Surgery Rotation 6 Flashcards
Damage and presentation of anterior shoulder dislocation
Axillary nerve damage - sensation to lateral shoulder and deltoid (shoulder abduction) weakness
Damage and presentation of humeral mid-shaft fracture
Damage to radial nerve - sensation to posterior arm, forearm, and dorsolateral hand; extensor muscles
Presentation of uncal herniation
Ipsilateral hemiparesis and CN III (oculomotor) palsy
Presentation of pulmonary contusion
Presents <24 hours after blunt thoracic trauma
Tachypnea, tachycardia, hypoxia
CT scan or CXR with patchy, alveolar infilatrate
Positive Neer’s impingement test indicates what?
Rotator cuff impingement or tendinopathy
What is wound dehiscence
Opening of wound
Salmon colored fluid coming from closed wound, indicating that peritoneal fluid is leaking out - aka deeper layers are not healed yet
Treatment of wound dehiscence
Protection of wound, minimal activity, give it time to heal without increased abd pressure
At a convenient time, repair wound
Management of abd fistula
- fluid replacement
- electrolyte replacement
- elemental nutrient replacement (something that won’t stir up enzymes)
- protection of abd wall from bowel contents (suction device)
Things that prevent a fistula from healing
FETID
- Foreign body
- Epithelialization (epithelium from skin and from bowel can grow towards each other to line the lumen)
- Tumor
- Infection, irradiated tissue, IBD
- Distal obstruction
Studies to evaluate blunt GU trauma
Clinical signs of renal trauma (e.g. CVA tenderness) = contrast CT
Clinical signs of urethral injury (e.g. gross hematuria) = gross hematuria
CAUSECause of hypoxia in flail chest
Pain causes patients to take shallow breaths
Rib fracture may cause lung contusion/hemothorax
Management of flail chest
Pain control, supplemental O2
Positive pressure ventilation (+/-) chest tube if respiratory failure
Presentation of esophageal rupture
subcutaneous crepitus in chest and pneumomediastinum
Will you have increased or decreased bowel sounds in small bowel obstruction and in ileus
SBO = increased bowel sounds Ileus = decreased/absent bowel sounds
Muscles of rotator cuff
SItS:
- Supraspinatus (initial abduction of arm, before deltoid)
- Infraspinatus (lateral rotation)
- Teres minor (lateral rotation and adduction)
- Subscapularis (medial rotation and adduction)
Test used to assess damage to supraspinatus
Drop arm test = patient’s arm is abducted above the head and patient is asked to lower arm slowly - in a tear, the arm will drop rapidly around mid-adduciton
What structures are at risk for damage in a supracondylar fracture of the humerus (right above the elbow)
Entrapment of brachial artery (which branches into radial and ulnar artery) or median nerve
Steps to find the source of blood per rectum
Could be from upper or lower GI:
1) NG tube to aspirate gastric contents to check for blood - if no blood, then you can exclude tip of nose to pylorus
2) Upper GI endoscopy to exclude duodenum - want to see green fluid (bile tinged)
3) Anoscopy to exclude hemorrhoids (cannot do colonoscopy during active bleeding b/c blood obscures the field)
4a) 1/2 options - angiogram for more severe bleeds
4b) 2/2 options - if less blood, wait until bleeding stops and do a colonoscopy
Most common cause of perforated abd
Perforated peptic ulcer
Presentation of glucagonoma
Necrolytic dermatitis, diabetes (hyperglycemia), DVT, weight loss, depression
Difference in gallbladder in obstruction caused by stones vs. malignancy
Stones = dilated ducts with nondilated gallbladder full of stones
Malignancy = large, thin-walled distended gallbladde
Describe the percentage of body surface area when dealing with burns in adults
Rule of 9s:
Head = one 9
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Each lower extr = two 9s; one in front and one in back
Describe the percentage of body surface area when dealing with burns in kids
Rule of 9s:
Head = two 9s
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Both lower extr = total of three 9s; 1.5 each
Definition of “-pexy”
To hold in place
Definition of “-rrhaphy”
To saw together
Components of Whipple procedure
- Cholecystectomy
- Truncal vagotomy
- Antrectomy
- Pancreaticoduodenectomy—removal of head of pancreas and duodenum
- Choledochojejunostomy—anastomosis of common bile duct to jejunum
- Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum
- Gastrojejunostomy—anastomosis of stomach to jejunum
Definition of “-tomy”
To cut
Definition of “-ectomy”
To take out or resect
Definition of “-ostomy”
To make a mouth/opening
Could be from a single organ to the outside (colostomy) or could be an anastomoses between two organs (gastrojejunostomy)
Definition of “-plasty”
To change the shape of something
Fluid given for hypovolemic hypernatrermia (both symptomatic and asymptomatic)•
Non-symptomatic
o 5% dextrose
Symptomatic
o 0.9% saline (isotonic solution) until Euvolemic, then 5% dextrose (hypotonic solution)
What causes metabolic alkalosis
♣ Causes: • Losing H+ excessive vomiting, diuretics, hyperaldosteronism ♣ Differential of metabolic alkalofis (pH > 7.45; HCO3- > 24) • Low urine chloride ♣ Will respond to saline o Vomiting/nasogastric aspiration o Prior diuretic use • High urine chloride o Hypovolemia/euvolemia ♣ Current diuretic use • Will responds to saline ♣ Bartter & Gitelman syndrome • Saline unresponsive o Hypervolemia ♣ Excessive mineralocorticoid activity o Saline unresponsive • Primary hyperaldosteronism • Cushing disease • Ectopic ACTH production
Differential dx of acute abd
Perforation
Obstruction
Inflammatory process
Ischemic process
Cause and presentation of thrombotic thrombocytopenic purpura (TTP)
o Platelets used up in pathologic formation of microthrombi in small vessels
o Due to decreased ADAMTS13, enzyme that normally cleaves vWF for degradation
♣ No vWF degradation = abnormal platelet adhesion = microthrombi
o Findings (Pentad):
♣ Thrombocytopenia = platelets being used up
♣ Microangiopathic hemolytic anemia = RBCs sheared by microthrombi
♣ Renal insufficiency (thrombi involve vessels of the kidney)
♣ Neurological symptoms (confusion, HA, seizures, coma) – thrombi involve vessels of CNS
♣ Fever
Will Na+ and K+ be high or low in DKA?
♣ Sodium levels will be low
• Hyponatremia due to sodium loss via diuresis (osmotic diuresis due to increased glucose)
♣ High serum potassium but low total body potassium
• Cells will exchange H+ for K+ causing high potassium
• Potassium in the blood will be excreted cause low total body potassium
What causes metabolic acidosis
• Anion gap Adding acid to the blood o MUDPILES: ♣ M – Methanol ♣ U – Uremia (renal failure) ♣ D – Diabetic ketoacidosis ♣ P – Propylene glycol/Paraldehyde ♣ I – Isoniazid/Iron ♣ L – Lactic acidosis ♣ E – Ethylene glycol (antifreeze) ♣ S – Salicylates (aspirin) • Non-anion gap Losing excessive HCO3- o Diarrhea, Renal tubular acidosis, Spironolactone, Acetazolamide
IV fluids given to treat DKA
♣ 0.9% normal saline initially
♣ Add dextrose 5% when serum glucose <200 mg/dL
What is the difference between an epidural and subdural hematoma (on XR and clinically)
Epidural = lens shaped; can occur from less serious trauma; longer lucid interval
Subdural = crescent shaped; can be acute with severe trauma, or chronic
What type of brain bleed can easily occur the elderly and alcoholics and why
Subdural
Their brains have shrunk but cranial cavity is the same size so it is easy for the brain to be “rattled” and to tear bridging veins
How do you manage head trauma in a patient with no bleed
Prepare for edema
Mannitol, furosimide, hyperventilation
Describe Cushing reaction (Triad of hypertension, bradycardia, and respiratory depression in response to increased intracranial pressure)
Increased ICP = pressure constricts arterioles in brain = cerebral ischemia = sympathetic response increases peripheral vasoconstriction, thus increasing BP = aortic baroreceptors sense increased BP = respond with reflex bradycardia and respiratory depression
How does hyperventilation help with cerebral edema
A drop in PaCO2 due to hyperventilation causes vasoconstriction = decreased cerebral blood flow = decreased ICP
Where is the damage in:
- initial hematuria (blood only at beginning of voiding)
- terminal hematuria (blood at end of voiding)
- total hematuria (blood throughout entire voiding)
- Urethral damage
- Bladder, prostate, or posterior urethra
- Kidney or ureters
Potential complication of thoracic aortic aneurysm surgery that causes bilateral flaccid paralysis and loss of pain/temp in lower extremities
Spinal cord infarction (due to aortic cross-clamping) leading to anterior spinal cord syndrome
What do hyperactive bowel sounds suggest?
Diarrhea, malabsorption (e.g. Celiac or lactose intolerance), incomplete mechanical bowel obstruction
