Surgery Notes Flashcards
When pt has good renal function, PE can be diagnosed via CT scan. How is PE diagnosed in pt with poor renal function?
V/Q scan
GERD pt doesn’t want meds — what do you do?
Nissen fundoplication
How do you evaluate for ureteral injury following traumatic pelvic fracture?
IV pyelogram preoperatively
-OR-
Methylene blue intraoperatively
Herniation of abdominal contents through the internal inguinal ring due to congenital patent processus vaginalis
Indirect inguinal hernia
Pt presents 3 days s/p lap chole with severe RUQ pain and a fluid collection. What is the first step in workup?
Fluid aspiration and analysis
[determine if blood, enteric contents, or bile]
Oligohydramnios, no urine output on first day of life, elevated creatinine, dx?
Posterior urethral valves
Rumbling diastolic murmur with opening snap
Mitral stenosis
How long do you give clopidogrel for a drug eluting stent
1 year
Succinylcholine can cause what electrolyte abnormality in burn and spinal cord injury patients? How does this manifest on EKG?
Hyperkalemia
Peaked T waves and shortened QT interval
[eventually, as hyperkalemia worsens, there is progressive lengthening of PR interval and QRS duration, the P wave may disappear, and ultimately the QRS widens further to a sine wave pattern]
Etiology of anterior cord syndrome
Almost always caused by a spinal artery occlusion (typically the artery of Adamkiewicz from a AAA), the infarct occurs in the front half of the cord
Holosystolic murmur that occludes both S1 and S2 at the cardiac apex that radiates to axilla
Mitral regurgitation
2 cardiac risk factors that are outright contraindications to non-cardiac surgery
EF <35% (75% chance of perioperative MI)
MI within last 6 months (40% chance of mortality at 3 months vs. 6% at 6 months)
Reynold’s pentad for ascending cholangitis
Jaundice Fever Abdominal pain Shock Altered mental status
Tx for acute epidural hematoma
Craniotomy and evacuation
What imaging study should be obtained FIRST in those with suspected small bowel obstruction?
Acute abdominal series
[includes upright CXR to look for pneumoperitoneum, upright abdomen to see air-fluid levels, and supine abdomen which best shows bowel dilation; Classic findings of SBO are ladder-like dilated loops of bowel with air fluid levels]
5 W’s of post-op fever
Wind — Atelectasis, PNA Water — UTI Walking — DVT Wound — Infection, abscess Wonder drugs
When should smoking cessation be done in relation to surgery?
8 weeks prior to surgery — because congestion initially worsens on quitting
70 y/o F presents with LUQ pain. US reveals calcified lesion in LUQ. Most likely dx?
A. AAA B. Accessory spleen C. Colorectal carcinoma of splenic flexure D. Mesenteric ischemia E. Splenic artery aneurysm
E. Splenic artery aneurysm
[these are the most common splanchnic aneurysms and often present with concentric calcification on imaging. They most often occur during childbearing years (d/t fibromuscular dysplasia) or later in life (d/t portal HTN). Surgical intervention indicated when symptomatic, present in childbearing years, or greater than 2 cm in size]
Tx for patients with CAD affecting 1-2 vessels
Angioplasty (PCI/stenting) + Clopidogrel
A 67 y/o female presents with complaints of a lump in her breast. PE reveals 2 cm mass in upper outer quadrant and 1 cm mass in lower inner quadrant, both in left breast. The 2cm mass is firm and appears fixed to underlying tissue; bx reveals invasive ductal carcinoma. Most appropriat management is:
A. B/l mastectomy B. Lumpectomy with SLND C. Radical mastectomy D. SLND E. Simple mastectomy with SLND
E. Simple mastectomy with SLND
[breast conserving therapy is contraindicated in multicentric disease with 2+ primary tumors in separate quadrants of the breast such that they cannot be encompassed in a single excision]
Wet vs. dry macular degeneration
Both present with chronic, progressive, central vision loss (peripheral is spared). Differentiate types via simple retinal exam
Wet (20%) — shows blood/fluid, tx with laser
Dry (80%) — shows Drusen/pigment changes, tx with supportive care
Transient synovitis is on the differential for septic hip. It’s synovial inflammation up to 4 weeks after URI or GI viral illness. It is differentiated from septic hip bc there is no fever or leukocytosis, and xray is normal. Tx is supportive. When differentiating this from septic joint, the ______ criteria can also be used — in which the more criteria you have, the higher risk for septic joint
Kocher
Pearly skin lesion that’s non-healing and bleeds easily
Basal cell carcinoma
Intraparenchymal hemorrhages are bleeds within the brain parenchyma itself. This occurs most often at what location?
Caudate and putamen
If a baby has persistent or worsening jaundice after 2 weeks of age, consider the dx of biliary atresia. Labs will show a direct hyperbilirubinemia. What is the hierarchy of testing?
Start with Ultrasound + LFTs
If unsure, do HIDA scan after 5-7 days of phenobarbital stimulation
If still unsure, can do liver biopsy and/or intraoperative cholangiogram
Hx of blunt trauma and you note pulsus paradoxus > 10 mmHg
Cardiac tamponade
When do you operate on a pancreatic pseudocyst?
6 weeks or 6 cm
T/F: Teratomas are typically benign in females and malignant in males
True
Tx for hemorrhoids grade I-IV
Grade I = conservative therapy with warm sitz baths and high fiber diet
Grade II = non-surgical removal procedure such as rubber band ligation
Grade III and IV = surgical hemorrhoidectomy (closed = most common, but can be done open)
Burn with blisters that have broken open, glossy pink, and blanches with pressure
A. Deep partial B. Epiderma C. Fourth degree D. Full thickness E. Superficial partial
E. Superficial partial
[epidermal burns do not blister. Superficial and deep partial are painful, but superficial blanche while deep do not]
_________ ________ syndrome can result after a chronic obstruction to a portion of the intestines causing bacterial overgrowth due to stasis within the obstructed limb. Bacterial overgrowth may be patchy, confined to distal small intestine, or located in inaccessible sites and may therefore be missed. The bacteria will bind with ____________ and decrease its absorption into the body, leading to megaloblastic anemia
Blind loop syndrome; Vitamin B12
1st step in working up esophageal cancer
Barium swallow
[however, BEST test in working up esophageal cancer is EGD with biopsy]
Upper vs. lower motor neuron symptoms
Upper = spastic paralysis, hyperreflexia, upward going Babinski
Lower = flaccid paralysis, hyporeflexia
Boot-shaped heart on CXR, association with Downs syndrome or DiGeorge syndrome
Tetralogy of Fallot
What type of imaging should be done if you are concerned for CBD perforation following an ERCP?
Nuclear medicine hepatobiliary scan
Galeazzi fracture bony deformity
Radius breaks, ulna dislocates
[occurs with downward blow against upward turned radius]
Hernia that contains Meckel’s diverticulum
Littre’s hernia
3 classifications of gallstones
Cholesterol
Black pigment (calcium bilirubinate)
Brown pigment (calcium salts of unconjugated bilirubin)
Causes of high anion gap metabolic acidosis
MUDPILES
Methanol Uremia DKA Paraldehyde Isoniazid Lactic acidosis Ethylene glycol Salicylates
Relationship between postmenopausal SERM therapy and breast cancer
SERMs have been shown to REDUCE the incidence of invasive breast cancer in women who are post-menopausal and have increased lifetime risk for breast cancer
Blunt trauma to the abdomen — what is the next step?
FAST scan
Tx for 3rd degree burn to anterior thigh
Silver sulfadiazine
Early mobilization
What type of surgeries are highest risk for DVT/PE?
Orthopedic surgeries
Workup for suspected pheochromocytoma
24-hr urine metanephrines and catecholamines (VMA most sensitive)
If elevated, do CT or MRI
Confirm laterality with MIBG scan or adrenal vein sampling and resect
Pre treat patients with alpha blockade, then beta blockade before surgery
Most reliable method to determine the cause of ascites
Serum-ascites albumin gradient (SAAG)
Calculated by (serum albumin concentration) - (ascites albumin concentration)
If <1.1 g/dL — absence of portal HTN (biliary ascites, nephrotic syndrome, pancreatic ascites, peritoneal carcinomatosis, post-op lymphatic leak, serositis with CT disease, tuberculous peritonitis)
If >1.1 g/dL — presence of portal HTN (alcoholic hepatitis, Budd-Chiari syndrome, cardiac ascites, cirrhosis, fulminant liver failure, massive liver mets, myxedema, portal vein thrombosis)
Direct vs. indirect hernias relative to inferior epigastric vessels
Mnemonic: MD’s Lie
Medial to inferior epigastric vessels in Direct hernias
Lateral to inferior epigastric vessels in Indirect hernias
Dx of brain tumors
MRI to identify, biopsy to definitively dx
Dx and tx of arterial insufficiency ulcer
U/S, CT angiogram, stent vs bypass
Stop smoking
Cilostazol
Bovine valves vs. mechanical valves in valve replacement surgery
Bovine have <10 year duration but no anticoagulation is needed
Mechanical have 10-20 year duration, require anticoagulation - typically warfarin with goal INR 2.5-3.5
________ are LDH associated testicular tumors that are exquisitely sensitive to chemo and radiation
Seminoma
5 type classifications of gastric ulcer
Type I = gastric ulcer on lesser curvature near incisura
Type II = gastric ulcer on body of stomach in combo with duodenal ulcer
Type III = prepyloric gastric ulcer
Type IV = gastric ulcer that occurs high on lesser curve near GEJ
Type V = drug-induced (NSAIDs) that may occur anywhere in stomach
Herniation of abdominal contents through floor of Hesselbach’s triangle due to acquired defect in transversalis fascia from mechanical breakdown
Direct inguinal hernia
A 60 y/o female undergoes surgery for duodenal ulcer disease. Gallstones are noted at the time of the original operation. 8 days following surgery, she develops abdominal pain and RUQ tenderness. To determine if the gallbladder is the cause of her sxs, she should undergo which study?
A. Supine Xray B. HIDA scan C. Ultrasound D. Erect Xray E. Cholangiogram
B. HIDA scan
[not ultrasound bc that would show gallstones but fail to distinguish acute cholecystitis. A HIDA scan will fail to visualize the gallbladder if acute cholecystitis is present, thus confirming dx]
Management of achilles tendon tear
Casting cures within months
Surgery cures within weeks
A malnourished pt needs to go to surgery; what’s the best course of action?
Oral feedings x10 days > oral feedings for 5 days > parenteral feeding for any time
Developmental dysplasia of the hip means the hip is insufficiently deep so the femur head constantly pops out. How is this dx and tx?
Dx during well baby exam with clicking on hip flexion (barlow and ortolani)
Confirm dx with US at 4-6 weeks, as there is physiologic laxity at birth that may resolve
Tx with harness to keep femur approximated as joint grows out
Imaging study of choice with suspected diverticulitis
CT scan with IV contrast
Mitral stenosis can lead to CHF and afib. Treatment isn’t necessary until pt gets tired of the symptoms. What are tx options?
Commissurotomy (balloon dilation) or simply replacement of the valve
Impacted stone in gallbladder neck causing extrinsic compression of common hepatic duct
Mirrizzi syndrome
Risk of parenteral nutrition
Fungemia
Posterior fossa brain tumors
Medulloblastoma
Ependymoma
Schwannoma
[posterior fossa tumors more likely in kids]
Hodgkin disease is predominately a B-cell malignancy. Excisional LN bx is the best mode of dx for Hodgkin lymphoma. Reed sternberg cells (large cells with slightly basophilic cytoplasm and bilobed eosinophilic inclusion-like nucleoli) are pathognomonic. The Ann Arbor staging system is the most widely used and is based on the number of affected LNs, presence of B symptoms, and whether the disease crosses the diaphragm or not. What are the stages in the Ann Arbor system?
Stage I = localized to single node or extralymphatic site
Stage II = multiple LNs or limited extralymphatic site on same side of diaphragm
Stage III = more than 2 sites on both sides of diaphragm
Stage IV = diffuse or disseminated disease
Sub-stage A = no constitutional symptoms
Sub-stage B = constitutional symptoms (fever, night sweats, weight loss)
Management of hemodynamically unstable + pelvic fracture + bleed
Explore
Internal fixation
Risk of bladder cancer increases with smoking and exposure to aniline dyes (dry cleaning). An ultrasound could be chosen if there are obstructive symptoms, but the first and best test should be _________
A cystoscopy with biopsy
Splenectomy pts should be vaccinated against encapsulated organisms, preferably preoperatively, but if not given preop they can be given 2 weeks postop. What 3 vaccines should be given?
Pneumococcal (PCV)
Meningococcal (MCV4)
Haemophilus influenza type b (Hib)
Management of hemodynamically stable + pelvic fracture + bleed
Do NOT explore
External fixation
Billroth I vs. Billroth II
Billroth I = creation of gastroduodenostomy
Billroth II = gastrojejunostomy
[Either technique is indicated for peptic ulcer disease or gastric adenocarcinoma]
Blunt neck trauma + focal neurologic deficit. First step in management?
High dose dexamethasone
[Reduces edema and preserves neuro function]
Alkalinization of the stomach, gastrin, epinephrine, cholinergic agents (bethanecol), and alpha adrenergic agents (metoclopromide) _______ the resting pressure of the LES
Increase
Brain tumors may present with Cushing reflex — what does this mean?
Cushing reflex = bradycardia + HTN
Components of Child-Pugh score to ascertain functionality of the liver
Encephalopathy Ascites Bilirubin Albumin INR
Which layer of the intestinal wall is most important in maintaining tensile strength and must be included when sewing intestinal anastomoses?
Submucosa
[due to collagen cross linking]
Baby with bilious vomiting and imaging shows double-bubble sign
DDx includes duodenal atresia, annular pancreas, malrotation
The chances are greater for malrotation if there is a normal gas pattern distally. Do a contrast enema followed by upper GI series. Malrotation can cause ischemia and must be r/o first.
What is the Pringle maneuver?
Compression of hepatoduodenal ligament, sealing the hepatic artery and portal vein
Acute limb ischemia presents with sudden onset of extremity that’s painful, pale, pulseless, paresthesias, paralysis, and poikilothermia (cold). You have 6 hours to fix it. Do an ultrasound or arteriogram to find the site of the lesion. What are the 3 choices of interventions for acute limb ischemia?
Embolectomy
Localized tPa
Heparin
An alcoholic Scandinavian male presents with palmar nodes and is unable to extend hand flat
Dupuytren’s contracture
[must be tx with surgery, splinting and NSAIDs don’t work]
In CABG procedure, the most significant vessel affected (usually the LAD) is connected to the __________ artery, while the others get the ________ vein
Internal mammary artery; great saphenous vein
Which is more likely associated with chromosomal abnormalities - Gastroschisis or Omphalocele?
Omphalocele — i.e., Beckwith-Wiedemann syndrome
What is trigger finger?
Stneosing tenosynovitis in which pt is unable to extend finger. When forced, there is a “pop”
Tx with splinting and NSAIDs or intraarticular injections
Esophageal cancer is often symptomatic only after it has blocked ___ of the lumen
2/3
Post-op fever day 2
Pneumonia
—Do CXR, treat for hospital acquired PNA (vancomycin and pip/tazo) while awaiting cultures
____________ is first line for medication therapy of prostate cancer. _________ are used if there is biochemical evidence of recurrence but not symptoms.
_________ is performed if refractory to medications. ______ is added to treatment if there is metastasis
GnRH analogs (Leuprolide); Anti-androgens (Flutamide)
Orchiectomy; radiation
Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves 30-40% blood volume loss, about 1500-2000 cc of blood, resulting in a significant drop in systolic BP and changes in mental status. HR is increased >120 bpm and RR is also markedly elevated. Urine output is decreased and cap refill is delayed
Class III
EGD shows dysplasia vs. cancer — what would you do in each case?
Dysplasia — local ablation
Cancer — resection
MCC of ulcer on malleolus
Venous stasis
Chronic cystic duct obstruction and gallbladder distention with clear mucoid fluid
Hydrops of gallbladder
Tx for GERD without alarm sxs
PPI
Patient presents with HTN and hypokalemia — what is your dx and what do you do next?
Get a renin-aldosterone level — could be primary hyperaldosteronism (Conn syndrome) if increased aldosterone/decreased renin; or secondary hyperaldosteronism (renovascular hypertension) if renin is driving aldosterone (approaches 1)
Antibiotic used in necrotizing pancreatitis
Meropenem
Other name for inguinal ligament
Poupart’s ligament
Options for prophylactic antibiotics for appendicitis prior to lap appy
Cefotetan Cefoxitin Ampicillin/sulbactam Cefazolin+metronidazole Clindamycin+fluroquinolone/aztreonam
Paralytic ileus of the colon that occurs in elderly sedentary patients who become immobilized after surgery; colon will appear very dilated
Ogilvie syndrome
[Do a colonoscopy to r/o cancer and to decompress the abdomen; leave a rectal tube in place]
A right shift in the hemoglobin-oxygen dissociation curve means that there is a decrease in hemoglobin’s affinity for oxygen. What things cause a right shift of the hemoglobin-oxygen dissociation curve?
Acidosis High altitude Increase in pCO2 Increase in temperature Increase in metabolic needs
[A shift to the left means an increased affinity of hemoglobin for O2. Factors that cause a left shift include decreased metabolic needs, hypothermia, decreased pCO2, increased pH, decreased 2,3-DPG, and fetal hemoglobin]
46 y/o female is dx with LCIS that is ER+. The most appropriate recommendation is:
A. B/l modified radical mastectomy B. Breast lumpectomy with SLND C. Breast lumpectomy with negative margins D. Partial mastectomy E. Tamoxifen therapy and surveillance
E. Tamoxifen therapy and surveillance
[LCIS, unlike DCIS, is not a cancer or a premalignant lesion. It simply places pt at higher risk of developing breast cancer. Tamoxifen reduces this risk and preserves breast tissue]
48 y/o female in the ED presents with RUQ abdominal pain, jaundice, acholic stools, dark urine, and a fever. Total bilirubin is elevated and LFTs suggest biliary ductal obstruction. WBC is 12,000. You suspect acute cholangitis. What is the best first imaging study to order?
US abdomen
Combination of jaundice and fever may indicate nonobstructive process or obstructive one. US abdomen can quickly distinguish between these, does not involve radiation, and may provide additional info such as presence of gallstones, CBD stone, or pancreatic mass
Hourly fluid requirments
4/2/1 rule —
4 cc/kg for the first 10 kg
2 cc/kg for the next 10 kg
1 cc/kg for every kg over 20 kg
Post-op patient feels the need to void 6+ hours after surgery but can’t — what do you do?
In-and-out cath
Head trauma resulting in LOC followed by lucid interval
Epidural hematoma
Football player passes out after colliding with another player. What do you do?
CT scan. If negative, dx is concussion — send home
Crescendo-decrescendo murmur in systole
Aortic stenosis
________ are brain tumors attached to the dura that are highly curable via resection; dx with CT showing connection to bone, and biopsy showing psammoma bodies
Meningiomas
Typical chemotherapy for breast cancer
Typically anthracycline based (Doxorubicin-Cyclophosphamide) + a taxane (Paclitaxel)
Best test for suspected coarctation
Arteriogram
But CTA or MRA can be sufficient
______ shock = loss of SVR from infection or anaphylaxis
Distributive
AR disorder resulting in increased conjugated bilirubin without elevation in LFTs
Dubin Johnson syndrome
_______ is a brain tumor found at the cerebellopontine angle. If it is bilateral, it is part of ______________ (syndrome)
Schwannoma; neurofibromatosis type II
Holosystolic murmur that radiates to axilla
Mitral regurg
Workup for Cushings
24-hr free cortisol level, confirmed by 1 mg low dose Dexamethasone suppression test
If cortisol is high, its Cushings. Follow up with ACTH level to distinguish adrenal (low ACTH) from extra-adrenal (high ACTH). If adrenal, spot it with CT/MRI of adrenals. If extra-adrenal, perform high dose dexamethasone suppression test to determine pituitary (suppresses) vs ectopic (no suppression)
If ectopic, find it with CT/MRI of the chest (lung Ca), abdomen (pancreatic Ca), then pelvis (adrenals)
Harsh holosystolic murmur, right-sided cardiac hypertrophy, increased right-sided pressures, failure to thrive, heart failure
VSD
Embolic occlusion of retinal artery presents with painless unilateral vision loss without any other stroke symptoms and possibly cherry-red spots on fovea. What is the tx?
Intra-arterial tPA
To buy time or to get clot further down the arterial tree to spare some vision, you can try to hyperventilate rebreathed CO2 to vasodilate arteries, and apply orbital pressure
Blood at the meatus, high-riding prostate — what test do you get?
Retrograde urethrogram
EGD shows metaplasia/Barrett’s/salmon — how tx?
High dose PPI
Tx and margins needed for melanoma with Breslow of 2-4 mm vs. >4 mm
2-4 mm = wide resection and SLND if tracer+, 2 cm margins
> 4mm = palliative chemo and radiation, debulking of tumor burden palliative only
Organophosphage toxicity manifests as SLUDGE — salivation, lacrimation, urination, defecation, GI upset, emesis. What is tx?
Atropine
Pralidoxime
Pt with hx of t(11;22) presents with mid-shaft bone pain and xray shows onion-skin pattern; tx is resection
Ewing’s sarcoma
Head trauma followed by LOC and retrograde amnesia
Concussion
Anticholinergic agents (atropine), glucagon, and secretin ______ the resting pressure of the LES
Decrease
Single large tortuous arteriole in the submucosa of the upper GI tract which does not undergo normal branching or a branch with caliber of 1-5mm. The lesion bleeds into the GI tract through a minute defect in the mucosa which is not a primary ulcer of mucosa, but an erosion likely caused in submucosal surface by protrusion of the pulsatile arteriole
Dieulafoy’s lesion
[approx. 75% occur in upper part of stomach within 6 cm of the GE junction, most commonly in lesser curvature]
__________ tenosynovitis may be caused by continued forced extension of the thumb (baby cradle, weights, etc) resulting in pain on thumb and hand when used
De Quervains
Inguinal hernia that contains elements of both direct and indirect inguinal hernia
Pantaloon hernia
Tx for BCC in the following locations:
Large lesion not on the face
Large lesion on an extremity
Any lesion on face
Large lesion not on the face = wide excision
Large lesion on an extremity = amputation
Any lesion on face = Mohs
Methanol (from moonshine) or ethylene glycol (from antifreeze) intoxication yield an anion gap acidosis and osmolar gap. Antifreeze has fluorescein which can be detected by Woods lamp of urine. Tx is _____ which inhibits conversion of either to their toxic metabolites
Fomepizole (or alcohol)
Chemotherapeutic often utilized in breast cancer that is associated with a dose-dependent irreversible CHF
Doxorubicin
_____________________________________________
Doxorubicin = dose-dependent irriversible CHF Trastuzumab = dose-INdependent Reversible CHF
Signs/sxs/tx for black widow spider bite
Abdominal pain/pancreatitis
Give IV calcium gluconate
Diagnostic criteria for SIRS vs. Sepsis
SIRS involves 2 or more of the following: Temp >38C or <36C, HR >90, RR >20 or PaCO2 <32 mmHg, WBC >12,000 or <4000, or >10% immature neutrophils
Sepsis = SIRS + documented infection
Presentation of posterior shoulder dislocation
Usually only occurs with extreme muscle spasm (seizure or electrocution)
Arm position is adducted and internally rotated (protected wrist position)
[dx with xray, tx is relocation and sling]
Dx and management of aortic stenosis
Dx with echocardiogram
Tx with surgical replacement; TAVR and TAVI may be attempted in poor surgical candidates
How is bleeding in the brain reduced pharmacologically?
IV beta blockers to reduce systolic BP (<140/<90)
Most common congenital heart defect
VSD
Hemisection of spinal cord
Ipsilateral loss of motor and sensory below the lesion
Loss of pain sensation contralaterally
Lower motor neuron symptoms at level of injury
Upper motor neuron symptoms below
Abx for dog/cat/human bite
Amoxicillin-Clavulanate
[human bites also require surgical debridement — do not suture them closed!]
Hemorrhage is a common cause of hypovolemic shock. Hemorrhage is further classified based on the amount of blood lost and there are characteristic symptoms associated with each class. Class ____ hemorrhage involves more than 40% blood volume loss, greater than 2L of blood, leading to significant decrease in BP and mental status. Tachycardia is present often greater than 140 bpm. Urine output minimal or absent. Skin is cold and pale and cap refill is delayed
Class IV
SIRS involves 2 or more of the following: Temp >38C or <36C, HR >90, RR >20 or PaCO2 <32 mmHg, WBC >12,000 or <4000, or >10% immature neutrophils
Sepsis = SIRS + documented infection
______________________________________________________
Define severe sepsis vs. septic shock
Severe sepsis = sepsis + organ dysfunction or hypoperfusion (lactic acidosis, oliguria, or altered mental status)
Septic shock = sepsis + organ dysfunction + hypotension (systolic BP <90 or >90 with vasopressors)
Hemothorax caused by penetrating trauma presents with decreased lung sounds with dullness to percussion. An X-ray will show horizontal lung shadow with a meniscus. Treatment is typically just to place a chest tube and drain the blood. When does surgical exploration become necessary?
Surgical exploration (thoracotomy) for the source of the bleeding is required if the chest tube produces 1500+ mL (20cc/kg) on insertion OR 200 mL/hr (3cc/kg/hr)
[these findings indicate peripheral arterial bleeding which will not stop on its own]
