/ examiner's thumb and index finger placed on medial and lateral joint lines
63
Apley test
Pain w/ pressing heel toward floor while internally and externally rotating foot w/ knee flexed to 90 degrees
64
What to use to dx meniscal injuries?
MRI
65
Manage traumatic spinal cord injuries
1) Hemodynamically stabilized
2) proper airway management
3) stabilize neck until spine injury r/o
4) Urinary catheter placement to assess urinary retention and prevent bladder distention and damage
66
Fat embolism signs
```
Severe respiratory distress
- increasing diffuse b/l pulm infiltrates on serial CXR
Petechial rash
Subconj hemorrhage
Tachycardia
Tachypnea
Fever
```
Dx w/ fat droplets in urine or intraarterial fat flobules on fundoscopy
Happens 12-72 hrs after fracture injrueis
67
Tx fat embolism
Respiratory support
Controversial:
- heparin
- steroids
- LMW dexxtran
68
Kidney stones in Chrons disease?
Hyperoxaluria
Usually Ca binds oxalate in gut and prevents absorption
In fat malabsorb from Crohns, Ca bound by fat and oxalate is unbound and free to absorb in blood
ALSO, failure of reabsorb bile salts can damage colonic mucosa and cause more oxalate absorption
69
What kinds of catheters have higher rate of infection?
Femoral > subclavian
Usually due to Staph but femoral catheters can also be due to Gm - bacteria
70
Dx ACL tears?
Lachman's test (like anterior drawer but 30 degree flexion)
Anterior drawer test
Pivot shift test
71
What is GCS used for?
Predicts prognosis of coma and other medical conditions (bacterial meningitis, TBI, subarachnoid hemorrahage)
NOT used to diagnose coma
72
Findings used to dx coma
Impaired brainstem activity (disruption of pupillary light, Extraocular, and corneal reflexes)
Motor dysfunction (decorticate or decerebrate posturing)
Impaired level of consciousness
73
Slipped capital femoral epiphysis
Displacement of femoral head on femoral neck b/c disrupt proximal femoral growth plate
Usually seen in obese adolescent boys
- obesity increases shear stress and physis (physical junction b/n femoral head and neck) fractures and femoral head slips POSTERIORLY + MEDIALLY relative to neck
PE
- loss of abduction and internal rotation
- + external rotation of thigh while hip flexed
Tx: surgical pinning of slipped epiphysis to lessen risks of avascular necrosis or chondrolysis
74
Most common carpal bone fracture
Scaphoid
ON radial side of wrist
Usually get max pain in anatomic snuffbox, min dec ROM, decreased grip strength, possible swelling
75
Suspected scapohid fracture but not present on xray - what do you do?
Can take up to 10 days to show abnormalities on xrays
Immobilize wrist w/ thumb spica cast for 7-10 days followed by repeating xrays
CT or MRI of wrist can distinguish b/n fracture and ligament injries
76
Needle shaped crystals on urinalysis + ileus - what do you do next/
CT scan of abdomen or intravenous pyelography
Probably have uric acid stones, not seen on xray
Ileus probably due to vagal rxn from ureteral colic - ileus over when ureterolithiasis is treated
77
Part of bladder that is covered by peritoneum and is most susceptible to rupture
Dome of bladder
Can get irritation of peritonitis and irritation of diaphragm
78
Most common site of extraperitoneal bladder rupture
Bladder neck
79
Ludwig angina
Rapidly progressive bilateral cellulitis of submandibular and sublingual spaces
Usually from infected 2nd or 3rd mandibular molar
Usually Strep and anaerobes
```
Sx:
Fever
Dysphagia
Odynophagia
Drooling
--> due to swelling of submandibular space + posterior displacement of tongue
```
COD: asphyxiation
80
How does hearing loss happen in Paget's?
Cochelar N damage
| - enlargement of temporal bone --> impinge on internal auditory meatus
81
Carcinomas that love to spread hematogenously
```
RCC
HCC
Follicular thyroid carcinoma
Choriocarcionma
Prostate adenocarcionma
```
82
Opioid agonist
Activate all 3 receptors
Fentanyl
Morphine
Hydromorphone
83
Agonist-antagonist opioids
Mixed: Butorphanol, nalbuphine, pentazocine
- block mu but activate kappa receptor
Partial: Buphenorphine
- block kappa, weak mu receptor activator
84
Antagonist opioids
Antagonist at mu receptors
Naloxone
Naltrexone
Alvimopan
Methylnatrexone
85
Cancers w/ osteolytic lesions (and hypercalcemia of malignancy as a result!)
BLT with a Kosher Pickle, Mustard & Mayo
```
B = breast cancer
L = lymphoma, lung cancer
T = thyroid cancer
K = kidney cancer
P = prostate cancer
M & M = multiple myeloma
```
86
How are opioids (morphine, hydromorphone, fentanyl) eliminated?
Renal
Hydromorphone is metabolized via glucuronidation (not lost as much w/ age) so can have inactive metabolite (vs morphine and fentanyl which are CYP metabolized so may have accumulation if CYP enzymes lost)
87
Acute limb ischemia
| - signs
- Pallor
- Paresthesias
- Pain
- Pulselessness
- Poiklothermia
- Paresis/paralysis
88
3 layers of blood vessel
Adventita
Media
Intima
Adventitia is strongest
89
Time before acute limb ischemia causes necrosis of tissue
6 hrs
90
1/2 life of heparin
90 min
91
If rutherford classification I, what do you do?
Time to work up
+ heparin ASAP
92
If rutherford classification IIa, what do you do?
still have some time but need to be quicker than I
+ heparin asap
93
If rutherford classification IIb, what do you do?
Now have only 6 hrs before necrosis of tissue
- ASAP emergency
- very acute emergency
+ heparin
94
Rutherford classification
Urgency need to tx acute limb ischemia
o I = No pulse, OK sensory and motor
o IIa = No pulse, no sensory, OK motor
o IIb = No pulse, no sensory, no motor
o III = Rigor (dead extremity)
95
If rutherford classification III, what do you do?
DO NOT reperfuse! Will get reperfusion injury from all the dead cell released products
Get an amputation
96
1st sign of compartment syndrome
paresthesia in 1st web space
- deep peroneal N innervates this and is in ANTERIOR compartment
REMEMBER: compartment syndrome is a clinical diagnosis
97
Compartment of leg most susceptible to compartment syndrome
Anterior compartment
98
Risks after vascular surgery after acute limb ischemia blood flow restoration?
Reperfusion injury
Edema
Compartment syndrome
99
Pulse volume recording
BP cuffs on whole leg (Thigh, calf, foot)
Increase cuff pressure to 60 mmHg to obstruct venous flow
Will give tracing of pulses
Height of tracing will tell you amount of blood flow going through.
Can tell you ~where obstruction is
100
What is utility of PVR?
Ex: if diabetic, can have falsely elevated ABI b/c not compressible vessels (they are calcified)
PVR will eliminate that problem with ABI
101
When do surgery on claudication of leg?
If have extreme impact on lifestyle (QOL) if there is relatively low risk
102
What are the components of a duplex ultrasound?
B mode imaging (architecture of vessels)
• Can see stenotic area
Color flow (velocities), in cm/s
• Will have increased velocity in stenotic areas
• Want to compare the increased velocity area with areas before and after – how hemodynamically unstable is this area based on how much increase in velocity?
103
Glasgow Coma Scale (GCS)
```
Eyes (4)
1 - No eye opening
2 - Eye opening in response to pain stimulus
3 - Eye opening to speech
4 - Eyes opening spontaneously
```
**if awaken sleeping pt w/ speech, this is a 4, not a 3
Motor (6)
1 - No motor response
2 - Decerebrate
3 - Decorticate
4 - Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5 - Localizes to pain.
6 - Obeys commands (thumbs up, wiggle toes)
Verbal (5)
1 - No verbal response
2 - Incomprehensible sounds. (Moaning but no words.)
3 - Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4 - Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5 - Oriented. (AAOx3)
104
Decerebrate posturing
```
extensor posturing:
abduction of arm,
external rotation of shoulder,
supination of forearm,
extension of wrist
```
105
Decorticate posturing
```
flexor posturing:
adduction of arm,
internal rotation of shoulder,
pronation of forearm,
flexion of wrist
```
106
CPP =
MAP - ICP
CPP should be > 50
If CPP too high, increase risk of HTN hemorrhage
- cerebral blood flow vs. CPP should be constant ratio
107
What happens when you have too much CO2 in brain?
Increase blood flow for O2 delivery, increase pressure in brain
108
What's the most sensitive test for weakness?
Pronator drift
Supinator muscle is smallest muscle in arm --> if have weakness, will pronate drift down
109
Hoffman's reflex
Flick middle finger, thumb will move up and down
110
How can you grossly test urinary function?
Cremasteric reflex
111
Why is blood hyperdense on CT?
Because of the iron! that's why it will become hypodense when the iron gets out of the blood in the brain on CT
112
Why is dura hyperdense on CT?
B/c it is very vascularized
113
CSF drainage path
```
Choroid plexus
Lateral ventricle
Interventricular foramen of Monro
3rd ventricle
Aqueduct of sylvius
4th ventricle
Foramen of Luschka and Magendie
Subarachnoid space around spinal cord
Arachnoid granulations
Venous sinuses
```
114
Why should you hyperventilate in brain injury?
Will decrease CO2
Brain will think it has too much blood perfusion
Will decrease arterial blood flow to brain
This will decrease ICP
115
Morton neuroma
Happens in runners
Mechanically induced neuropathic degen w/ sx of numbness, burning of toes, achin and burning in distal forefoot radiating forward from metatarsals to 3rd and 4th toes
PE
- pain b/n 3rd and 4th toes, plantar surface
- clicking sensation (mulder sign) w/ palpating space and squeezing metatarsal joints
Tx;
metatarsal support w/ padded shoe inserts
- surgery if conservative tx fails
116
Tarsal tunnel syndrome
Compression of tibial N as passes through ankle
| - caused by fracture of bones around ankle
117
Malignancy on chronically wounded, scarred or inflamed skin
Squamous cell carcionma
Is Marjolin ulcer if SCC arises in burn wounds
118
Where should central venous catheters be to avoid myocardial perf?
Tip should be proximal to cardiac silhouette
OR
Angle b/n trachae and R mainstem bronchus
Catheter should be in SVC
Always do CXR after get catheterized
119
Effect of + pressure mech ventilation
Increases Intrathoracic P -->
Inc R atrial pressure -->
Decrease systemic venous return
Can cause circulatory failure and death
120
Diffuse axonal injury
Result of traumatic acceleration/deceleration-shearing forces
Damage axons in brain
Head CT: nl or diffuse small bleeds at grey-white matter junctions
121
Leriche syndrome
Arterial occlusion @ bifurcation of aorta into common iliacs
Bilateral hip, thigh, and buttock claudication
Impotence
122
Psoas test
passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip
The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues
123
Volkmann's ischemic contracture
Final sequel of compartment syndrome
Dead muscle replaced w/ fibrous tissue
124
Causes of hypocalcemia
Hypoalbumin
HypoMg
HYPERcitrate (eg blood transfusion)
125
1st physio signs of hemorrhage
Tachycardia
Peripheral vascular constriction
126
High PTH, normal Ca --- what does person have?
Vitamin D deficiency if getting Ca supplements
127
Dx urinary stones
non-contast sprial CT of ab + pelvis
128
Most commonly injured metatarsal in hairline fractures of metatarsals
2nd
Tx: rest, analgesia, hard-soled shoe
129
Valgus vs varus
Valgus = abducion at knee
Varus = adduction at knee
130
Tx MCL tears
Surgery rarely necessary
Bracing and early ambulation preferred
131
When is brachial artery usually injured
supracondylar fracture of humerus (esp in children)
Can get ischemia - pain, pallor, pulselesness, pressure, paresthesia
132
Tx subluxation of head of radius
Extend and distract elbow
Supinate forearm
Hyperflex elbow w /thumb over radial head to feel reduction as it occurs
133
Artery of adamkieqicz spans...
T9 -T12
ASA
134
Nasopharyngeal carcinoma associations
EBV
Smoking
Chronic nitrosamine consumption
135
Legg-Calve-Perthes disease
Idiopathic avascular necrosis of femoral capital epiphysis
Usually in boys 4-10yo
```
Sx:
Unilateral subacute hip pain
Antalgic gait
thigh muscle atrophy
dec ROM
Collapse of ipsilateral femoral head on plain pelvic xrays
```
Tx:
Conservative
Observation + bracing
136
```
What are these?
abl
cmyc
bcl2
Her2/neu
ras
L--myc
N-myc
ret
c-kit
```
Oncogenes
abl = CML
cmyc = Burkitts lymphoma
bcl2 = follicular lymphoma
Her2/neu = breast, ovarian, gastric
ras = colon carcinoma
L--myc = Lung tumor
N-myc = Neuroblastoma
ret = Men 2A and 2B
c-kit = GIST
137
```
What are these?
Rb
p53
BRCA1
BRCA2
p16
BRAF
APC
WTf
NF1
NF2
DPC4
DCC
```
Tumor suppressor genes
- lose function, increase cancer risk
Rb = retinoblastoma, osteosarcoma
p53 = li-fraumeni, most human cancers
```
BRCA1 = breast + ovarian
BRCA2 = breast + ovarian
```
```
p16 = Melanoma
BRAF = Melanoma
```
APC = Colorectal cancer
WTf = Wilms Tumor
```
NF1 = NF-1
NF2 = NF-2
```
DPC4 = Pancreatic cancer
DCC = Colorectal cancer
138
Trousseau's sign
Carpal spasm
OR
Use BP cuff to cut off brachial A flow
In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm.
The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
139
Chvostek's sign
When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia with resultant hyperexcitability of nerves
Will get spasm of obicularis muscle
Can also happen w/ hypoMg
140
What do you watch out for in P vera surgical pt?
Usually are thrombocytosis but have hemorrhagic tendency b/c qualitative deficiency of platelets
Can use busulfan or chlorambucil to decrease Hct levels
141
1/2 life of FFP
4-6 hrs
b/c factor 7 is most stable 1/2 life at 4-6 hrs
142
Body water distribution
60-40-20
60% TBW
40% ICF (2/3 of TBW)
20% ECF (1/3 of TBW)
50% TBW ---> 2/3 ICF, 1/3 ECF --> 1/4 plasma volume, 3/4 interstitial volume
Plasma volume measured by albumin
Extracellular volume measured by albumin
143
Serum osmolality =
2Na +
BUN / 2.8 +
Glucose / 18
144
If you give normal saline in huge amounts for resuscitation, what can happen?
Hyperchloremic metabolic acidosis
145
What is in lactate ringers?
Less Na, Cl
BUT also has K, Ca, Bicarb
Be careful with hyperkalemia!
Good for hyperchloremic metabolic acidosis
146
```
Replacement strategies for losses in:
sweat
gastric
biliary/pancreatic
small bowel s/p NGT
colon
3rd space losses
```
```
Sweat - D5 1/2 NS + KCl
Gastric - D5 1/2 NS + KCl
Biliary/pancreatic - LR
Small bowel - LR
Colon - LR
3rd space losses - LR
```
147
Indicators of successful resuscitation
Tachy gone
UO
Clearance of lactate
Resolution of base deficit
SvO2 = 70%
- [ O2] at pulmonary A port and is most deO2 blood in body
BP IS BAD INDICATOR!
148
Major drawbacks of general anesthesia
Increase incidence of pulm complications
| Mild cardiodepression from anesthetic
149
Effect on platelets of aspirin and NSAIDs?
Aspirin = irreversible on plt aggregation for 7-10 days
NSAIDs = reversible
D/c aspirin for 7-10 days before surgery
D/c NSAIDs 2 days before surgery
150
Should hypercholesterolemia alone postpone surgery?
NO!
151
w/ PAD, how do you do a stress test?
Persantine thallium stress test
Dobutamine echo
152
BK virus
Specific to kidney transplant
"bad kidney"
In same family as JC virus
Will attack kidney
153
Does platelet transfusion in a pt w/ plt dysfunction due to uremia help?
NO!
Use
demopressin (ddAVP)
FFP
Conjugated estrogens (slower)
154
Most common physio cause of hypoxemia is
Ventillation perfusion inequality
155
What to do after hemolytic reaction caused by ABO incompatability happens?
Stop transfusion
Put in foley catheter and monitor UO hourly
Give mannitol + alkalinze urine to prevent precipitation in kidneys
Restrict fluids and K in presence of severe oliguria or anuria
156
Which anesthetic has low solubility and fills air spaces during prolonged anesthesia?
Nitrous oxide
157
Dopamine actions on receptors
Low doses --> D receptor --> increase renal flow, slight increase
Med dose --> B1 receptor --> inotropic effect on heart to increase CO and BP
High dose --> a1-receptor --> periph vasoconstriction, decreased kidney fxn, HTN
158
In blood, where is CMV?
Blood leukocytes
Blood products not routinely tested for CMV
159
Most common viral transfusion in blood transfusion?
non A non B hepatitis (usually hep C)
CAn cause chronic hepatitis in ~16% of pts
160
Foster Kennedy syndrome
refers to a constellation of findings associated with tumors of the frontal lobe.
161
Early phase of shock, what is
pH
pCO2
pO2
Mild hypoxia --> low O2
Compensatory hyperventilation --> low CO2
Respiratory alkalosis --> high pH
162
What does epi in lidocaine do for the drug?
Double duration of infiltration anesthesia
Increases max safe total dose by decreasing rate of absorption of drug into bloodstream
DO NOT INJECT into finger, nose, toes, hose (penis), ears
163
Transfusions of blood through
- hypotonic solutions
- ringers lactate
what happens?
Hypotonic (D5W / NS)
- swelling of erythrocytes and lysis
Ringers lactate
- has Ca and causes clotting in IV line --> PE can happen
164
Paradoxical aciduria
Hypokalemic metabolic alkalosis
| - kidneys excrete H+ to try and save K+
165
Oxygen demanding organs
Brain
Kidney
Liver
Heart
Kidney is not as metabolically active as brain and heart but gets lots of blood for filtration
Coronary V lowest O2 content in blood because heart really extracts O2
166
S/E: anesthetic causing seizures
Enflurane
HaLi MeKid EnCon
Halothane = liver
Methoxyflurane= Kidney
Enflurane = Convulsant
167
S/E: Halothane
CV depression
Hypotension
decreased peripheral vascular resistance
168
S/E: Methoxyflurane
nephrotoxicity due to free F ions released during biodegradation
169
Carotid body innervated by
CN 9 - nerve of Herring
170
PT measures
Extrinsic path
```
Factors:
2
5
7
10
Fibrinogen
```
171
PTT measures
Intinsic path
```
Factors:
8
9
11
12
```
172
Bleeding time measures
Interaction of plt and formation of plt plug
Qualitative and quantitative defect in plt fxn
173
Thrombin time measures
Qualitative abnormalities in fibrinogen and presence of inhibitors to fibrin polymerization
174
Lymphangitic inflammatory streaking up a person's limb - what is it caused by?
Strep infection
Penicillin to tx!
175
Early wound management....
```
Early excision of areas of devitalized tissue with exception of deep wounds of
palms
soles
genitals
face
```
Staged excision of deep partial thickness or full thickness burns happen 3-7 days after injury
176
Carpal tunnel syndrome
- associations
- surgery - what do you do?
Assoc w/ pregnancy b/c have fluid retention
Surgery will release adhesions of median N and divide transverse carpal ligament
Extensor retinaculum is on DORSUM of the wrist and has extensor tendons -- NOT FOR CARPAL TUNNEL
177
How often is leukoplakia develping into cancer?
5%
178
Cystic hygromas
Mass of lymphatic vessels in the head and neck region
Usually congenital
Surgical excision
179
Hypocapnia and preggers
Caused by direct stim effect of progesterone on central respiratory center
--> leads to increased resp drive and exaggerated resp effort --> primary resp alkalosis w/ metabolic compensation
180
Clotting factors
| - where do they come from?
Liver! All do except 8 (come from endothelium too)
Vit K dependent: 2, 7, 9, 10, C, S
181
Anion Gap =
Na - (HCO3 + Cl)
```
Increased AG met acidosis:
Methanol
Uremia
DKA
Phenacetin
INH
Lactic acidosis
Ethylene Glycol
Salicylates
```
182
Electolyte abnormalities in chronic EtOH
hypoMg
hypo K
hypo PO4
hypo Mg will cause refractory hypo K
183
Reactive leukocytosis after surgery - causes
Steroids
Infection
Stress
184
What test is best to eval bladder?
Cystoscopy
185
Good markers for ischemia
Lactate
Base deficit
- A base deficit (a below-normal base excess), thus metabolic acidosis, usually involves either excretion of bicarbonate or neutralization of bicarbonate by excess organic acids
186
If need an airway but intubation can't be done for some reason, what do we do?
Cricothyroidotomy
Usually don't do before 12 yo b/c of possible need for future laryngeal reconstruction
187
Trauma - Airway
- how do you know it is there?
- when do you secure one
- how do you secure one?
OK - pt is conscious and speaking in nl tone of voice
Need if:
- pt unconscious
- breathing noisy or gurgly
- inhalation injury
Get airway BEFORE securing cervical spine injury
Secure w/ orotracheal intubation or nasotracheal intubation
Use fiberoptic bronchoscope if there is subQ emphysema in neck --> sign of major traumatic disruption of tracheobronchial tree
188
Trauma - Breathing
| - how do you know it is ok?
breath sounds b/l
| ok pulse ox
189
Trauma - Circulation
- signs of shock
- causes of shock
- tx hemorrhagic shock
Signs:
- low bp
- fast pulse
- low UO
- pale, cold, shivering, sweating, thirsty, apprehensive
Causes:
- bleeding (CVP low)
- pericardial tamponode (CVP high)
- tension pneumo (CVP high, resp distress)
Tx:
- if big trauma center nearby surgery 1st, then vol replacement
- if not, vol replacement (2L Ringer lactate w/o sugar) + blood until UO = 0.5 mL/kg/hr and CVP not more than 15 mmHg
190
Ways to do fluid resuscitation
2 peripheral IV lines, 16 gauge
Percutaneous femoral vein catheter
Intraosseous cannulation of proximal tibia
191
Tx linear skull fracture
If closed --> leave alone
Open --> wound closure
Comminuted or depressed --> OR
192
Signs of fx @ base of skull
Racoon eyes
Rhinorrhea
Otorrhea
Ecchymosis behind ear
CT scan to see
DO NOT do nasal endotracheal intubation
193
Penetrating neck traumas - tx for:
- upper zone
- middle zone
- base of neck
- when do surgical exploration?
Surgical exploration in all cases where there is an expanding hematoma, deteriorating vital signs or clear signs of esophageal or tracheal injury
Upper = arteriographic dx
Middle = surgery if symptomatic
Base = arteriography, esophogram (barium), esophagoscopy, bronchoscopy to help decide surgery
194
Central cord syndrome
Usually in elderly
Forced hyperextension of neck (ear end collision)
195
Tx rib fracture
Nerve block + epidural catheter
NOT binding!
196
Rare potential sequelae of injuries affecting renal pedicle in blunt trauma..
AV fistula --> CHF
197
Extent of burns in adult
Rule of 9's
```
9 = Head, each of upper extremities
18 = each LE
36 = trunk
```
198
Fluid replacement in burns
Aim for hourly UP of 1-2 mL/kg/hr while avoiding CVP > 15 mmHg
Usually 1000 cc/hr Ringer lactate (w/o sugar) if burns > 20%
- don't use sugar b/c will induce osmotic diuresis from glycosuria which would invalidate the UO measurement
199
Extent of burns in babies
```
18 = head
27 = both lower extremities
```
200
Tx burns
Tetanus ppx
Clean burn areas
Topical agents:
- silver sulfadiazine
- mafenide acetate (for deep penetration)
- triple abx if burns near eyes
2-3 wks wound care -- >if not regen, grafting needed
201
When do you graft asap for burns?
Limited burns that are obviously 3rd degree
202
Snakebites
- dosage of antivenin?
- first aid at site?
Dosage relates to size of envenomation, not size of pts
First aid = splint extremity during transport
DO NOT suck out venom, wrap with ice, touniquet, or make cruciate cuts
203
Tx black widow bite
IV calcium gluconate
204
Tx brown recluse spider bites
Dapsone
Surgical excision may be needed- tx
205
Developmental dysplasia of hip
- dx
- tx
Signs:
- uneven gluteal folds
- hops easily dislocated posteriorly w/ jerk and click
Dx: US (NO Xray as babies hips are not calcified)
Tx: abduction splinting w/ Pavlik harness for 6 mo
206
Dx osteo
MRI
207
Osgood Schlatter disease
IN teens w/ persisten pain over tibial tubercle
- aggravated by contraction of quads
No knee swelling
Tx: Rest, Ice, compression, elevation (RICE)
extension or cylinder cast if RICE doesn't work
208
Scoliosis
Usually girls
Thoracic spines curve towards right
209
Fractures:
- Colles
- Monteggia
- Galeazzi
Colles = wrist fracture, usually on old women
Monteggia = direct blow to ulna (protect yourself from cop with stick) --> fx proximal ulna, anterior dislocation of radial head
Galeazzi = Hit distal radial
210
Open fx treatment
Cleaning in OR
| suitable reduction w/in 6 hrs of injury
211
DeQuervain tenosynovitis
Usually in women w/ babies
Pain along radial side of wrist and first dorsal compartment
Get pain w/ thumb inside closed fist and forcing wrist into ulnar deviation
Tx w/ steroid injection best
212
Jersey finger vs Mallet finger
Jersey = injured flexor tendon; can't flex
"Jersey can't flex"
Mallet = injured extensor tendon
213
Tx amputated fingers
clean w/ steroile saline
wrap in saline gauze
put in sealed plastic bag on icee
DO NOT allow to freeze, do not put antiseptic solutions on
214
Lumbar disk herniation usually...
L4-L5
L5-S1
+ Straight leg test
MRI to dx
215
What is a sign of sepsis in babies?
Rapidly dropping platelet count
216
Branchial cleft cyst
Along anterior edge of SCM
217
Cystic hygroma
at base of neck as large, mushy ill definied mass
Usually takes up entire supraclavicular area and can extend deeper into chest
CT scan before surgery is best so know how far lesion goes
218
Epistaxis in juvenile - what do you suspect?
Cocaine abuse or juvenile nasopharyngeal angiofibroma
WIll be posterior septum problem (vs anterior septum in nosepicker).
Resect the angiofibroma b/c it is benign but can eat away at nearby structures
219
Dizziness 2/2 inner ear vs brain
Inner ear = room is spinning around them
- tx w/ meclizine, Phenergan or diazepam
Brain = room is steady but pt is unsteady
220
Tx reflex sympathetic dystrophy (causalgia)
Sympathetic block is diagnostic
Surgical sympathetctomy to cure
221
TEsticular torsion vs. acute epididymitis
Very similar in presentation
Torsion - no imaging needed. Surgery + orchiopexy to tx
Epididymitis - fever + pyuria, testis in normal position
- use sonogram to r/o torsion just in case
222
Urologic workup
IV pyelogram used to be in favor but limitations include allergic rxn and contraindication if Cr > 2
CT for renal tumors
US for obstruction in kidney
Cystoscopy for cancers in blader mucosa
223
#1 cause for newborn boy not to urinate in 1st day of life
Posterior urethral valves
Voiding cystourethrogram is dx
Tx: endoscopic fulguration or resection
224
Hypospadia
urethral opening on ventral side (underside) of penis
DO NOT do circumcision as will need tissue for plastic reconstruction
225
Workup of hematuria
Whn do you not work up?
CT scan
Cystoscopy (r/o bladder ca)
Dont work up if hematuria (trace) after significant trauma
226
Tx bladder ca
Surgery
Intravesical BCG
F/u closely b/c local recurrence is high
227
When does a man w/ urinary retention get worse?
During a cold
W/ use of antihhistamines adn nasal drops + abundant fluid intake
228
What is a contraindication to organ donation
HIV status is only absolute contraindication
229
Severe nutritional depletion signs
| - can you have surgery?
Loss of 20% of body wt
Albumin < 3
Anergy to skin antigens
transferrin < 200
Very high risk surgery but can undergo if get 7-10 days (optimal) of TPN
230
tx penetrating urologic injuries
Surgical exploration - do for all!
231
When can femoral fractures cause shock?
If bilateral and comminuted (smashed into a million pieces!)
232
What happens when a person trying to pass a stone (kidney) spikes a fever or white count?
Put in stent or nephrostomy tube asap to decompress! This is emergency and kidneys could fail in a few hrs
233
Will aorta look bigger or smaller on lateral xray?
bigger
subtract 20% from size
234
Easiest method to evaluate ab aorta
US
5mm error in measurement
235
Most accurate to assess ab aortic aneurysm
CT
CT angiography
236
F/u s/p endovascular repair of AAA
Annual CT and US exams
Need to make sure no endograft leak (~20% do)
237
If have hematoma s/p carotid endartectomy, what do you do first?
Open up wound at bedside
DO NOT intubate first
238
CN injury in CEA
Glossopharyngeal
- dysphagia
- soft palate dysfunction
- nasal regurg
vagus
- hoarseness
Hypoglossal
- ipsilateral tongue deviation
239
INITIAL trauma series is usually
an AP (supine) CXR on a trauma board
an AP pelvis radiograph
a cross-table lateral c-spine radiograph
240
Eval aortic arch injury without contrast media
MRI is a great means of studying the aorta, but it is a much longer examination and may not be suitable for unstable patients. We also cannot allow any ferromagnetic metal into the MRI scanner and it can be very difficult to be sure there is no metal in or on a trauma emergency patient.
Transesophageal echo would probably be the next choice in this situation - this can be performed in the ED or the operating room, but may require sedation or anesthesia.
Transthoracic ultrasound is not a good option to evaluate Mr. Roger’s aorta. Although it may show the lower portion of the ascending aorta well, it does not display the arch and descending aorta adequately due to the overlying lung.
241
Contraindications to CT contrast
Contraindications to CT IV contrast media:
- Previous allergic reaction to IV iodinated contrast
- Renal failure
Not contraindications:
- Glucophage/Metformin - Metformin is discontinued for 48 hours after the contrast enhanced CT and reinstated after confirming that the creatinine is normal.
- Multiple myeloma
- Thyroid disease
- Seafood allergy - This allergy is to a protein in seafood not the iodine. Actually the ‘allergy’ to contrast is to the compound that the iodine attaches, not the iodine
242
Hematuria evaluation
ivp first then cystoscopy if normal
243
Flank mass eval
do ivp and ct to eval for rcc
244
Asymptomatic prostatic cancer not treated after age..
75
245
Rock hard testicle
- what to suspect
- what do you do?
Testicular cancer
Do not bx. Do orhiectomy ASAP
246
Complicated UTI in men
| - management
start with ivp and sonogram instead of cystoscopy as you risk septic shock with instrumenting an infected bladder
247
Pneumaturia
- 2/2
- what do you do?
will be due to a colovesicular fistula
need to do ct scan to rule out cancer in sigmoid
248
Psychogrnic impotence tx
needs psychotherapy ASAP. Will be reversible after 2 yrs
249
Perioperative risk of stroke for CEA
1-3%
250
Most common site of lower body arterial occlusion 2/2 arterial emboli
Common femoral artery (45%)
251
Tx arterial embolism in lower periphery
ballroon cathete embolectomy
252
Most common site for claudication occlusion (long trm process)
superficial femoral artery
253
rest pain ABI
0.3-0.5
254
Why will BP / ABI measurements be incorrect in diabetics?
B/c usually ahve calcified vessels preventing arterial occlusion w/ BP cuff
Reverse flow component can be lost
255
What does it mean that the Doppler waveform is triphasic?
Phases:
1- rapid systolic flow
2- brief reverse flow 2/2 elastic recoil of vesel
3 - long diastolic outflow
If severe atherosclerosis, wafeform can become monophasic as may lose 2 and 3 phases
256
Tx for patiens with claudication in distal lower extremity (peripheral artery disease)?
Mostly don't perform surgery
257
Tx claudication causing absence of femoral pulse
This is suggestive of aortoiliac occlusive diseae
Surgery is considered b/c more progressive than periph occlusive diseas
258
What is a pt with peripheral artery disease likely to die of?
coronary artery disease / MI
259
When do you get an artetriogram for claudication?
If you decide to proceed with surgery
260
Does LVEF predict myocardium at risk for ischemia perioperatively?
No
Good indicator of postop heart failure but does not adequatly predict myocardium at risk for ischemia
261
Complications of AAA repair
- immediate
- later
Immediate:
Ischemia to colon - IMA is disrupted
- sigmoidoscopy to est dx
Anteror spnal syndrome
Later:
- vascular graft infection
- aortoenteric fistula (aorta + duodenum)
262
Tx aortic dissection
- type 1
- type 2
- type 3
Type 1 = ascending + descending aorta
- surgery ASAP
Type 2 = ascending aorta
- surgery ASAP
Type 3 = descending aorta
- beta blockers
- CONTROL HTN!
263
DVT outpatient treatment
Warfarin for 3-6 months
264
Popping in knee + rapid onset of pain and swelling with hemarthrosis - what happened?
ACL tear
265
Most common cause of hypotension adn distended neck veins in trauma pts
Tension PTX
--> Other less likely = cardiac tamponade
266
Pregnant women in trauma - how to evaluate
At basline because of preggers, can have increased HR and hypotension 2/2 uterine compression on vena cava
Evaluate preggers on her left side
267
Findings in fresh spinal cord injury
Priapism
loss of anal sphincter tone
loss of vasomotor tone
bradycardia
268
What can DPL miss?
Retroperitoneal structure injury
- duodenum
- pancreas
269
Most common nephropaathy assoc w/ carcionma
Most common nephropathy assoc w/ hodgkin's
Carcinoma - membranous nephropathy
Hodgkins - minimal change disease
270
Selenium deficiency feature
Cardiomyopathy
271
Zinc deficiency feature
Alopecia
Abnormal taste
Bullous, pustulous lesions around body orifices and/or extremities
Impaired wound healing
272
Places LARGE amt of blood could hide in body
Abdomen
Pelvis
Thigh (femoral fracture)
273
Intraoperative development of coagulopathy
+ FFP
If tehre is hypothermia and acidosis too, need to stop laparotomy and pack bleeding surfances + temporary closure
Resume op after pt warmed and coagulopathy treated
274
Best for human bites
Amoxicillin + clavulanate
