Surgery Pestana Flashcards
which pts do not require an airway placed
fully conscious and normal voice
which pts require an airway
going to lose airway soon:
- expanding hematoma (quick induction then intubate)
- subcutaneous air/tissue emphysema
need airway now:
- unconscious
- gurgly noises
- spinal cord injury (airway needed first)
- facial trauma (cricothyroidotomy
what does subcutaneous air/tissue emphysema indicate?
signifies tracheobronchial injury
how do you manage tracheobronchial injury
intubate over fiberoptic bronchoscope
how do you you manage a pt with spinal cord injury and needing an airway
(pts will present with neck pain pro unable to move extremities)
establish airway first:
- nasotracheal over fiberoptic bronchoscope
- do not move/hyperextend neck
- do not pick CT/XR as first action
how do you evaluate breathing?
- pts are starting their own breathing motion
- both lungs are spontaneously inflating
- O₂ is being put into blood (O₂ sat)
how does a classic trauma shock pt present?
BP <90
tachy, poor quality pulse
diaphoretic, pale, cold, shivering, anxious
trauma scenario
what are the 3 conditions responsible for shock in trauma
bleeding
pericardial tamponade
what is the most common cause of shock in trauma
hypovolemic hemorrhagic shock
“bleeding”
where hypovolemic hemorrhagic shock present
>1.5L lost not enough space in head neck and arm bleeds are visible pericardial sac --> tamponade + high CVP pleural cavity --> seen on CXR abdomen, pelvis, thighs can hide big bleeds (pelvic instability, femur fractures)
empty (non-distended) veins
how do you manage hypovolemic hemorrhagic shock
Emergency:
-ex lap
STOP BLEEDING before prioritizing resuscitation fluids, w/ exceptions
-“scoop and run” if you’re near medical help and you know where bleeding is (direct finger pressure)
2 large-bore (16 gauge) peripheral IVs:
arms, ankles, femoral vein
-1-2 L balanced electrolyte soln (LR; sugar = osmotic diuresis = invalidate UOP)
-followed by blood as available
eventually monitored by pt response and UOP/CVP
last-resort access in child:
intraosseous cannulation in proximal tibia
-20mL/kg initial bolus
how do you identify pericardial tamponade in trauma setting
trauma to chest
DISTENDED VEINS; high CVP >20-25 (must be mentioned)
pt is BREATHING FINE
how do you manage trauma pericardial tamponade
it’s based on clinical dx,
don’t ask for CXR or blood gases
empty the pericardial sac (window, pericardiocentesis, decompression)
meanwhile, give fluid and blood
- heart is not failing, the ventricle just cant feel blood from the pressure buildup
- more blood = more to squeeze = somewhat improve status
fix the underlying problem:
-start w/ sternotomy if tamponade is the only problem
how do you identify tension pneumothorax in trauma setting
trauma to chest DISTENDED VEINS AND BREATHING DIFFICULTY -labored breathing/no breath sounds/tympany -deviated trachea -high CVP
how do you manage tension pneumothorax
based on clinical dx,
don’t ask for CXR, CT, or blood gases
immediately decompress pleural space’s pressure
- large bore needle in 2nd intercostal pleural space
- follow with chest tube on suction and water seal
what 3 things can cause shock in non-trauma setting
bleeding
cardiogenic
vasomotor
how does non-trauma bleeding shock happen
spontaneous; ruptured ulcer
how does cardiogenic shock happen
non-trauma setting:
- Myocardial infarction
- high CVP; DISTENDED NECK VEINS
how do you manage cardiogenic shock
Tx the MI
do not give fluids (this is intrinsic shock)
what is vasomotor shock
loss of peripheral vascular tone
- low CVP, low BP, tachy
- WARM AND FLUSHED
anaphylaxis
-bee sting, penicillin allergy, spinal anesthesia)
how do you manage vasomotor shock
vasoconstrictors
restore vascular tone that’s been lost
(volume replacement does not hurt this pt)
which head traumas need to be taken to the OR vs ER?
OR:
- penetrating trauma (repair entry spot and control possible bleeding)
- comminuted depressed skull fracture
ER/Other:
- blunt
- linear skull fracture
- scalp laceration
what is required for every pt who has LOC
CT scan
what is indicated by:
ecchymosis in eyes or behind ear
clear fluid dripping from nose
basilar skull fracture
how are basilar skull fractures managed
evaluate airway
CT to look for potential hematoma
**also get cervical XR or CT head+neck to evaluate for neck injury, since this is big trauma
- the skull fracture itself doesn’t need tx
- Abx are not indicated
what head injury is caused by BIG trauma (like highway car crash)
subdural hematoma
how does subdural hematoma present on CT
concave semilunar crescent shaped hematoma
midline structures may shift to opposite side
management of subdural hematoma?
(neurosurgeons do craniotomy/decompression if structures are shifted)
control ICP:
hyperventilation
avoid fluid overload
what is prognosis of subdural hematoma
grim prognosis-
original trauma does a lot of damage
how does chronic subdural hematoma present
elderly and alcoholics
-brain shrinks, can easily rattle, and tear venous sinus
slow bleed
-ex. become senile over 3-4 weeks
how do you manage chronic subdural hematoma
decompress/evacuate the hematoma
memory loss will return to normal
how does epidural hematoma present in pt and on CT
2/2 trivial trauma (baseball bat)
pt will be completely normal between LOC (LUCID INTERVAL)
blown pupil on ipsilateral side of injury
CT:
biconvex/lens shape
midline structures shift to opposite side (especially w/ materializing sings)
how do you manage epidural hematoma
emergency craniotomy to evacuate the clot
excellent prognosis
what is a major concern of an acute hematoma?
CNS damage:
- the initial trauma’s damage isn’t fixable
- hematomas may push midline structures, which is fixed with surgery
- swelling frequently follows trauma and ICP (mostly a medical fix)
how does a diffuse axonal injury present in pt and on CT
trauma, coma, bilateral fixed pupils
CT:
- diffuse blurring of grey/white interface
- multiple small hemorrhages
- no single large hematoma or displaced midline structures
how do you manage diffuse axonal injury
no indication for surgery (no single large hematoma or displaced structures)
correct the high ICP without pushing the pt to dehydration
what are the absolute indications to go to the OR in neck trauma pts
any penetrating injury where pt is rapidly deteriorating
(low BP, not responding to fluids)
all GSW to middle neck
(asymptomatic stab to middle neck = observe)
any evidence of injury to important structures
(spitting up blood = tracheobronchial)
(hematoma = major vessel)
how do you manage upper neck trauma
need proximal and distal control before fixing
- difficult to operate
- angiogram to identify injury
- radiologist to embolize bleeding vessel
how do you manage base of neck trauma
Dx studies before operating
-arteriogram, esophagram, bronchoscopy, etc
what type of spinal cord injury presents with:
different sides/different functions
(R trauma = loss of proprioception on R; loss of pain on L)
Hemisection
AKA Brown Sequard Syndrome
what type of spinal cord injury presents with:
loss of motor, pain, temp on both sides distal to injury
with preservation of vibratory/positional sense
anterior cord syndrome
how does anterior cord syndrome happen
blow out of vertebral body
- spinal cord is posterior to vertebral body
- anterior section is damaged first
- posterior cord is preserved
can also be seen with vascular puppy injury
what spinal cord injury occurs with neck hyperextension
central cord lesion
how does central cord lesion present
neuro damage in UE
LE largely unaffected
(UE travels closer to center of cord)
what does some evidence suggest is helpful in improving outcome of spinal cord lesions?
high dose steroids ASAP
what are the bone clues of big chest trauma
sternum
first rib
scapula
what do you need to look for in major chest trauma
traumatic transection of aorta
how do you manage penetrating chest trauma
penetrating trauma rarely requires surgery in the chest
however, a blunt trauma can cause a penetrating trauma, like when a rib is broken and pierces lung to create a penetrating scenario
what are 3 things you need to consider with blunt chest trauma
pulmonary contusion
myocardial contusion
traumatic transection of aorta
what presents with “white out” lungs on CXR
pulmonary contusion
how do you determine if pulmonary contusion needs respirator, fluid restrictions/diuretic?
blood gases
how do you identify myocardial contusion
EKGs and cardiac enzyme monitoring
may be 2/2 sternal injury (tenderness, gritty bone-on-bone feeling by palp)
which portions of the aorta move where in a traumatic transection of the aorta 2/2 deceleration injury
ascending moves forward
descending stays put/stops
most of these pts die on scene
what tears in a small subset of aorta transection pts?
small subset of pts who don’t die immediately get transection of intima/media with intact adventitia
a hematoma forms but is contained for several hours (asymptomatic)
what is the work up for traumatic transection of aorta
widened mediastinum = high suspicion (not diagnostic)
spiral CT
arteriogram if at least 1 of those 2 is positive
how does a pt develop pneumonia 2/2 rib fracture
elderly pt
hurts to breathe, avoids breathing, atelectasis, pneumonia
how do you manage rib fracture to prevent pneumonia
alleviate pain in a way that does not hinder breathing
- local anesthetic/nerve block that alleviates focal pain (Lidocaine)
- still allows pt to drive breathing
do not bind chest or prescribe heavy narcotics
what injury presents w/ large flap-like wound; sucking and air trapping with every breath
sucking chest wound
what happens to sucking chest wound if left untreated
pt will develop tension pneumo
air trapping with every breath
how do you manage sucking chest wound
occlusive dressing:
- vaseline gauze stuck to chest wall
- prevents air moving in during inspiration
- taped on 3 sides to push some air out during expiration
what injury presents w/ paradoxical breathing
flail chest
caves in with inhalation; bulges with exhalation
how do you manage flail chest
tx underlying pulmonary contusion
- fluid restriction and diuretics (sensitive to fluid overload)
- give colloid over crystalloid
- measure blood gases to watch for deterioration and intubate as needed
- need a preventative chest tube if you intubate
continue to monitor for less obvious injuries:
-MI, transection, etc
what presents with shock, distended neck veins, and no breath sounds
tension pneumothorax
how do you manage tension pneumo
needle for air escape
what presents with penetrating trauma, STABLE VITALS, no breath sounds?
plain pneumothorax
how do you manage plain pneumothorax
CXR first
-no need to rush with placing an emergency needle
then chest tube in 2nd intercostal space
what presents with penetrating trauma, SOB, stable vitals, no breath sounds at base, dull to percussion, faint/distant breath sounds at apex?
hemothorax
how do you manage hemothorax
CXR first
-pt is not actively dying; confirm hemothorax
where are most pts bleeding from in a hemothorax
most are bleeding from lung (a low pressure circuit)
-bleeding usually stops on its own (seldomly need to operate)
how do you manage a hemothorax
if there’s penetration, there’s risk of infection/empyema
chest tube to evacuate pleural space
how can you identify bleeding source in hemothorax
place a chest tube:
lung bleed = some bleeding that tapers in next hour
systemic bleed = significant bleed and hypotension (commonly intercostal)
- sums to 600cc in 6 hours
- need a thoracotomy to stop bleed
what does a large, single air/fluid level mean
need to manage both blood and air conditions in the lungs
begin with a chest tube
what does multiple air/fluid levels in chest mean
bowel in chest
how does bowel in chest present
traumatic rupture of diaphragm
always L side
need abdominal surgical correction
imaging shows NG tube tip curve up into the chest
what are 4 causes of air in chest
esophageal perforation
tension pneumo
major tracheobronchial injury
air embolism (rare)
what scenario would you connect w/ esophageal perforation
ex. pt had endoscopy and now has air in chest
how do you confirm dx of major trachobronchial injury
something has ripped in 2:
fiberoptic bronchoscopy to guide the airway/visualization to confirm dx
how would you get air embolism sudden death in post-trauma intubated pt
rare
chest tube in pleural cavity
pt was previously hemodynamically stable
sudden cardiac arrest
injury to major bronchus and adjacent major vessel
respirator blows air into lung, leaks to vessel, travel to ventricle –> arrest
how would you get air embolism sudden death in an awake pt
major vein near SVC becomes open to air in awake pt
if it happens when pt is inhaling to give neg pressure, it may suck enough air into the ventricle to make it foam –> arrest
put pt in Trendelenburg L side down; tube to suck air; cardiac massage
many pts die
how does fat embolism present
severe trauma with long bone fractures disorientation 12 hors later petechial rash in axilla and neck febrile, tachy RESPIRATORY DISTRESS and hypoxemia low platelets
CXR shows bilateral fat infiltrate
how do you manage fat embolism
respiratory support and blood gas monitoring
what are the 3 circumstances where ex lap is required
every GSW to abdomen (below nipple line)
stab wound with clear penetration into abdominal cavity
penetrating or blunt trauma where pt develops acute abdomen
what is the prep process for ex lap
indwelling catheter
large bore venous lines
broad spectrum Abx
what are cons of diagnostic peritoneal lavage
invasive: cut belly + catheter
only gives yes/no; doesn’t give origin, or whether or not bleeding will stop naturally
vignette must say pt is hemodynamically unstable / needing resuscitation***
otherwise, you’d get a CT
what are the pros of emergent CT scan
excellent to see presence of blood and source of bleeding
noninvasive
however, if pt is in shock/crashing, cannot leave ER to get CT scan
—must be hemodynamically stable (otherwise,get a DPL)
how is a splenic laceration/ rupture handled
surgeons will do everything possible to repair rather than remove a spleen, esp in children
when is a splenectomy (vs spleen repair) indicated
shattered beyond repair
other critical life-threatening injuries that require time/attention
what changes in a pt’s immune status after a splenectomy
pt now needs immunizations against encapsulated bacteria to prevent sepsis
- pneumovax for pneumococcus
- immunize for H influenza meningococcus
when should you suspect a coagulopathy in an abdominal trauma pt
multi-trauma pt requiring massive blood transfusions
>10-12 units of blood
blood oozing from all dissected surfaces and IV sites
hypothermia + acidosis
how should you manage blood oozing from dissected surfaces and IV sites
pt has a coagulopathy
ideally, you’d do labs to determine what factor the pt needs,
but there’s no time
shotgun approach:
give FFP and plt bags
what is pt’s temp when oozing blood from IV sites?
nl core temperature
how do you handle a coagulopathy with hypothermia + acidosis
stop operation ASAP
give FFP and plts
pack all areas that are bleeding
rewarm and tx the coagulopathy before resuming operation
what is dx for surgical pt with abdominal wall edges that cannot be closed without tension
abdominal compartment syndrome
pt usually has lengthy ex lap procedure for multi-trauma abdomen
tension cutting through sutures, hypoxia, renal failure
what is the complication of pulling closed an abdomen w/ compartment syndrome
pulling closed –> unable to bleed, perfuse kidneys –> kidney failure
how is abdominal compartment syndrome managed
temporary closure w/ plastic or mesh stapled around opening
how can you identify a pelvic fracture
bleeding helped by fluids
pelvic hematoma
nearby viscera injury
- rectum and urinary bladder
- vagina (F)
- urethra (M)
how do you manage a pelvic hematoma
leave alone if not expanding
how can you evaluate a pelvic fracture
proctoscopic / pelvic exam
how do you manage a pelvic fracture
difficult to stop pelvic bleeding- unable to reach it easily in the OR
what is the hallmark of urological injury
trauma with hematuria
where could the blood be coming from in a urological injury
kidney, bladder, or urethra (M)
what does this story hint at as a source of urological bleed:
broken ribs with no fractured pelvis; flank injury
Kidney injury as source of bleeding
how do you manage kidney injury
a retrograde cystogram will be nl
CT scan next
most blunt kidney injuries don’t require surgical repair
-RARE possible AV fistula development –> overload circulation –> HF –> bruit
what does this story hint at as a source of urological bleed:
pelvic fracture; blood at meatus; resistance from foley
bladder injury
where will dye appear on cystogram in a dome vs base/trigone of bladder injury
dome: dye will be seen in picture
base/trigone: dye will extravasate posterior/extraperitoneal; dye will not be seen
–you need a 2nd picture to identify this leak
what does this story hint at as a source of urological bleed:
blood in meatus
bladder or urethra injury
what is the next step when blood in meatus has been found
retrograde urethrogram w/ dye to find source of bleed: either bladder or urethra
do NOT place foley w/ evidence of potential urethral injury
what does this story hint at as a source of urological bleed:
high-riding prostate; sensation of needing to urinate but cannot
posterior urethra injury
how should you work up microhematuria in an adult vs pediatric pt
adult: inconsequential
big trauma justifies microhematuria
pediatric, esp w/ small trauma:
hematuria may be first sign of congenital abnormality or urinary tract
–need further studies
what should you order in a scrotal hematoma
sonogram to evaluate testicles
what injury results from “slip in shower” story
penile shaft hematoma
what is the complication in a penile shaft hematoma
fracture of the tunica albugenia / corpora cavernosa
how do you manage penile shaft hematoma
prompt surgical repair is indicated
what injury do you suspect in penetrating injury traveling antero-medial thigh
femoral artery/vein
how do you manage a femoral artery/vein injury
arteriogram, even if pt has normal pulses
hematoma needs immediate surgical exporation
what should you focus on first if pt has a combined vasculature, nerve, and bony injury
greatest urgency is vascular
–repair/recovery is very technical
however, you should set the bones first
–repair requires violent maneuvers that could undo your intricate vascular repair
nerve repair last
when and where is compartment syndrome likely to happen
likely to happen after prolonged ischemia –> reperfusion
most likely in the forearm and lower leg
–potentially permanently disabling
extent of GSW damage based on type of gun?
bigger bullet = more damage
low velocity <1500 ft/sec = injury limited to path of bullet
(civilian weapon)
high velocity >3000 ft/sec = E is dispersed into tissue; creates column of destruction; large exit wound
(hunting rifle, ex.)
likely needs debridement and amputation
what lab value makes you suspect a crush injury
myoglobinemia / myoglobinuria
–crush injury frees up myoglobin into blood –> kidney –> renal failure
how should you manage a crush injury
IV fluids, osmotic diuretics to protect kidneys
monitor serum K (released from crushed muscle cells)
possible fasciotomy 2/2 compartment syndrome
what are 3 types of thermal burns
confined environment burn
circumferential burn
small patch burn
what should you think of with a confined environment burn
think respiratory burn (chemical burn of upper respiratory tract)
how do you manage an upper respiratory burn
confirm dx with fiberoptic bronchoscopy
monitor with blood gases
—only tx is via respiratory support (no steroids, Abx, or airway)
tx w/ 100% O₂ (shortens the life of carboxyhemoglobin)
what should you suspect in a dry, white, 3rd degree burn called
circumferential burn
what happens in a circumferential burn
fluid escapes circulation and becomes trapped as edema
cuts off circulation to extremity
how do you manage circumferential burn
monitor circulation in that extremity
(pulse, cap refill, Doppler)
Escharotomy to enable skin to swell
- -can do at bedside (skin is already anesthetized and contaminated)
- -if the burn is on the trunk: escharotomy at breast plate w/ 4 cuts
what happens in a small patch burn
swelling underneath can easily push up eschar
–nothing happens
which burn is “the gift that keeps on giving”
chemical burn
- -will continue to burn until chemical is removed
- -eliminate the chemical ASAP
how do you manage a chemical burn
acid (battery) or alkaline (Drain-O) is the same
do not play chemist
remove clothing
running water for 30 min before going to ER
- -exception: drinking liquid plumber (you can’t drink water for 30min)
- -play chemist a little bit
what should a pt immediately do after swallowing alkali substance
give diluted vinegar, orange/lemon juice
what should a pt immediately do after swallowing acid substance
give milk, egg whites, antacids
what is the concern with electrical burn
far more tissue destruction than what initially appears
–bone and muscles are readily cooked, even if exterior skin doesn’t look that bad
how do you manage electrical burn
extensive surgical debridement
potentially amputation
monitor for myoglobinemia
look for vertebral compression fractures
what are 2 long-term sequelae in electrical burns
long-term sequelae of cataracts and demyelination
what are 2 burns suspicious for child abuse
bilateral burns on buttocks w/ moist blisters (2nd degree)
glove pattern of hand/foot being immersed in boiling water
what is the initial tx for burn victims
need vicious fluid resuscitation for ~2 days
- -estimation formulas are used
- -judge the adequacy based on UOP and CVP
what is the modified Parkland formula for adult surface area burns
Rule of 9s x 11 = 99%
9% head
9% each UE
9% x 4 in trunk (2 in front; 2 in back)
9% x 2 in each LE (1 in front; 1 in back)
what is the Parkland formula for child surface area burns
two 9%’s in head
trunk and UE’s are same as adult
9% x 4 trunk
9% in each UE
three 9%’s total for LE
what is the modified Parkland formula to calculate fluid resuscitation
cc’s of balanced electrolyte soln (LR) pt needs in the first 24 hours
(Body weight kg) x (%burned up to 50%) x (A factor)
A factor = 2-4 for adults; 4-6 for peds
being burned >50% means you’re already losing fluid at a max rate
how should you distribute the cc’s of an electrolyte soln in a burn pt
give half in first 8 hours; other half over 16 hrs
pts typically cannot eat/drink; so give additional 2L for maintenance fluids
why should you not give a sugar fluid to burn pts
the osmotic diuresis invalidates UOP values
how do you manage resuscitation in burn pt on day 2 and 3?
day 2: typically needs ~half of first day fluids
day 3: trapped fluid tends to go back to pt; may see extensive diuresis
what is a good initial rate rule for fluid resuscitation
~1000/hr for >20% burn initially;
then monitor UOP to adjust
what is the normal UOP for fluid resuscitation
nl UOP is ~1cc/kg/hr, but anywhere between 0.5 -2x that is acceptable
(70kg M should produce 35-140 cc/hr)
what is the basic management for burn care
standard tetanus prophylaxis
suitable cleaning of areas; OR for cross-debridement
topical burn care (no parenteral Abx)
IV pain meds (cannot be subQ)
intensive nutritional support (GI tract; high calorie; high Nitrogen)
rehab beginning on Day 1 (function, not survival, is endpoint)
graft areas that did not regenerate after 2-3 weeks
or, take pt to OR on Day 1 if severe burn is isolated and can easily be grafted
–save time, money, pain/suffering
what are the 3 types of topical burn care depending on pt presentation (standard, severe, eyes)
standard: silver sulfadiazine
- -soothing white paste; works well against bacterial infection
deep penetration w/ thick eschar or involved cartilage: mafenide acetate
–painful; can produce acidosis
near eyes: triple Abx ointment
how do you manage a bite from a provoked domestic dog
tetany prophylaxis
dog is presumably vaccinated and provoked, so has low risk of rabies
- -no rabies prophylaxis needed
- -vet puts animal under observation to look for rabies indication
how do you manage a wild animal (ex. coyote) bite w/ animal brought back alive
can kill animal to examine its brain and look for sings of rabies +/- rabies prophylaxis for bite victim
how do you manage bat attack w/o animal to examine
rabies prophylaxis
includes immunoglobulin + vaccine
what is the description of a venomous rattlesnake
elliptical eyes fixed behind nostrils, big fangs, rattles
how do you manage a snake bite, depending on timing and pt presentation
up to 1/3 of bites do not inject venom, even in a venomous snake
in ER 1 hr after bite; no local plain, swelling, or discoloration = no venom
–tx: wound cleaning, tetanus prophylaxis, observation
in ER 1 hr after bite; local pain, edema, ecchymosis = venom
–tx: anti-venom in large doses
at least 5 vials; maybe 10-20
venom has to do with size of envenomation, NOT size of pt
immediately type and cross (venom eventually interferes)
Coag studies and renal/liver function tests
surgical excision is rarely needed
do not: cut/excise bite area elevate extremity fasciotomy give sterods
how do you tx anaphylaxis 2/2 bee sting
(wheezing, hypotension, purulent rash)
tx: 1/2 to 1/3 cc EPI
remove stinger carefully
how does a black widow spider bite present
black spider w/ red hourglass
pt has N/V; severe muscle cramps
how do you tx black widow spider bite
Tx: IV Calcium gluconate +/- muscle relaxants
how does a brown recluse spider bite present
hurts when it happens; develop an ulcer overnight; dead skin w/ halo of erythema
how do you tx brown recluse spider bite
Tx: local excision of ulcer
get rid of venom
may need skin graft
how do you tx human bite / punch in the face?
ortho surgeons take to OR for massive irrigation and debridement to prevent bad infection
–could destroy joint
what is dx in newborn with uneven gluteal folds; hip can easily be dislocated posteriorly w/ jerk/click
developmental dysplasia of hip
what is the concern with developmental dysplasia of hip
permanent disability if not recognized early
–femoral heads can grow outside of socket
how do you dx and manage developmental dysplasia of hip
Dx w/ PE or sonogram
–XR in newborn is not helpful (not enough calcification)
manage: abduction splinting w/ pelvic harness; or double diapers
what is dx in ~6yo w/ insidious development of limping w/ decreased hip motion
+/- ipsilateral knee pain
avascular necrosis of capital femoral epiphysis
how do you dx and manage avascular necrosis
dx w/ XR
manage: controversial; some use casting/crutches
what is dx in ~13yo M, often overweight, with groin pain, limping, inverted foot; limited hip motion;
as hip is flexed, leg goes into external rotation and cannot be rotated internally
slipped capital femoral epiphysis
how do you dx and manage slipped capital femoral epiphysis
dx w/ hip XR
manage: ortho emergency
pin femoral head into position so it does not die
what is dx in ~toddler with febrile illness, then acute hematogenous osteomyelitis
septic hip
how do you dx and manage septic hip
dx w/ radio nuclear bone scan (not CT)
–XR takes too long to show osteomyelitis
mange: Abx
what age is bow legged normal
(genu varum)
normal up to 3yo
do not prescribe ortho braces/casts etc
how do you treat genu varum after 3yo?
pt likely has Bowen’s disease if bow-legged persists past 3yo
needs surgical correction
what age is knock knee’d normal
(genu valgus)
normal up to 8yo
co not prescribe ortho braces/casts etc
what does knee pain w/o swelling generally indicate
intrinsic knee problem
what is dx and tx of tibial tubercle pain aggravated w/ quad contraction
osteochondrosis of tibial tubercle
AKA Osgood-Schlatter disease
Tx: immobilization of knee; extension cast 4-6 weeks
what is dx of baby born w/ both feet turned inward
club foot
AKA congenital talipes equinovarus
adduction of forefoot
inversion of foot
flexion of ankle
internal rotation of tibia
how do you manage club foot
serial plaster casts beginning in neonatal period
–start most distal and move proximally
50% respond in 6mo and don’t require surgery
–do surgery <1yo before they’re ready to walk
what is dx in ~F w/ curved spine; hump in thorax when bending forward in premenstrual growth spurt yrs
scoliosis
S-form is seen lateral in progression
progresses as long as skeletal maturity has not yet been reached
how do you manage scoliosis
corsets and casts +/- surgery until skeletal maturity
consider possible limited pulmonary function
what are “pros” of a childhood vs adult fracture
most have better outcome than adults- more plastic
faster healing and capacity for remoodeling- grow back straight
what are 2 bad childhood fractures
elbow
growth plate involvement
what is the concern w/ childhood elbow fracture
high risk of neovascular compromise
–monitor w/ cap filling; Doppler, pulse, etc for vascular supply
what is the fracture in elbow fracture
supracondylar fracture of humerus
–distal fracture displaced posteriorly
what is needed with childhood fracture involving growth plate
precise re-alignment is needed
–open reduction and internal fixation is best
what type of bone tumor has a sharply demarcated edge that distinguishes it from the rest of bone (boundary)
benign bone tumor
what type of bone tumor has fuzzy/ill-defined edge between tumor and bone
malignant bone tumor
what are the 2 buzzwords for malignant bone tumors on radiology
“sunburst” pattern (fuzzy demarcation edge)
periosteal onion-skinning (tumor is growing fast and displacing periosteum from bone; new layer of bone that gets displaced again)
what is the presentation of 2 childhood bone tumors:
osteogenic sarcoma vs Ewing sarcoma
osteogenic sarcoma:
10-25yo
around the knee (lower femur/ upper tibia)
Ewing sarcoma:
younger children
around diaphysis/shaft of bone
how do you manage malignant bone tumors
refer to specialized ortho surgeon
do not do anything invasive to this pt
what are most adult bone tumors (primary or metastatic?)
metastatic
what is the most common primary malignant bone tumor in adults
multiple myeloma
what is dx in pt who is old, anemic, multiple bones involved; Benz Jones protein in urine; abnl immunoglobins
multiple myeloma
how do you tx multiple myeloma
chemo usually
what is a pathologic fracture and what does it signify
fracture 2/2 trivial event
signifies metastatic tumor presence
what does XR show on pathologic fracture
XR shows lytic lesion (eating bone) vs plastic lesion (growth of bone)
where do you assume bone metastasis in a male vs female
male: assume to be metastatic from lung
female: assume to be metastatic from breast
what fracture commonly occurs in osteoporosis
vertebral compression fractures
all others need some sort of trauma
what is generic dx of an older pt with soft issue mass that grows, hard, fixed
sarcoma
(don’t know if it’s lipo, fibro, chondro, rhabdo - sarcoma yet
how do you dx sarcoma
MRI
do not do invasive maneuver
- doc who discovers the tumor should not be doing the biopsy
- pt requires large tissue sample and open bx from a specialist
what imaging should you get for a fracture
XR at 90 degrees to each other;
include the obvious and suspicious fracture sites
how do you manage clavicle fracture
spint w/ figure 8 device for 4-6 weeks to retract shoulders
what is the buzzword for colles fracture
dinner fork shaped, painful wrist
what does XR show for colles fracture
dorsally displaced dorsally angulated fracture of distal radius;
small fracture of ulnar head
(dinner fork wrist)
how do you tx colles fracture
closed reduction and long arm cast
dinner fork wrist
what type of fracture gives you a broken ulna and a dislocated radius
Monteggia fracture
diaphysial fracture of proximal ulna with anterior dislocation of radial head
how does one typically get a Monteggia fracture
protecting with outstretched forearm
broken ulna; dislocated radius
what type of fracture gives you a broken radius and dislocated ulna
Galeazzi fracture
how should you cast a Galeazzi fracture
in supinated form
broken radius; dislocated ulna
what is the general rule for fixing broken bones and dislocated bones, respectively
open reduction/internal fixation for the broken bone
closed reduction for the dislocated bone
what bone is commonly fractured with FOOSH, wrist pain, tender to palp over anatomic snuff box
scaphoid bone
XR will be negative for 3 weeks, so clinical dx is useful
how do you manage scaphoid bone fracture
needs thumb spiker cast (not displaced)
what does a XR showing an adulated fracture of scaphoid notorious for
high rate of non-union/delayed healing (displaced)
this requires open/internal fixation
what is commonly fractured with a closed fist hit
fracture of 4th/5th metacarpal neck
how do you manage the 4th/5th metacarpal neck fracture (closed fist hit)
management depends on degree of angulation, displacement, or rotary malalignment
mild: closed reduction and ulnar gutter splint
severe: wire plate fixation
which should dislocation is most common
anterior dislocation
what is dx for pt presenting holding arm close to body; rotated out as if to shake hands; numb in deltoid
anterior shoulder dislocation
how do you dx and tx anterior shoulder dislocation
dx: AP/lateral XR
tx: reduction
what is dx for pt presenting with arm held close to body; internally rotated
posterior dislocation of shoulder
how do you dx and tx posterior shoulder dislocation
difficult to dx; may have history of small clinic visit + pain meds that aren’t helping
(may occur when all muscles in body contract at same time- electrical burn, epileptic seizure, etc)
dx: axillary or scapular/lateral XR
tx: reduction
what is dx in shortened and externally rotated leg
broken hip
what is concern in femoral neck fracture
the fracture will likely kill femoral head 2/2 tenuous blood supply
if this occurs in an elderly pt, they’ll be immobilized, pneumonia, and die
how do you tx femoral neck fracture
OR to remove femoral head and replace w/ metal prosthesis
how do you tx intertrochanteric fracture
open reduction and pinning
immobilization and anti-coag (esp in elderly pts at risk for DVT)
how do you tx/manage femoral shaft fracture
intramedullary rod fixation
monitor for hypovolemic shock
monitor for fat embolism (low pO2)
–resp support to improve oxygenation
what is likely dx in pt who has h/o repetitive use of bone beyond toleration; localized tibia pain in specific area of bone
stress fracture
how do you dx and tx stress fracture
XR is nl until later on
tx: cast
what should you suspect hours after cast alignment when pt c/o persistent pain, tight muscle compartments, extreme pain with passive extension of toes
compartment syndrome
severe disability if not recognized
how do you tx compartment syndrome in legs
emergency fasciotomy in all compartments (4 in legs) with 2 skin incisions
what is dx in out of shape pt who over-exerts, hears a loud pop; can initially move, but then progresses to being unable to move
achilles tendon rupture
how do you tx achilles tendon rupture
casting in equinus position (pt on tip toes to not stretch tendon) for several months
open surgical repair for faster healing
what is dx in pt who falls on inverted/everted foot
malleoli fracture
it doesn’t matter which way they fall; both malleoli will be broken
how do you manage malleoli fracture, depending on what XR shows
XR shows good position fracture: casting
XR shows displaced fractures: open reduction and internal fixation for proper ankle healing
what is dx in pt with medial knee pain/swelling
passive abduction elicits pain
positive valgus stress test
medial collateral ligament injury
which direction can you bend knee in MCL injury
can bend leg further in direction of broken ligament (medial) without limited motion
what is dx in pt with lateral knee pain/welling
passive adduction elicits pain
positive varus stress test
lateral collateral ligament injury
how do you treat MCL/LCL injuries
hinge cast if that’s the only problem
otherwise, surgical repair
what is dx in positive anterior drawer test
Anterior cruciate ligament tear
what is dx in positive posterior drawer test
posterior cruciate ligament tear
which imaging confirms a ligament tear
MRI
how do you manage knee ligament tear
immobilization and rehab for sedentary pts
athletes: arthroscopic reconstruction for quick healing
what is dx in pt with catching and locking of knee that limits its motion; click when forcefully extended
meniscus injury
how do you dx meniscus injury
XR is nl
difficult to dx
may have h/o small clinic visit with unhelpful tx
MRI shows meniscal tear
how do you tx meniscus tear
arthroscopic repair
try to save as much meniscus as possible to avoid degenerative arthritis
how do you manage pt with cast and compartment syndrome
always remove cast immediately if pt presents with pain under recently placed cast
—do not select analgesics or XR to confirm bone placement
what are pulses in compartment syndrome
presence of pulses does NOT rule out compartment syndrome
what is the buzzword for compartment syndrome
severe pain with passive extension
how do you manage exposed bone
OR, clean, cover, close bones within 6 hours
to avoid infection, osteomyelitis
what is dx in pt who hit dashboard with knees
posterior dislocation of hip
drives the femur out of the socket backwards
how do you manage posterior hip dislocation
reduction ASAP to prevent femoral head necrosis
what is likely dx in pt who stepped on rusty nail –> swollen dusky foot w/ gas crepitus 2-3 days later
gas gangrene
how do you manage gas gangrene
requires extensive debridement +/- amputation
immediate tx:
large doses IV penicillin
surgical debridement (bugs feed on dead tissue)
hyperbaric O₂ to deactivate toxin
life threatening soft tissue infection
–can happen to anyone (vs an infection mostly happening in an immunocompromised/diabetic pt)
how do you evaluate nerve symptoms in a bone injury
reduce fracture and re-evalutate nerve function
(ex humeral fracture could damage radial nerve)
you could trap nerve when splinting bones and cause nerve symptoms
–need open reduction to unwrap nerve
what artery is damaged with posterior dislocation of knee
popliteal artery
how do you manage popliteal artery damage
immediate reduction of posteriorly dislocated knee w/ Doppler, pulses, arteriogram studies
feeble collateral circulation could cause damage –> leg loss
what is dx in pt who falls and lands on feet
compression fracture of thoracic and lumbar spine
what should you also check in a pt with facial trauma
check cervical spine
what should you look for in pt with dashboard MVC injury
XR hip in MVC to evaluate a posterior dislocation of femur
what is dx in pt with numbness/tingling in hand, esp at night, esp hanging hand limply, esp pressing on carpal tunnel or pericostal
carpal tunnel syndrome
what nerve distribution is involved with carpal tunnel syndrome
median nerve distribution (radial 3.5 fingers)
how do you dx and manage carpal tunnel syndrome
dx: XR including carpal tunnel views
tx: splints and anti-inflammatories
- –do not inject steroids
- –pt may need electromyography +/- surgery
what is dx in pt with finger acutely flexed; unable to extend; painful snap; almost exclusively F
trigger finger
how do you manage trigger finger
steroid injections
what is dx in pt with painful radial wrist and 1st dorsal compartment; pain w/ flexion and simultaneous thumb extension
deQuervain’s tendosynovitis
what are 2 unique actions that elicit pain in a pt with deQuervain’s tendosynovitis
pain w/ holding baby head
pain w/ holding thumb inside closed fist and forcing wrist into ulnar deviation
how do you tx deQuervain’s tendosynovitis
steroid injections
what is dx in pt with contracted hand; can no longer be extended; palmar fascial nodules palpated; commonly in Scandinavian M or chronic alcoholic
Dupuytren’s contracture
how do you tx Dupuytren’s contracture
surgery to free up fascia
what is dx in pt with abscess in pulp of index finger w/ throbbing pain, fever
felon
what is concern in pt with felon
pulp of finger has fascial trabeculae made for closed spaces
swelling –> necrosis
how do you tx felon
immediate surgical decompression
what is dx in pt with injury of ulnar collateral ligament of thumb
Game Keeper’s thumb
what is PE in game keeper’s thumb
collateral laxity at 4th metacarpal phalangeal joint from thumb jam
can be dsyfunctional/painful –> arthritis
what activity commonly causes Game Keeper’s thumb
skiing
thumb jam
how do you tx game keeper’s thumb
casting for opportunity to heal
what is dx in pt with injury to flexor tendon, for example when grabbing another person’s shirt
jersey finger
what is PE in jersey finger
distal phalanx of ring finger doesn’t flex with others when making a fist
how do you manage jersey finger
splint
what is dx in pt with injury to extensor tendon; for ex when playing volleyball
mallet finger
what is PE in mallet finger
distal phalanx cannot extend; tip of finger remains bent down; looks like hammer/mallet
how do you manage mallet finger
splint
how do you manage a severed finger
clean severed finger with sterile saline
wrap in saline-moistened gauze
place in plastic bag
then on bed of ice
what is prognosis for severed fingers
replantation of severed extremities is done only for very distal parts
nerve regneration is limited, and replanting a denervated part is not useful
what is dx in pt who has vague back pain that turns into “electrical shock” down the leg; severe back pain when lifting heavy objects; aggravated by sneezing, coughing, ambulating, or straining; pt will keep legs flexed to avoid pain
lumbar disc hernia
how do you dx lumbar disc hernia
straight leg raise test produces excruciating pain
what is dx in pt who has vague back pain
disc bulge (discogenic pain)
the disc bulge pushes anterior spinal ligament to cause the vague back pain
what is pathogenesis of lumbar disc hernia
first you have a disc bulge that pushes anterior spinal ligament, producing vague back pain
then, a sudden/violent motion will herniate disc
compresses nerve root
gives you severe neurogenic root pain (“electric shock”)
where is disc herniation located if pain radiates to big toe vs little toe
pain radiating to big toe = L4/L5
pain radiating to little toe = L5/S1
how do you dx and manage a herniated disc, including 2 exceptions?
dx with MRI image (two soft tissue structures: disc and nerve)
bed rest for 3 weeks
2 exceptions:
- -neurosurgical intervention if there’s progressive weakness
- -sphincter defects are an emergency (rectum, bladder, etc); likely permanent if not quickly reversed
what is dx in pt with “herniated disc” symptoms + distended bladder, flaccid retrosphincter, and perianal saddle anesthesia
cauda equina syndrome
how do you manage cauda equina syndrome
surgical emergency
what is dx in young M (20s-30s) with chronic progressive back pain that improves with activity (worse in the morning)
Ankylosing spondylitis
what imaging goes with ankylosing spondylitis
eventually shows bamboo spine
how do you manage ankylosing spondylitis
anti-inflammatories and PT
what ulcer commonly presents:
pressure point, usually foot
classically the heel or 1st metatarsal
painless (neuropathy)
diabetic ulcer
why do diabetic ulcers not heal wel
ulcer develops and does not heal due to poor peripheral vascular supply
what is management of diabetic ulcer
control diabetes, stay in bed, keep leg horizontal
most diabetics suffer amputation; however, healing is possible
what ulcer commonly presents:
atherosclerotic disease causing ulcer at tip of toe- blue/pulseless
ischemic ulcer
how do you manage ischemic ulcers, depending on vessel size
big vessel: surgery, bypass big vessels
small vessel: surgery does not help
take BP at certain points to determine pressure gradient/blockage (or Doppler)
- -no pressure gradient = no single point that can be bypassed; not a surgical candidate
- -pressure gradient = next do an arteriogram for obstruction details
what ulcer commonly presents:
above medial malleolus in hyper pigmented, edematous skin;
cellulitis
varicose veins
venous insufficiency ulcer
how do you manage venous insufficiency ulcer
provide support so peripheral superficial veins are not engorged with blood
stockings, compression, stiff support, possible varicose vein surgery
what cancer commonly develops in longstanding site of chronic irritation
squamous cell carcinoma
what is this a classic story for:
chronic draining sinus in lower leg for years since osteomyelitis; but recently developed indolent, dirty ulcer with heaped up edges
squamous cell carcinoma
what is this a classic story for:
chronic shallow ulcerations at burn scar site that heal/break down, but recently developed indolent dirty ulcer w/ heaped up edges that are not getting smaller
squamous cell carcinoma
how do you dx and manage squamous cell carcinoma
biopsy of edge of ulcer where heaped up edge is
treat with wide resection and skin grafting
what is dx in chronic inflammation of plantar fascia pulling, leading to bony spur
plantar fasciitis
what presents with sharp heel pain with every strike on the ground; worse in the AM; with a bony spur matching pain site on XR and tenderness over bony spur on PE
plantar fasciitis
how do you manage plantar fasciitis
supportive analgesics
rigged devices of stepping (NOT excision of the bony spur)
it usually goes away 1-2yrs
what is dx in F wearing high heel/pointed shoes or a Cowboy wearing pointed boots
w/ pain from prolonged standing/walking; PE will be very tender on 3rd interspace
Morton’s neuroma
what nerve is inflamed in Morton’s neuroma
common digital nerve
pointed shoes
what is management of Morton’s neuroma
conservative management
wear better shoes
excision of neuroma
what is dx in pt with red, painful swelling of 1st metatarsal joint
gout
how do you dx and manage gout
dx: serum uric acid level or uric acid crystals in joint fluid
manage: medical (colchicine, allopurinol, probenecid)
what cardiac risk factors need to be considered in a pre-op assessment
EF <35% = high risk of intraoperative MI
Goldman’s findings- high operative risk for non-cardiac surgery:
–age, chronically bedridden, emergency operation, major body cavity, recent MI, A-fib, premature ventricular beats, JVD
CHF (JVD), esp in elective surgery
recent MI, esp <6mo ago
Angina + AAA
what is your mortality risk in a non-cardiac operation with a recent MI vs non-recent MI
MI <6mo ago = 40% mortality
MI >6mo ago = 6% mortality
what should be done first in a pt with angina and AAA to improve operative cardiac risk
coronary revascularization before AAA repair
how do you assess an operative pt’s pulmonary risk
smoking and ability to ventilate (vs oxygenate)
quantify with blood gases (high pCO2) or pulm studies (FEV1 = ability to ventilate)
what value does FEV1 represent
ability to ventilate
how can you reduce an operative pt’s pulm risk prior to surgery
cessation of smoking for 8 weeks
incentive respiratory therapy (PT, expectorants, IS, humidified air)
1st week of cessation = bronchorrhea and mucus secretions
how do you assess a surgical pt’s hepatic risk
liver function is important for anesthetic operation
high Bil due to hepatocellular dysfunction = high risk
—can operate if high Bil is due to obstruction/hemolysis
high PT
low serum Alb
encephalopathy
high ammonia
how do you assess a surgical pt’s nutritional risk
unable to eat / weight loss = malnutrition
serum Alb <3
allergy to skin test antigens
serum transferrin level <200
brief prior, intense nutritional support can lower operative mortality; preferably 7-10 days
what must be done for DKA pts before an operation
cannot operate in DKA
need to rehydrate pt; no coma; begin to fix acidosis; lower blood glucose first
what is dx in pt who develops intraoperative fever shortly after onset of general anesthesia >104
malignant hyperthermia
what is pathology of malignant hyperthermia
congenital absence of enzyme needed to break down succinylcholine, so you generate heat from muscle activity
what do lab values look like in pt with malignant hyperthermia
fever >104
metabolic acidosis
hypercalcemia
FHx
how do you treat malignant hyperthermia
IV dantrolene (different MOA than succinylcholine) to stop muscle activity
100% O₂
cooling blankets
correct the acidosis
monitor for myoglobinemia/uria and treat accordingly
how do you assess surgical pt’s aspiration risk
prefer to prevent vs treat
can kill pt or cause chemical injury to bronchial tree–> failure
NPO before elective surgeries
–give pts anti-acids pre-op
how do you manage aspiration once it’s happened
bronchoscopy to lavage and remove particulate matter
bronchodilators and respiratory support
how might an intraoperative pneumothorax happen
giving a pt positive pressure ventilation and a bleb breaks –> one way valve into pleural space
what values indicate an intraoperative pneumothorax
BP decreases as CVP increases
how can you manage an intraoperative pneumothorax
surgeon can poke a hole in the diaphragm w/ needle
place a chest tube at end of procedure
what is dx in pt with post-op fever immediately after surgery
bacteremia
how do you manage post-op bacteremia
blood cultures x 3
empiric Abx
what are the 4 W’s in the ddx of post-op fever (actually 6)
Wind Water Walking Wound Wonder Where Wonder drugs
go through “wind” post op fever
♣ POD1: Inability to ventilate; atelectasis
• Tx: improve ventilation, breathing, coughing, IS, chest drainage
• Bronchoscopy rarely needed
♣ If continues to ~POD3 –> pneumonia
• Tx: CXR, Abx, sputum cultures
go through “water” post op fever
♣ POD3: Urinary Tract Infection
• Dx: urinalysis
go through “walking” post op fever
♣ POD5: DVT
• Could do Doppler studies of deep vein flow restrictions
go through “wound” post op fever
♣ POD7: Wound infection
• Only erythema = Abx
• Pus = needs to be drained
o Sonogram helps
go through “wonder where” and “wonder drugs” post op fever
Wonder where:
♣ POD10: Deep abscess infection
• Subphrenic, subhepatic, or pelvic abscess
• CT or sonogram to visualize
Wonder drugs:
♣ Potential cause when everything else has been ruled out
what are the 2 big things on your ddx for post-op chest pain
MI POD 1-2
PE POD 5-7
how do you dx and manage post-op MI
dx: EKG, cardiac enzymes; usually POD 1-2
cannot lyse clots in a fresh post-op pt
have to treat the complications of MI but without blood thinners
what is seen in a preoperative MI
ST depression, T wave flattening; commonly 2/2 hypotension
dx: CK, CK-MB isoenzyme
how does post-op PE present
POD 5-7
sudden severe SOB and pleuritic chest pain; prominent veins, anxious, diaphoretic, tachy
how do you dx post op PE
ABGs show hypoxemia and hypocapnia
- -cannot get O₂ into blood, but pt is also hyperventilating
- -all areas that are perfused are ventilated; hypocapnia/hypocarbia is classic
V/Q scan only works if lungs are otherwise normal
spiral CT
what lab values distinguish PE vs respiratory failure
PE:
hypocapnia/hypocarbia (classic)
–all areas that are perfused are ventilated
respiratory failure:
hypoxemia and hypercarbia
–cannot get O₂ in and CO₂ out of blood
how do you manage post-op PE
anti-coagulation to prevent new clots (Heparin)
–lungs will lyse the existing clot
vena cava filter if the pt has experienced a PE while on anti-coagulators
what is the ddx for disorientation
post-op hypoxia
drug overdose; hypoglycemia
ARDS
Delirium tremens
Acute water intoxication
diabetes insipidus
ammonium intoxication
what is initial work-up of post-op disorientation
check ABGs for pulmonary insufficiency –> hypoxia
–inadequate brain oxygenation
what should be an initial thought of pt in ER in coma
possible drug overdose, hypoglycemia (insulin)
–inject with 50% dextrose
what is the classic story for an ARDS pt
classically in a long, complicated post-op pt
–good chance that sepsis is present
what is the work-up for post-op ARDS
CT scan to look for source/drainage
what will you see in post-op ARDS
pulmonary infiltrates, low pO2, no evidence of CHF
how do you manage post-op ARDS
mechanical respiration support and PEEP; max 40% O₂ long-term
PEEP: allow some degree of hypercapnia to not push more than necessary
what is dx in post-op alcoholic who is disoriented, combative, hallucinating
delirium tremens
how do you manage delirium tremens
IV 5% alcohol and 5% dextrose
psychiatrists disagree- tx addiction w/ non-addictive agent
what is likely dx in pt who is hours post-op with confusion, lethargy, HA, grand mal seizures, and coma
acute water intoxication
their 5% dextrose in water infusion was running way too high
(a large fluid that does not include Na –> water retention)
what will pt get with acute water intoxication
SIADH (metabolic response to trauma)
how do you dx acute water intoxication
serum Na concentration is low (water retention is diluting Na)
how do you manage acute water intoxication
high morbidity and mortality scenario
carefully administer hypertonic saline
- acute hyponatremia + CNS symptoms = brain has not adapted
- -acceptable to use hypertonic saline
what is dx in pt hours post-op who is lethargic, confused, comatose
with high UOP despite normal IV fluid rate
Diabetes insipidus
what is pathology of diabetes insipidus
inability to produce ADH
surgery was ~near pituitary; transient interference
how do you diagnose diabetes insipidus
serum Na concentration is high (losing water in urine)
how do you manage diabetes insipidus
rapidly reverse with several liters of D5W or diluted 1/3 to 1/4 normal saline
or ADH absorption via nasal mucosa
what is dx in pt with liver failure and delirium
ammonium intoxication
how might a pt with ammonium intoxication present with labs
liver failure:
cirrhotic, hypokalemic alkalosis, high CO, low PVR
delirium
bleeding varices (belly full of blood)
what is pathogenesis of ammonium intoxication
pt has hepatic failure/ delirium, and is bleeding from varices (belly full of blood)
blood from GI tract is absorbing ammonium
liver cannot convert it to ammonia
how do you manage ammonium intoxication
clean out bowel with enemas
locally acting Abx to rid the ammonium source
what is the story of a pt with post-op urinary retention
needs to void but unable
palpable suprapubic mass dull to percussion
how do you manage post-op urinary retention
catheter into bladder to empty
if you need to do it 2 or 3 times, some docs will leave in an indwelling catheter
or a prophylactic catheter (common/predictable problem)
what is the likely dx in a pt with zero UOP
mechanical problem-
plugged/kinked catheter
what are the 2 possibilities of a pt with oliguria (low UOP with normal vital signs)
pt is either behind on fluids or in acute renal failure
walk through the 3 tests to distinguish between behind on fluids vs Acute Renal Failure
Test:
bolus 500cc IV NS over 10-20min
–pt behind on fluids will increase UOP
–pt in renal failure is already making max UOP; the bolus won’t improve UOP
Test:
measure urine Na
–pt behind on fluids (dehydration) Na conc <20mEq/L (good kidneys; they’re holding onto fluid via Na retention)
–pt in renal failure will have urinary Na conc >40mEq/L (bad kidneys; making plasma filtrate; cannot change Na conc)
TesT:
fractional excretion of Na
–Dehydration <1
–Renal failure >1
how do you manage a dehydrated pt vs a renal failure pt with oliguria
dehydrated: fluid administration
renal failure: fluid restriction
what are 3 things on the ddx for post-op abdominal distension
post-op paralytic ileus
mechanical obstruction
Ogilvie syndrome
what is dx in pt with ~POD4 abdominal distension w/o pain; no bowel sounds/flatus vs ~POD6-8
POD4 = post-op paralytic ileus POD6-8 = mechanical obstruction
what does XR show in post-op paralytic ileus
dilated Small bowel loops w/o air-fluid levels
what lab abnormality can perpetuate a paralytic ileus
hypokalemia
what does barium study show in a paralytic ileus vs obstruction
inject 30cc via NG tube:
paralytic ileus: barium goes to colon
obstruction: barium stops moving
how do you manage a post-op mechanical obsturction
re-operation to fix adhesions/anastamotic defect
what is likely dx in pt with ~POD5 abdominal distension; tense, but not tender; and occasional bowel sounds; typically elderly M who isn’t active, then further immobilized from surgery
Ogilvie syndrome
what does XR in Ogilvie syndrome show
massively distended colon w/ a few distended small bowel loops
what is management of Ogilvie syndrome
colonoscopy
- -suck out gas that’s diluting the colon
- -rule out cancer of the colon
- -long rectal tube left in place for continued gas exit
rarely, a cecostomy or colonostomy is needed
what is dx in pt with salmon-colored clear fluid soaking wound dressings, and what is that fluid
wound dehiscence
peritoneal fluid
what causes wound dehiscence
deeper layers of surgery have failed to heal before skin heals
how do you manage wound dehiscence
careful protection of wound
keep in bed; don’t move
tape the wound together; use abdominal binders
later: re-operate to prevent vental hernia (non-emergency)
what is the concern with wound dehiscence
could turn into evisceration
- -wound opens and small bowel falls out
- -emergency; high morbidity/mortality
how do you manage evisceration following wound dehiscence
pt back to bed, cover bowel w/ moist dressings soaked in warm saline
- -rush to OR for immediate closure
- -do not allow bowel to dry out
- -avoid hypothermia
what is dx in pt with ~POD7 fever and red, hot, tender wound
wound infection
how do you manage wound infection caused by either cellulitis or abscess
cellulitis: Abx directed toward nl skin flora
Abscess: drainage (check via sonogram)
what is dx in pt with luminal content leaking through belly and afebrile
fistula
describe fistula fluid from proximal GI tract
high volume 2-3 L /day
causes a fluid/electrolye/nutirition problem because the fluid has digestive enzymes digesting the abdominal wall
how do you manage proximal GI fistula
maintenance fluids and replacement electrolytes (LR)
nutritional replacement distal to fistula (NPO)
protection of abdominal wall; do not let fluid soak dressing; protect skin
describe fistula fluid from distal GI tract
low fluid / nutritional absorption /enzymes
non-life threateningn
what happens with most GI fistulas 2/2 anastomosis
most heal unless something is preventing closure
what would cause fistula closure prevention
"FETID" foreign body Epithelialization Tumor Infection Irradiated tissue IBD Distal obstruction
requires surgical intervention
describe epithelialization in a GI fistula
granulation tissue grows from conduit while epithelium is migrating from inside the lumen
long and narrow hole = granulation tissue will win and fill epithelium
short and wide hole = epithelialization; hole will not close
what is likely dx in pt with hypernatremia (water loss) 2/2 surgery acutely
DI
how do you manage acute DI
diluted fluid to replenish loss with several liters of D5W, 1/3 to 1/4 NS +/- ADH
every 3mEq that serum Na is above 140 represents ~1L water lost
what is likely dx in pt who is awake/alert but hypernatremia (dehydrated)
chronic hypernatremia
- selectively lost water
- developed hypernatremia over ~days, so the brain has adapted (normal mentation)
how do you manage chronic hypernatremia
reverse the volume loss over ~hrs to improve hemodynamics/kidneys
correct the hypertonicity over ~days
using 5L D5 1/2 NS
–fluid that’s neither as diluted as D5W nor as concentrated as NS
–rapid correction of volume and ~modest/safe impact on tonicity
what is likely dx in pt with hyponatremia (water gain_ 2/2 rapid drip of Na-free soln during an inappropriate ADH response to trauma
acute water intoxication
every cell is swollen, including the brain
–> comatose
how do you manage acute water intoxication
hypertonic 3-5% Saline in small quantities
mannitol
what is likely dx in pt who is alert/awake but hyponatremia (water retention)
chronic hyponatremia
too much ADH
hyponatremia has developed over ~days, so brain has adapted (normal mentation)
how do you manage chronic hyponatremia
slow correction of serum Na
- -water restriction (cannot take away the excess ADH in the body)
- -meds to counteract ADH effects
a rapid correction would cause central pontine lysis of myelin
what is pathogenesis in “loss of hypertonic fluids” or “selective loss of Na”
doesn’t realistically happen- no mechanism to selectively lose Na to cause chronic hyponatremia
first, the pt begins losing isotonic fluids via vomiting (Na-containing, but still isotonic)
–the initial insult is dehydration w/o tonicity change
several days –> volume depletion; pt is likely unable to eat/drink, so cannot replace fluids being lost
–body is eager to retain fluids at this point
pt drinks Na-free fluid (water/soda vs HCO3/Na) –> production of free water
- -body is willing to sacrifice tonicity to retain volume
- -fluid drank is stained
- -does not correct vol depletion; you’ve created a tonicity gradient, so the water ends up in cells but with a low serum Na due to retaining water and losing isotonic fluids
the pt lost isotonic fluid then eventually retained water –> hyponatremia
how do you manage chronic hyponatremia
slowly correct the hyponatremia with rapid correction of volume replenishment
use isotonic fluids to rapidly correct the volume and slowly correct tonicity
NS: when pt is alkalotic (vomiting gastric acid and juice)
LR: when pt is acidotic (vomiting small bowel content, bile, pancreatic juice, alkaline fluids)
how do you manage severe DKA
insulin + IV fluids + K
what is the rationale for giving K to a DKA pt
pt is acidotic
–excessive H+ in blood is pushed into cells in exchange for K being brought out of cells
high K in blood is seen by the kidneys, so kidney puts K into urine
when you correct the pt’s acidosis, the H+ goes back into the blood, and K tries to go back into cells
–> profound hypokalemia
what is the normal safe upper limit of K administration in a normal vs DKA pt
normal pt:
10 mEq/hr = 24 mEq/day
DKA pt :
20 mEq/hr = 480 mEq/day
what lab abnormality are you likely to see after a crush injury
hyperkalemia
adding K to the blood via:
- -crushed/killed cells
- -blood transfusions (hemolysis in the blood bank as blood ages)
- -acidosis with H+ moving into cells
how do you manage dangerous hyperkalemia 2/2 crush injury
dangerous hyperkalemia >6
hemodialysis (long process)
50% glucose and insulin to create momentary anabolic phase (K into cells)
GI tract to remove K (NG suction)- not effective
–Kayaxolate resins: exchange Na for K in lower GI
IV Ca administration: highly effective and protective of myocardium while waiting for hemodialysis
run through metabolic acidosis with pH 7.1 pCO2 36 Na 138 Cl 98 HCO3 15
look at pH = acidosis
look at pCO2; low = hyperventilating to try to compensate by breathing faster and removing CO₂ and therefore acid
causes:
either excessive production of acids, insufficient buffering from HCO3 loss, or inability of kidney to make necessary adjustments
–renal acidosis takes several days to develop
–HCO3 loss: biliary fistula, pancreatic fistula ostomy output, diarrhea
–high H+ production: pt is in a low-flow state (shock, hypotension, not perfusing well, cells using anaerobic metabolism with high lactic acid levels)
how do you manage metabolic acidosis with pH 7.1 pCO2 36 Na 138 Cl 98 HCO3 15
correct the underlying problem
this pt needs rehydration to correct the low-flow state so the pt can correct the acidosis
- -fluid that doesn’t compound the existing acidosis
- -use LR, a primary volume expander, which also contains a little HCO3
giving HCO3 or a precursor (like acetate/lactate) does not address the volume problem
- -give HCO3 if pt is losing HCO3 via fistula and doesn’t have enough to buffer
- -do not give NaHCO3: it makes a ppt
run through hypochloremic metabolic alkalosis 2/2 loss of acid gastric juice
protracted vomiting of clear gastric contents ~days
need to rehydrate and also correct the metabolic alkalosis
–rarely, provide hydrogen NH4Cl or HCl diluted in amino acid solution (buffers)
how do you manage hypochloremic metabolic alkalosis 2/2 loss of gastric acid and juice
help the kidney correct the problem
kidney can: bring in NaCl, NaHCO3, or exchange Na/K or Na/H
pt is alkalotic in this scenario (H+ depleted)
–do not want to put H+ into urine or retrieve HCO3-
want to: bring in NaCl or exchange Na for K
- -give generous KCl to retrieve Na without using HCO3/H+
- -only works if pt has functioning kidneys
when should you use pH monitoring to evaluate esophagus
use in pain that cannot be well characterized and cannot be timed
how can you dx reflux with pH monitoring
if pain coincides w/ low pH: reflux
when do you use manometry to evaluate esophagus
use if pt has horrible pain w/ every swallow; uncoordinated contractions
what is dx in pt who has burning, retrosternal pain and heartburn w/ bending, tight clothes, lying flat;
symptomatic relief with antacids, seems to be progressive; present ~yrs
GERD
how do you dx GERD
endoscopy and biopsy to determine extent of damage
how do you manage severe peptic esophagitis
surgery is indicated if there’s progression despite strict adherence to PPI meds
how do you manage Barret’s esophagus
this is pre-malignant
–a Nissen fundoplication only helps with acid reflux
you need intensive treatment directed at acid
- -PPIs can take care of histological damage, but high doses are required for a long time
- -may create a carcinoid tumor 2/2 PPI from long-term achlorhydria
what is the purpose of each study before esophageal surgery
- endoscopy
- manometry
- gastric emptying study
- barium swallow
endoscopy: evaluate extent of mucosal damage
manometry: evaluate motility
gastric emptying study: evaluate for pyloric obstruction
barium swallow: evaluate location of LE sphincter and GE junction
what is dx of pt with difficulty swallowing liquids > solids
achalasia of esophagus
what type of problem is achalasia
functional/motility problem
which esophageal problem starts with difficulty swallowing solids
mechanical problem
what is this a classic story for:
middle aged F who sits up straight when eating; has regurgitation of undigested food, like finding food on a pillow
achalasia
how do you dx achalasia
manometry to assess motility
–establishes that LE sphincter doesn’t relax
(Barium swallow/ endoscopy would both show mega-esophagus, but not the nature of the problem)
how do you manage achalasia
treat medically with repeat dilations
or surgery with Heller myotomy
which esophageal cancer classically develops with history of smoking, drinking, and black race
squamous cell carcinoma
which esophageal cancer classically develops with long-standing GERD
adenocarcinoma
progresses from Barrett’s esophagus
how do you dx cancer of esophagus
first, Barium swallow to visualize tumor and amount of lumen left to avoid perforation
then CT to determine surgical candidacy
Endoscopy and biopsy
Trans-hiatal esophageestomy for short-term palliation
what is tear in mucosa of esophagus 2/2 repeated vomiting and profuse bright red blood
Mallory Weiss Tear
how do you dx Mallory Weiss tear
endoscopy to visualize bleeding point
how do you manage Mallory Weiss tear
photocoagulation to stop bleeding
what is perforation of lower esophagus 2/2 repeated/forceful vomiting with sudden onset of wrenching epigastric pain and lower sternal pain; diaphoretic, febrile, and WBC count
Boerhaave syndrome (rare)
how do you manage Boerhaave syndrome
prognosis depends on timing of dx/tx
begin with gastrographing swallow (water-soluble solution)
–bad quality pictures, but safe if the fluid extravasates (vs harmful high-quality Barium swallow)
Negative gastrography –> Ba swallow study
immediate surgical repair of perforation
what is dx in pt with severe, constant, retrosternal pain ~hrs after GI endoscopy;
febrile, diaphoretic, subQ emphysema
instrumental perforation of esophagus
how do you manage instrumental perforation of esophagus
begin w/ gastrographing swallow
- -positive –> surgical repair
- -negative –> Ba swallow
Abx and overnight watching if the tear is very small
if the perforation was made ~3 days ago, you need to do an esophageal derivation in the neck (cannot repair now with all of the inflammation)
–derivation at GE junction; and eventual esophageal repalcement
what is likely dx in older pt with weight loss, anorexia, and epigastric discomfort
stomach malignancy
how do you manage a suspected stomach cancer
endoscopy and biopsy
–you don’t need a Barium swallow because there’s enough lumen to not require a safety roadmap
if the biopsy shows cancer,
do a CT scan to determine if it’s resectable,
then surgery
what is likely dx in pt with protracted colicky abdominal pain; vomiting, hyperactive bowel sounds; progressive distension
mechanical obstruction of small bowel
what will XR show in mechanical small bowel obstruction
distended bowel loops and air-fluid levels
what is most likely causes of mechanical bowel obstruction
2/2 previous surgery adhesions
how do you initially manage mechanical small bowel obstruction
since the SB has avoided falling into adhesion trap in the past, it is likely that the bowel can un-trap itself
manage w/ NG suction, NPO, IV fluids, and wait to let the bowel extricate itself
how do you manage a partial vs complete small bowel obstruction
complete:
typically willing to wait 24 hours before taking to the OR
partial:
typically willing to wait 3-5 days
monitor pt for deadly complication:
bowel becomes wedged/compromised/strangulated
–pt will have early fever/WBC –> constant pain/peritoneal –> peritonitis –> septic shock
–immediate OR if pt begins to develop these signs
what is dx in pt with SB obstruction + growing mass that’s no longer reducible
strangulated/incarcerated hernia
how do you manage strangulated/incarcerated hernia
OR
–esp if discolored/strangulated/fever/WBC
operate electively, even if not strangulated, to indefinitely fix problem
what is likely dx in pt with protracted diarrhea, bizarre h/o flushing face, expiratory wheezing, prominent JVD?
carcinoid syndrome/tumor
where is carcinoid tumor likely to be
in small bowel / ileum
why does a carcinoid tumor produce its particular symptoms
carcinoid tumor is serotonin-producing
serotonin is normally deactivated in the liver, but if the pt has liver mets, the serotonin may dump into IVC –> systemic serotonin
- -R heart damage (JVD)
- -lungs can deactivate serotonin, so L heart is protected
how do you dx carcinoid tumor
serum 5-HIAA (byproduct of serotonin breakdown)
how do you manage carcinoid tumor
remove primary tumor
treat/remove liver mets
tends to be slow growing, so any palliative effort is helpful
what is likely dx in young adult w/ anorexia, vague periumbilcial pain –> sharp, severe, constant, well-localized RLQ pain with guarding/rebound tenderness
acute appendicitis
what will pt labs look like in acute appendicitis
mild fever w/ WBC count
L shift neutrophilia
how do you dx acute appendicitis
based on clinical presentation;
additional lab tests aren’t necessary
how do you manage acute appendicitis in a pt before vs after perforation
before: emergency appendectomy
after perforation: appendectomy; ICU with prolonged post-op care
what are 98% of colon cancers
adenocarcinomas (grow out of mucosa)
–can impinge along lumen or bleed
how do you dx colon cancer
endoscopy and biopsy
start with flexible sigmoidoscopy to evaluate L sided cancer (any doc can do)
then do a full-length colonoscopy for R/L sided cancer
(done by surgeon doing the full colonoscopy)
how do you manage colon cancer
blood transfusions
CT scan to assess OR candidacy
cancers are often multi-centric
colectomy
what is dx in classic pt with anemia + occult blood in stool
R sided olon cancer
why is impingement unlikely in R sided colon cancer
liquid feces + larger lumen
what is dx in classic pt with change in bowel habits, constipation, and change in caliber/shape of stool (“toothpaste”); with blood visibly surrounding already-solid feces
L sided colon cancer
what should you think with villous adenoma in rectum and adenomatous polyps in the descending/sigmoid colon
most likely to be malignant:
a pre-malignant condition of Familial polyposis (Gardner’s syndrome)
–it’s ~100% predictive to progress to cancer
–should do proctocolectomy
next most likely to be malignant: villous adenoma
- -50% progress to cancer
- -should do resection
next most likely: adenomatous polyp:
- -remove, often endoscopically
- -surgery if sessile
no malignant potential: Juvenile polyps, Peutz Jehgers, or inflammatory/hyperplastic polyps
–no surgery is necessary
what are the indications for surgery in chronic ulcerative colitis
> 20 yrs of UC = risk of malignancy
low weight many hospitalizations (interfering with nutritional status or lifestyle of pt)
needing long-term steroids to control disease
toxic megacolon (abdominal pain, fever, distended transverse colon) --emergency
what determines need for surgery in ulcerative colitis
surgery depends on extent of disease
- rectal mucosa will always be removed
- ileoanal anastomosis or ileostomy
what is likely dx in pt with watery diarrhea, crampy pain, febrile, WBC, and usually told specific Abx treatment (esp taking clindamycin)
pseudomembranous enterocolitis 2/2 Clostridium difficile
how do you dx pseudomembranous colitis 2/2 C diff
stool cultures (takes time)
proctosigmoid scope exam (helpful if disease is severe)
best: toxin in stool with kit (rapid)
how do you manage pseudomembranous colitis 2/2 C diff
stop offending Abx
do not use anti-diarrheal (keeps toxin in GI)
some docs prefer vancomycin or metronidazole or replenish normal flora
what does the management of anal/rectal problems always begin with
always begin with r/o cancer
–never prescribe meds over the phone
do rectal exam and proctosigmoid exam to r/o cancer
what is likely dx in BRB after bowel movement; painless
internal hemorrhoids
how do you manage internal hemorrhoids
rubber band ligation or laser/destruction
what is likely dx in painful perianal area w/o blood
external hemorrhoids
how do you manage external hemorrhoids
formal operation w/ anesthesia
what is dx in pt w/ severe pain with defecation and blood streaks, causing them to avoid BMs and not allow a PE
anal fissure
what is anal fissure thought to be caused by
thought to be 2/2 tight sprinter tone, causing limited blood supply, and unable to heal the tears
what is management of anal fissure
first examine pt to r/o cancer
–likely have to do under anesthesia since pt might refuse a painful PE
manage conservatively:
- -stool softeners and topical agents
- -nitroglycerin cream to relax sphincter
surgical management:
–lateral internal sphinterotomy, forceful dilation, Botox injections to paralyze sphincter
what should you suspect in a pt w/ h/o operation making a perianal fistula worse, causing an unsealing ulcer and purulence
Crohn’s disease affecting the anus
how should you manage crohn’s disease affecting the anus
rectal endoscopy exam to r/o necrotic cancer
what is likely dx in pt saying it’s painful to sit or have BM, fever/chills; hot, tender, red defluction mass between anus and ischial tuberoscity
anorectal abscess
how should you manage anorectal abscess
r/o cancer or a fun gating tumor
drain all abscess with I&Ds
what should you think in a diabetic/immunocompromised pt with an anorectal abscess
if pt is diabetic/immunocompromised: the abscesses tend to be the beginning of necrotizing fasciitis
–treat with close F/U over next few hours to monitor the development of a soft tissue infection
when will an anal fistula develop
only in pts who have previously had ischial rectal abscess drainage
the abscess bacteria comes from anal crypts of the anal canal
drained through skin of perineum
epithelial migration
tract formation
how will an anal fistula pt present
pt must have previously had an ischial rectal abscess drainage
fecal streaks soiling underwear
PE shows perianal opening in skin and cord-like tract palpated from opening to inside
how do you manage anal fistula
r/o cancer
then surgery to to unroof the fistula so granulation tissue can fill in the tunnel
what is dx in blood coating the outside of stool + changed bowel habits
sigmoid adenocarcinoma
where does sigmoid adenocarcinoma metastasize to
metastasis only to Lymph nodes inside abdomen
what is dx more likely in an HIV+/homosexual pt (no viral connection)
grows close to anal canal opening; often felt as mass protruding from anus
squamous cell carcinoma of anus
where does squamous cell carcinoma of anus metastasize to
metastasizes to lymph nodes inside abdomen (like sigmoid adenocarcinoma),
but ALSO GROIN NODES
how do you dx and manage squamous cell carcinoma of anus
dx: biopsy the mass
manage: best to first shrink before surgery
- -Nigro protocol: combo of chemo + radiation
- -+/- resection if necessary
where are pts likely to be bleeding from in a GI bleed, statistically
75% pts are bleeding from upper GI
(nose to Ligament of Trietz in duodenum)
25% of pts are bleeding from distal GI tract
(mainly colon)
which location of bleed is common in younger vs older pts
upper GI: common in younger pts
lower GI: common in older pts (except hemorrhoids)
–elderly = equal opportunity bleeders
what are 5 things possibly causing a lower GI bleed
hemorrhoids, polyp, cancer, angiodysplasia, diverticulosis
what does vomiting blood tell you
upper GI bleed
how do you identify upper GI bleed site
endoscopy easily identifies an upper GI bleed site
–blood goes away as soon as you pass lesion
how do you manage upper GI bleed
stop bleeding with photocoagulation
what does a GI bleed with an NG tube w/ clear green fluid w/o blood mean
the fluid contains bile; you’ve sampled the duodenum
you can r/o it as a source of bleeding
what does a GI bleed with an NG tube w/ clear white fluid w/o blood mean
you can r/o the tip of the nose to the pylorus as a source of bleeding
–could still be in duodenum
when is a lower endoscopy/colonoscopy not helpful in locating a GI bleed
if the pt is presently and significantly bleeding
–it’s too bloody distal to the lesion
what imaging is helpful to r/o hemorrhoids
anoscopy
what imaging is helpful in >=2cc/min GI bleeding
arteriogram
how do you calculate the extent of GI bleeding
calculate how often you’re perfusing to keep stable vitals
2cc/min = 120cc/hr = every 4 hours a unit of blood is required
<5cc/min = every 16 hours a unit of blood is required (no arteriogram)
when can you perform a colonoscopy to evaluate a small bleed <5cc/min
after bleeding as stopped
what study can be done to evaluate “in-between” bleeds of 0.5-2cc/min
tagged RBC study
who does a tagged RBC study work to show where GI bleed is
can give rough indication of which side for hemicolectomy
some docs always order this before an arteriogram
some docs skip this and go straight to arteriogram
- -pt has stopped bleeding by the time you get results back
- -no guarantee the arteriogram will work, though
what imaging is helpful if the pt last bled 2 days ago from GI bleed
double endoscopy
tagged RBC or arteiogram is useless
what is dx in young child w/ bloody BM
Meckel’s diverticulum
what test can you do to dx Meckel’s diverticulum
radioactively labeled Technetium scan to identify gastric mucosa
what is dx in pt with multiple shallow furiously bleeding ulcers in gastric mucosa 2/2 complicated ICU course
stress ulcers
how do you dx and manage stress ulcers
dx: endoscopy
prefer to prevent vs tx
–ICU pts get H2 blockers, antacids, or both
manage:
radiologic angiogram to selectively catheterize stomach blood supply (L gastric artery)
what is the generic/broad ddx of acute abdominal pain
perforation
obstruction
inflammatory process
what classically presents as sudden onset, constant severe pain that is GENERALIZED
abdominal perforation
what is the most common abdominal perforation
duodenal ulcer perforation
what is dx in pt who lies motionless to avoid pain in abdomen and PE elicits extreme peritoneal irritation (pain to palp, guarding, rebound tenderness); and absent bowel sounds
abdominal perforation
how do you manage abdominal perforation
r/o other things before arriving at perforation
first: CXR to r/o lower lobe pneumonia
EKG for coronary ischemia
plain abdominal XR for free air perforation, ureteral stone
amylase for pancreatitis
then, immediate ex lap
what is classic dx for sudden onset of pain, colicky, that is localized w/ associated radiation
abdominal obstruction
stone in ureter, cystic duct, common duct, or small bowel lumen
what is dx in pt who is moving around looking for positional comfort and PE localizes to the problem
obstruction
what is most likely in female, fat, forty, fertile
gall stones
stones could be asymptomatic
low rate of conversion –> symptomatic
what is typical PE in biliary tract disease
severe RUQ colicky pain that radiates to R shoulder towards back, N/V that turns into constant pain
PE will show tender to palp, guarding/rebound
mild fever and WBC
what is abdominal pain that quickly resolves with OTC meds, often 2/2 fatty foods; and no residual findings after pain subsides
biliary colic
no residual findings afters stone falls back
how do you manage biliary colic
cholecystectomy to prevent further episodes
what is abdominal pain that persists to constant, localized pain with fever and WBCs;
acute cholecystitis
how do you dx acute cholecystitis
sonogram to show stones
thickened gallbladder wall
pericholecystic fluid
rarely, and inconclusive US will cause you to do a HIDA scan
HIDA scan shows bile flow NOT in the gallbladder
how do you manage acute cholecystitis
anticholinergics do not resolve symptoms
typically tx w/ medical management, including NG suction, NPO, Abx, and IV fluids
then do an elective cholecystectomy
what is likely dx in pt with abdominal pain and highly elevated Alkaline Phosphatase
Ascending cholangitis
pt will be very sick- high 104 fever, high WBC
what causes ascending cholangitis
partial obstruction from a stone that allows an ascending infection
how do you manage ascending cholantigis
emergency
IV Abx, hospitalization, decompress biliary tract with ERCP
catheter above the stone to drain the duct; percutaneous PTC
how does a stone cause acute pancreatitis
stone stuck at ampulla of Vater
occludes both common bile duct and pancreatic duct
what is dx in pt with sudden onset flank pain, radiates to thigh/scrotum; and microhematuria
ureteral stone
how do you dx ureteral stone
IV pyelogram, sonogram, CT scan
what is dx in elderly pt w/ abdominal distension, N/V, no flatus/BM, tympanic abdomen, and hyperactive bowel sounds
sigmoid volvulus
what does sigmoid volvulus XR show
distended loops w/ air fluid levels and “bird beak” sign
how do you manage sigmoid volvulus
proctosigmoid exam
try to untwist bowel and leave long rectal tube to prevent coil
surgery may be indicated
what is likely dx in elderly pt w/ A fib or a recent MI now presenting with an acute abdomen
mesenteric iscemia
how does a recent MI or A fib cause mesenteric ischemia
embolus occluding SMA
how is the bowel affected in an SMA occlusion
distension up to transverse colon
what does a sick pt with acute abdomen and acidosis likely have
mesenteric ischemia that has progressed to a dead bowel
how do you manage mesenteric ischemia
ex lap to resect dead bowel
call vascular surgeon ASAP to try arteriogram to prevent irreversible necrosis
what is dx in pt with gradual onset of abdominal pain, which builds up to maximal intensity in 2-12 hrs; constant, and localized
some sort of inflammatory process
what generic dx will have an abdominal exam showing peritoneal, but localized; and likely signs of systemic inflammation (fever, WBC)
abdominal inflammatory process
what presents with ascites + vague acute abdomen
bacterial hematogenous peritoniits
how do you dx and manage bacterial hematogenous peritonitis
sample ascites for culture
then tx
what is dx in alcoholic pt with abdominal pain that radiates to back w/ N/V
pancreatitis
how do you dx pancreatitis, depending on when pt presents
serum amylase/lipase if recent onset
urinary amylase/lipase if seeing the pt 3 days later
what is dx in pt with abdominal pain with: inflammatory mass; LLQ pain; pain building up to a constant, localized pain; with fever and WBC
diverticulitis
what is the blood marker for HCC
alpha-fetoprotein
what is alpha-fetoprotein a blood marker for
HCC
who gets HCC
only seen in pts who already have cirrhosis
what is the most common liver cancer in the US
metastatic cancer to the liver
20:1 metastatic in the US
where does liver mets likely come from
h/o colon cancer
what is blood marker for liver mets
carcinogenic antigen CEA
what is carcinogenic antigen (CEA) a blood marker for
liver mets
how do you manage liver cancer
CT to evaluate extent of tumor
attempt surgical resection or radioablation
what is commonly seen in females on chronic birth control
hepatic adenoma
what presents in a female on birth control with sudden abdominal pain that leads to faint, pale, tachy, hypotensive, and mildly distended/tender abdomen
hepatic adenoma
birth control can develop hepatic adenomas with tendency to bleed
how do you dx and manage hepatic adenoma
dx w/ CT scan to show adenoma
tx with surgical resection
–not common and not an indication for a female to discontinue OCPs
what is likely dx in late-pregnancy female who suddenly experiences shock
visceral aneurysm of hepatic artery bleeding into abdomen
what type of liver abscess is a complication of biliary tract disease
pyogenic liver abscess
how do you manage pyogenic liver abscess
needs drainage (percutaneous)
what type of liver abscess will commonly present with a “Mexico connection”, likely in a M
amoebic liver abscess
what do labs look like for amoebic liver abscess
fever, WBC, tender over liver, jaundice, elevated Alk phos
what will sonogram show in amoebic liver abscess
normal biliary tree and liver abscess
how do you dx and manage amoebic liver abscess
dx: serology (requires time for pt to develop antibodies)
manage:
empiric tx w/ metronidazole
drain if pt is not responding to Abx and the abscess is growing
do not draw pus to send to lab for growth; the amoeba grows from the wall of the abscess
what type of jaundice gives you:
mild 6-10 Bil elevation with almost ALL INDIRECT (not being processed by liver)
hemolytic jaundice
what is your work up geared toward with a mid Bil elevation that’s almost all indirect
this is hemolytic jaundice, so you should direct your focus on what’s destroying the RBCs
what type of jaundice gives you:
both high Bil’s
very high transaminases
only modest elevation of Alk Phos
hepatocellular jaundice (hepatitis)
what should your work up be directed at with very high transaminases
identifying the type of hepatitis the pt has
what type of jaundice gives you:
classically both high Bil’s (direct is high in early cases)
mildly high transaminases
very high alk phos
obstructive jaundice
what should your work up be directed at with very high alk phos
sonogram to identify where the obstruction is
what is the quick/obvious jaundice answer when labs show:
elevated Bil that is all indirect
very high transaminases
very high alk phos
indirect Bil = hemolytic jaundice
transaminases = hepatocellular
alk phos = obstructive
what type of obstruction occurs when the gallbladder is contracted, thick-walled, and full of stones
benign obstruction
what are the next steps after you identify a benign gallbladder obstruction
ERCP and sphincterotomy to retrieve stones
then cholecystectomy to prevent more stones
what type of obstruction occur when the gallbladder is nontender, distended, and thin-walled
malignant obstruction
cancer of the pancreas, common duct, or ampulla of Vater/hepatopancreatic duct
what is the next step after a malignant gallbladder obstruction has been identified
CT scan to determine cancer location
what type of pancreatic cancer will be symptomatic
pancreatic cx will be advanced if it’s big enough to be symptomatic
what does a negative CT scan in a malignant gallbladder obstruction mean
a negative CT scan = small cancer of pancreatic head, cholangiocarcinoma, or ampulla of Vater carcinoma
next = ERCP
what gives you apple core appearance on ERCP
cholangiocarcinoma
what are the next steps after dx cholangiocarcinoma
brushings to obtain cytologic confirmation
whipple procedure (relatively curable, vs pancreatic tumor)
what gives you a slightly anemic pt with blood in GI lumen and evidence of malignant gallbladder obstruction
ampullarf cancer
how do you manage ampullary cancer
CT scan will unlikely show this small cancer
endoscopy (not ERCP) to see the tumor, biopsy it, and confirm dx
easily resectable
what gives you evidence of malignant gallbladder obstruction, growing into retroperitoneum w/ milk pain deep to epigastrium and upper back; possibly w/ FHx
pancreatic head cancer
what are your next steps after suspecting pancreatic head cancer
first: sonogram
next: CT shows big cancer (big enough to be symptomatic)
percutaneous biopsy
palliative biopsy
what is dx in alcoholic pt with abdominal pain
acute pancreatitis
how do you dx acute pancreatitis
blood or urine amylase / lipase
when does serum vs urine elevation occur in acute pancreatitis with amylase / lipase
serum elevation occurs 12hrs - 2 days after onset of symptoms
urine elevation occurs 2- 5 days after onset of symptoms
what is dx when pt has plasma deposited around pancreas
benign edematous pancreatitis
how do you dx benign edematous pancreatitis
dx with a high Hct (hemoconcentrated blood)
plasma has been removed from the blood and deposited around the pancreas
how do you manage benign edematous pancreatitis
NPO, NG suction, IV fluids
pt will improve
which pancreatitis is diagnosed with a low Hct
Hemorrhagic pancreatitis (losing blood)
what is used to calculate the prognosis of hemorrhagic pancreatitis
Ranson’s Criteria
what is happening with lab values in bad hemorrhagic pancreatitis
the Hct is continuing to drop low serum Ca high BUN metabolic alkalosis low pO2 high blood glucose
how do you treat hemorrhagic pancreatitis
intensive ICU support and expect lots of complications
what is concerning for oncoming death in hemorrhagic pancreatitis
pancreatitis abscess development often means death is coming
you have a destroyed, necrotic, hemorrhagic gland
what should be done daily to monitor hemorrhagic pancreatitis
daily CT scans to find the earliest indication of pus collection
drain the abscesses immediately as the only hope to survive
what is dx in pt with chronic epigastric pain that radiates to back for ~yrs.
pt may also have DM, steatorrhea, malnourishment, alcoholism
pt typically has no job, family, home, and frequents ER for pain control
chronic pancreatitis
what does XR show in chronic pancreatitis
upper abdominal Ca
why can amylase no longer be used in dx of pancreatitis in chronic pts
pt has a history of continuing to drink after alcoholic pancreatitis –> destroyed pancreas
how do you tx chronic pancreatitis
attempt to control DM, pancreatic enzymes for steatorrhea, but the pain isn’t well treated
ERCP to drain pancreatic duct
total pancreatectomy: usually die 2/2 extremely poorly controlled DM
what is dx in pt with ill-defined upper abdominal discomfort, early satiety, and h/o recent d/c from hospital for pancreatitis tx
pancreatic pseudocysts
what will PE show in pancreatic pseudocysts
large epigastric mass deep in the abdomen
what is dx in pt with vague upper abdominal discomfort, early satiny, and h/o recent MVC hitting the steering wheel
pancreatic pseudocysts
how long is the “incubation” period for pancreatic pseudocysts
typically ~5 weeks between trauma/pancreatitis and fluid collection/pressure
what causes pancreatic pseudocysts
trauma/pancreatitis leading to pancreatic juice leaking out of duct and collecting nearby
where is the classic collection site for pancreatic pseudocyst fluid
lesser sac
how do you dx pancreatic pseudocysts
sonogram or CT showing fluid collection
how do you manage pancreatic pseudocysts based on 4 outcomes
careful monitoring w/imaging for resolution
spontaneously resolve:
–go away within 6 weeks
deadly complications typically happen >6 weeks later
- -rupture into peritoneal cavity –> massive fulminating peritonitis
- -erode into major vessels –> bleeds and exsanguinate
- -infected juice 2/2 arterial infection; pseudocyst–> pancreatic abscess –> death
endoscopic internal drainage by gastroscopy:
–create a cystogastrostomy that can drain it without a fistula (via perc drain)
what is the standard recommendation for any hernia
repair electively to prevent possible incarceration/strangulation of bowel
what is the exception for fixing hernias
umbilical hernia <2yo child
will resolve/close spontaneously
what is recommendation for sliding esophageal hernia
not an actual hernia;
not an indication for surgery itself,
but paraesophageal hernia is indicative for surgery
what does breast disease management always begin with
r/o cancer
what is the only way to certainly r/o or dx breast cancer
pathology report
clinical/radiology can only suspect cancer
what are the 5 types of breast biopsies from least to most invasive
least invasive:
FNA cells from mass, cytology
core biopsy: needle collects cores of tissue
mammotome to obtain bigger mass
incisional bx in the OR
most invasive: excision biopsy (remove the entire suspicious mass)
what does the extent of breast biopsy depend on
depends on clinical suspicion
what is the most important factor for clinical suspicion of breast pathology
age
what method would you use in a young person vs middle-aged to r/o breast pathology
young: non-invasive r/o measures
middle aged: either a core biopsy or bigger biopsy; may not even stop until an excision biopsy is done
what should your clinical suspicion be in a female pt with recent trauma to breast
do not allow recent trauma to r/o potential dx of cancer by assuming it’s fat necrosis or a hematoma
–still need mammogram and tissue sampling
what is the role of a mammogram
does not dx cancer of the breast
it detects potential/probable cancer that’s too small to be palpated
–always done first is mass is found on exam in a F >30yo
what is description of irregularities suspicious for cancer
irregular density
no sharply demarcated borders
fine microcalcifications
recent finding (not present on mammogram ~2yrs ago)
what are 2 contraindications for mammogram
<20yo (dense breast tissue won’t allow pathology visualization)
lactating (only see milk)
can you do a mammogram during pregnancy
YES!
what is dx in young F with rubbery mass; easily movable
fibroadenoma
what is the term for a quickly growing fibroadenoma
giant juvenile fibroadenoma
what is work up for fibroadenoma suspicion
FNA/sonogram to confirm dx of fibroadenoma
+/- remove mass depending on pt preference
what is dx in late 20s F with a mass, typically long history, grows big, remains movable; no axillary involvement
cystosarcoma phyllodes
what is management of cystosarcoma phyllodes
removal is mandatory; malignant potential
what is dx in 20-40yo F with painful cyclical lumps that come/go
fibrocystic disease: mammary dysplasia, cystic mastitis
how do you manage fibrocystic disease
mammogram for baseline picture and cyst visualization
if cyst becomes firm and doesn’t go away with cycle:
- -aspiration of cyst (not FNA) to remove cystic fluid
- -retrieve clear fluid and mass disappears: you’re done
- -retrieve blood fluid: send for cytology
- -if mass doesn’t go away/quickly returns: needs formal tissue sampling/bx
what is dx in F with blood discharge from nipple w/o palpable masses
intraductal papilloma
what is a small benign tumor 2-3mm that grows inside breast duct
intraductal papilloma
how do you manage intraductal papilloma
need to r/o carcinoma possibility
- -mammogram first
- —lesion = probably cancer; need bx
can see with galactogram or retroareolar surgical exploration: remove that section of breast
what is the pt presentation that is only acceptable in a lactating F
crack in nipple with red, hot, tender mass in breast with fever and WBC
otherwise, assume it’s cancer until proven benign
how do you manage a F with cracked nipple, red, hot, tender mass in breast with fever and WBC
r/o cancer, but no point in a mammogram if the F is lactating (only see milk)
need I&D, but also take small sample from the wall to path to r/o infected cancer
what are the 2 limitations of pregnancy and breast cancer
cannot give chemo in 1st trimester of pregnancy
cannot give radiation at any time during pregnancy (diagnostic XRs are ok)
not necessary to terminate pregnancy
what is dx in classic orange peel / retracted skin with red/swollen breast
inflammatory breast cancer
what is prognosis and management of inflammatory breast cancer
lethal
manage w/ mammogram, tissue sampling, pre-op chemoradiation
what is dx in F with hard mass under nipple causing nipple retraction
desmoplastic rxn of breast cancer
how do you manage desmoplastic rxn of breast cancer
mammogram, generous tissue sampling
what is dx of non-palpable eczematous lesion in areola of F not improved w/ lotions
Paget’s disease of breast
it’s infiltrative under areolar tissues
how do you manage Paget’s disease of breast
mammogram, biopsy, then proceed
what is dx in mass in axilla; discrete, hard, movable, and a negative breast PE
breast cancer metastatic to axilla
how do you manage metastatic breast cancer to axilla
mammogram needed to show primary tumor; then proceed
if negative, biopsy and remove the axillary lymph node
how should you manage incidental micro calcifications off mammogram
tissue biopsy,
core biopsy by radiologist 8-12 samples
surgical removal w/ wire guidance for path
what are your management options for breast cancer after dx
lumpectomy + radiation
modified mastectomy
axillary sampling
also need to look for signs of systemic metastasis
when is lumpectomy + radiation indicated
relatively small cx compared to breast ratio and far from nipple
–also need axillary sampling
when is modified mastectomy indicated
relatively large cx compared to breast ratio or near the nipple
- -includes axillary sampling
- -no radiation necessary
how is axillary sampling conducted
different from axillary dissection
axillary sampling = sentinel node biopsy
–inject radioactive material into tumor; migrate via lymph; trapped by 1st LN –> biopsy that LN
what are the 2 breast cancers that call for a special management, and what is it
inflammatory carcinoma of breast
or Carcinoma in situ
pre-op radiation/chemo before surgical resection
how do you manage/ what should you suspect in h/o breast cancer w/ recent onset HAs
need CT san looking for brain mets
resect any resectable brain mets
TNM classification
how do you manage/ what should you suspect in h/o breast cancer w/ recent onset back pain
need radio bone scan (sensitive, not specific)
–positive –> XR to see it light up; or consider other causes (fracture; arthritis)
manage bone mets with radiation, ortho stabilization, braces, etc
what are 4 rules for systemic tx of breast cancer
any pt with positive axillary lymph nodes
premenopausal pts: prefer chemotherapy
postmenopausal pts: prefer hormonal therapy (Tamoxifen), esp if ER/PR positive
give chemo to everyone who already has obvious metastasis (liver, bone, brain)
how do you manage ductal carcinoma in situ
standard recommendation: simple total mastectomy
- -offers 100% cure
- -not yet capable of metastasis
- -axillary examination is not needed
how do you manage thyroid masses based on biopsy results
negative: leave alone
positive: operate to remove tumor (most are benign)
indeterminate: operate
what is dx in pt who is losing weight, big appetite, heart palps, heat intolerance, thin, fidgety, diaphoretic, tachy
hyper functioning thyroid adenoma- “hot” –> hyperthyroidism
how do you dx and manage hyperthyroidism
high free T4 or low TSH
localize with radioactive iodine scan
- -surgically resect the isolated area
- -or radioactive iodine tx if whole thyroid lights up
what is dx in lateral mass near thyroid
metastasis from follicular carcinoma of thyroid that has completely replaced a lymph node
how do you manage metastatic follicular carcinoma of thyroid
thyroid scan to identify primary tumor
then surgery
what is dx in pt with high serum Ca and low serum P
hyperparathyroidism
how does hyperparathyroid pt present
“stones, bones, moans, psychiatric overtones”
nephrolithiasis cystic bone lesions GI complains w/ pancreatitis peptic ulcer constipation psych
how do you dx hyperparathyroidism
verify primary hyperPTH with simultaneous high serum Ca
what are most hyperparathyroid conditions
90% are adenomas (vs hyperplasia)
how do you tx primary hyperparathyroidism
remove offending adenoma
–localize with Sestamibi, sonogram, CT scan prior to surgery
–high rate of conversion, so you should treat even if pt is asymptomatic
what is dx in pt who goes pretty –> monster (lolz)
cushing
what is dx in pt with round face, acne, hair, hump, supraclavicular fat pads, thin extremities, truncal centripetal obesity w/ striae
cushing
what should you think in a pt with HTN, DM, osteoporosis, amenorrhea, wide mood swings +/- psych service
cushing
how do you work up cushing
measure AM and MP cortisol (high; and no longer diurnal variation)
Dexamethasone tests
what is dx in pt whose cortisol is suppressed with small dose of dexamethasone
does not have Cushing’s
what is dx in pt whose cortisol is not suppressed with low-dose dexamethasone
Cushing’s
don’t know location/cause yet
- -could be pituitary adenoma –> both adrenals
- -or adenoma in adrenal –> cortisol
what is dx in pt whose cortisol suppresses at high doses of dexamethasone
ACTH-secreting pituitary micro-adenoma
what is dx in pt whose cortisol does not suppress at high doses of dexamethasone
adrenal or extra-adrenal cortisol production
depending on your Dex results, what is your next step
MRI of pituitary or CT of adrenals
–remove the offender
what is dx in pt with gastronoma of pancreas or duodenum
Zollinger-Ellison syndrome
what is dx in pt with extremely virulent PUD that does not respond to normal therapy + watery diarrhea
Zollinger Ellison syndrome
–gastrinoma
what is work up up for Zollinger Ellison syndrome
measure serum gastrin
CT scan of pancreas/duodenum to see primary tumor
resect the gastronoma
what is ddx for hypoglycemia
terminal stage liver failure, retroperitoneal sarcoma
insulinoma
reactive hypoglycemia
injecting insulin
what is dx in pt who gets a hypoglycemic attack during fasting (skip breakfast; late for lunch)
insulinoma
what will labs be in insulinoma
endogenous insulin = high C peptide + high insulin
what is dx in pt who gets hypoglycemia attack after a big meal
reactive hypoglycemia (pancreas overreacts)
what are labs in reactive hyoglycemia
endogenous insulin - high C peptide + high insulin
what is dx in pt who gets hypoglycemia attack and has knowledge of how insulin works
injecting insulin
refer pt to psych to determine motivation of action
what will labs look like for a pt injecting insulin
exogenous insulin = low C peptide + high insulin
